In e na ional Jou nal o
En i onmen al Resea ch
and Public Heal h
A icle
P edic o s o Adhe ence in Th ee Low-In ensi y In e en ion
P og ams Applied by ICTs o Dep ession in P ima y Ca e
Ado ación Cas o 1,2,* , Azucena Ga cía-Palacios 3,4, Yolanda López-Del-Hoyo 5,6,7 , Fe mín Mayo al 8,
Ma íaÁngeles Pé ez-A a 1,2 , Rosa Mª Baños 4,9 , Ja ie Ga cía-Campayo 5,6, Ma ía M. Hu ado 8,
C is ina Bo ella 3,4, Albe o Ba celó-Sole 5, Amelia Villena 8, Miquel Roca 1,2,6 and Ma galida Gili 1,2,6


Ci a ion: Cas o, A.; Ga cía-Palacios,
A.; López-Del-Hoyo, Y.; Mayo al, F.;
Pé ez-A a, M.Á.; Baños, R.M.;
Ga cía-Campayo, J.; Hu ado, M.M.;
Bo ella, C.; Ba celó-Sole , A.; e al.
P edic o s o Adhe ence in Th ee
Low-In ensi y In e en ion P og ams
Applied by ICTs o Dep ession in
P ima y Ca e. In . J. En i on. Res.
Public Heal h 2021,18, 1774. h ps://
doi.o g/10.3390/ije ph18041774
Academic Edi o s: Diana Cas illa,
Ca los Suso-Ribe a and
Sab ina Cipolle a
Recei ed: 23 Decembe 2020
Accep ed: 7 Feb ua y 2021
Published: 11 Feb ua y 2021
Publishe ’s No e: MDPI s ays neu al
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Copy igh : © 2021 by he au ho s.
Licensee MDPI, Basel, Swi ze land.
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A ibu ion (CC BY) license (h ps://
c ea i ecommons.o g/licenses/by/
4.0/).
1Resea ch Ins i u e o Heal h Sciences (IUNICS), Uni e si y o Balea ic Islands,
07122 Palma de Mallo ca, Spain; m.pe [email p o ec ed] (M.Á.P.-A.); [email p o ec ed] (M.R.); [email p o ec ed] (M.G.)
2Heal h Resea ch Ins i u e o he Balea ic Islands (IdiSBa), 07120 Palma de Mallo ca, Spain
3Depa men o Clinical and Basic Psychology and Biopsychology, Facul y o Heal h Sciences,
Uni e si y Jaume I, 12071 Cas ellón, Spain; [email p o ec ed] (A.G.-P.); [email p o ec ed] (C.B.)
4CIBER Physiopa hology Obesi y and Nu i ion (CIBERobn), Ca los III Heal h Ins i u e,
28029 Mad id, Spain; banos@u .es
5Ins i u e o Heal h Resea ch o A agon (IIS), Hospi al Miguel Se e , 50009 Za agoza, Spain;
[email p o ec ed] (Y.L.-D.-H.); [email p o ec ed] (J.G.-C.); aba [email p o ec ed] (A.B.-S.)
6P ima y Ca e P e en ion and Heal h P omo ion Resea ch Ne wo k, RedIAPP, 28029 Mad id, Spain
7Depa men o Psychology and Sociology, Uni e si y o Za agoza, 50009 Za agoza, Spain
8Men al Heal h Depa men , Ins i u e o Biomedicine o Malaga, Uni e si y Regional Hospi al o Malaga,
29010 Málaga, Spain; [email p o ec ed] (F.M.);
[email p o ec ed] (M.M.H.); [email p o ec ed] (A.V.)
9Depa men o Psychological, Pe sonali y, E alua ion and T ea men , Uni e si y o Valencia,
46010 Valencia, Spain
*Co espondence: a.cas [email p o ec ed]; Tel.: +34-971-259-888
Abs ac :
Dep ession is one o he mos common diso de s in psychia ic and p ima y ca e se ings,
and is associa ed wi h disabili y, loss in quali y o li e, and economic cos s. In e ne -based psycholog-
ical in e en ions ha e been shown o be e ec i e in dep ession ea men bu p esen p oblems wi h
a low deg ee o adhe ence. The main aim o his s udy is o analyze he adhe ence p edic o s in h ee
low-in ensi y in e en ions p og ams applied by In o ma ion and Communica ion Technologies
(ICTs) o dep ession. A mul i-cen e , andomized, con olled clinical ial was conduc ed wi h
164 pa icipan s wi h dep ession, who we e alloca ed o: Heal hy Li es yle P og am, Posi i e A ec
P omo ion P og am o mind ulness P og am. Sociodemog aphic cha ac e is ics, Pa ien Heal h
Ques ionnai e-9, Visual Analog Scale, Sho Fo m Heal h Su ey, Posi i e and Nega i e A ec Sched-
ule, Fi e Face s mind ulness Ques ionnai e, Pembe on Happiness Index and T ea men Expec ancy
Ques ionnai e we e used o s udy adhe ence. Resul s showed ha posi i e a ec esul ed in a
p edic o a iable o Heal hy Li es yle P og am and Posi i e A ec P omo ion P og am. Pe cei ed
heal h was also a nega i e adhe ence p edic o o he Posi i e A ec P omo ion P og am. Ou
indings demons a e ha he e a e di e ences in clinical a iables be ween ea men comple e s
and non-comple e s and we p o ide adhe ence p edic o s in wo in e en ion g oups. Al hough new
addi ional p edic o s ha e been examined, u he esea ch is essen ial in o de o imp o e ailo ed
in e en ions and inc ease adhe ence ea men .
Keywo ds: dep ession; p ima y ca e; ICTs; adhe ence; p edic o s
1. In oduc ion
Abou 30 million Eu opeans a e es ima ed o su e om dep ession [
1
]. In Spain,
p e alence o dep ession anges be ween 13.9% and 29% [
2
,
3
] and mo e han 50% o
dep essi e pa ien s a e a ended in p ima y ca e [
4
]. I is well es ablished ha pha ma-
co he apy and psycho he apy, o a combina ion o bo h, a e he bes op ion o ea ing
In . J. En i on. Res. Public Heal h 2021,18, 1774. h ps://doi.o g/10.3390/ije ph18041774 h ps://www.mdpi.com/jou nal/ije ph
In . J. En i on. Res. Public Heal h 2021,18, 1774 2 o 15
dep ession [
5
,
6
]. Ne e heless, only 65% o pa ien s show good medica ion adhe ence [
7
]
and ace- o- ace psycho he apy mee ings p esen di icul ies in deli e ing in e en ion
gi en he ace- o- ace ime equi ed, he cos , and he lack o ained p o essionals [
8
–
11
].
Consequen ly, In e ne -based ea men s may help o o e come hese impedimen s making
i possible o deli e he apy o a la ge numbe o people in hei own en i onmen , a a
con enien momen [12,13].
A la ge body o esea ch has epo ed ha In e ne -based in e en ion p og ams ha e
been shown as an e icacious he apeu ic op ion o he ea men o many men al heal h
p oblems including dep ession [
14
–
19
]. Despi e i s backg ound, In e ne in e en ions
p esen p oblems wi h a high deg ee o non-adhe ence, wi h many pa icipan s no com-
ple ing he whole in e en ion [
20
,
21
]. D opou du ing ea men anged om 0 o 78% in
In e ne -based in e en ions o psychological diso de s [
22
]. Rega ding In e ne -based
p og ams o dep ession, he li e a u e shows ha adhe ence ends o be highe when
he in e en ion has some guidance by a p o essional, wi h a e age le els o adhe ence
es ima ed a 72%. By con as , adhe ence a e is a ound 25% when he in e en ion is
unguided [
15
]. Wi h ega d o he leng h o he in e en ions, Ch is ensen e al. [
23
] ound
ha longe p og ams a e associa ed wi h highe a es o d opou .
A la ge body o esea ch has ocused on he s udy o adhe ence p edic o s in he
pas yea s [
21
,
24
–
31
]. Ne e heless, he esul s a e con adic o y. P e ious s udies ha e
shown ha speci ic sociodemog aphic cha ac e is ics, such as gende and age, a e ela ed
o adhe ence ea men . In pa icula , i has been shown ha emales [
24
,
26
] and younge
indi iduals a e mo e likely o adhe e o online in e en ions [
21
,
24
,
25
]. Bu opposi e
indings ha e also been epo ed. Se e al s udies ha e ound ha be e adhe ence was
associa ed wi h olde indi iduals [26,29,32,33] and wi h males [28,33].
In e e ence o clinical p edic o s, baseline dep ession se e i y is one o he mos
commonly explo ed cha ac e is ics. Many s udies ha e epo ed ha lowe le els o base-
line dep ession p edic ed adhe ence [21,25,28] whe eas o he s s udies ound he opposi e
esul [24,27] o e en no ela ionship [29].
O he psychological cha ac e is ics we e also s udied, such as p e- ea men expec a-
ions, pe cei ed c edibili y o he ea men , and/o a i udes owa d In e ne -in e en ions.
Ne e heless, esul s showed ha hese a iables we e no ela ed wi h ea men comple-
ion [
27
,
34
]. I is impo an o no e ha hese esul s mus be ea ed wi h cau ion because
o he he e ogenei y o he s udies in e ms o he di e ences o sample size, in e en ion
cha ac e is ics, and adhe ence de ini ions.
Fo all hese easons, i is c ucial o examine new addi ional cha ac e is ics such as
ac o s o mind ulness, posi i e and nega i e a ec , and well-being, in o de o ha e new
knowledge o which a iables a e associa ed and p edic ea men adhe ence.
The aim o he p esen s udy is o examine he di e ences in sociodemog aphic and
clinical cha ac e is ics be ween ea men comple e s and non-comple e s and o analyze
he adhe ence p edic o s in h ee low-in ensi y in e en ion p og ams applied by ICTs:
Heal hy Li es yle P og am; Posi i e A ec P omo ion P og am and mind ulness P og am,
o dep ession ea men in Spanish P ima y Ca e.
2. Ma e ials and Me hods
2.1. S udy Design
The cu en s udy is a seconda y analysis o a mul i-cen e , con olled, andomized
clinical ial conduc ed wi h pa ien s wi h dep ession ec ui ed in he p ima y ca e. They
we e andomized o ecei e one o ou in e en ion g oups: (a) imp o ed p ima y ca e
usual ea men (iTAU), (b) Heal hy Li es yle P og am + iTAU, (c) Posi i e A ec P omo ion
P og am + iTAU o (d) mind ulness P og am + iTAU.
T ial Numbe Regis a ion om he o iginal s udy is ISRCTN82388279. The aim
o he o iginal s udy was o assess he e ec i eness o h ee low-in ensi y in e en ion
p og ams applied by ICTs (Heal hy Li es yle P og am, Posi i e A ec P omo ion P og am
In . J. En i on. Res. Public Heal h 2021,18, 1774 3 o 15
and mind ulness P og am) compa ed wi h a con ol condi ion. The esea ch p o ocol and
main esul s ha e been epo ed elsewhe e [35,36].
2.2. Pa icipan s
In he o iginal s udy, a o al o 221 pa ien s wi h dep ession we e ec ui ed in p ima y
ca e se ings, be ween Ma ch 2015 and Ma ch 2016 in he Spanish egions o A agon,
Andalucía and Balea es. Inclusion c i e ia we e: olde han 18 yea s old; DSM-5 diagnose
o Majo Dep ession o Dys hymia, wi h mild o mode a e se e i y dep ession assessed
as sco e lowe han 14 acco ding o he Pa ien Heal h Ques ionnai e (PHQ-9) [
37
], wi h
symp oms p esen ed o a leas wo mon hs, be able o ead and unde s and he Spanish
language, and ha e he capaci y o unde s and and sign he w i en in o med consen o m.
We excluded pa ien s who we e diagnosed wi h any disease ha may a ec cen al ne ous
sys em (b ain pa hology, auma ic b ain inju y, demen ia), o any psychia ic diso de
o he han majo dep ession, dys hymia, anxie y diso de s, o pe sonali y diso de s, any
medical, in ec ious o degene a i e disease ha may a ec mood; pa ien s wi h delusional
ideas o hallucina ions consis en o no wi h mood and wi h suicide isk.
Fo he p esen s udy, a o al o 164 pa icipan s we e selec ed and included, hose
who we e alloca ed o one o he in e en ion g oups (Heal hy Li es yle P og am; Posi i e
A ec P omo ion P og am and mind ulness P og am). Those alloca ed o iTAU we e
excluded om he analysis because hey we e con ol g oup, wi h no access o online
ea men . Ou small sample size (n= 164) led o a lack o s a is ical powe , esul ing in ou
majo limi a ion.
2.3. In e en ion G oups Desc ip ion
All in e en ions consis ed o one ace- o- ace g oup session and ou sel -guided
online he apeu ic modules.
Face- o- ace session in ol ed up o i e pa icipan s o he same in e en ion p og am
and was 90 min in leng h. The aim o his session was o explain he p og am s uc u e and
main componen s o ea men , cla i y he ins uc ions o he use o he online pla o m,
and o mo i a e pa icipan s o change, as well as ein o ce commi men and ea men
adhe ence. The pa icipan s we e gi en a lea le wi h a b ie summa y o he opics co e ed
in his session.
Online modules we e a low-in ensi y psychological in e en ion o ien ed o wo k
on di e en psychological echniques. The du a ion o each module was app oxima ely
60 min. Modules included an explana ion o he module con en s and exe cises o p ac ice.
These modules we e sequen ial, in o de o mo e s ep by s ep, all along he p og am, wi h
he possibili y o e iewing module con en s once hey we e inished. Du a ion o each
in e en ion p og am a ied among use s, bu i is es ima ed ha o he mos people, i
las ed be ween 4 and 8 weeks (a ound one module o a week).
The Heal hy Li es yle P og am p o ides in o ma ion o unde s and he ela ionship
be ween physical and men al heal h and physical ac i i y, die and sleep con ol. Modules
a e: (1) Beginning o a li es yle change, ocused on he impo ance o heal hy li es yle
o imp o e emo ional heal h and gene al well-being; (2) physical ac i i y—lea ning o
mo e, o gi e in o ma ion abou exe cises o imp o e mood, o inc ease mo i a ion, o
s a being mo e ac i e, and o main ain his physical ac i i y; (3) die —lea ning o ea ,
ocused on he impo ance o die o achie e a good physical and men al heal h, and
he ole o he Medi e anean die in he p e en ion and ea men o dep ession; and
(4) sleep— he impo ance o good sleep, o unde s and he ela ionship be ween sleep, and
gene al heal h.
The Posi i e A ec P omo ion P og am aims o dec ease dep essi e symp oma ology
and o p e en elapses using he p omo ion o well-being and posi i e a ec . The modules
a e: (1) Lea ning o li e, ocused on he impo ance o es ablishing and main aining an
adequa e ac i i y le el and he ele ance o choosing ac i i ies ha a e signi ican o he
indi idual; (2) lea ning o enjoy, o gi e educa ion abou he e ec o posi i e emo ions and
In . J. En i on. Res. Public Heal h 2021,18, 1774 4 o 15
o ain he pa ien in lea ning p ocedu es o inc ease he likelihood o expe iencing posi i e
emo ions; (3) accep ing o li e, ocused on he aining o he pa ien in concen a ing on
posi i e emo ions ela ed wi h he pas o he u u e; and (4) li ing and lea ning, o ain
he pa ien in unde s anding li e as a con inuous p ocess o lea ning and pe sonal g ow h,
emphasizing he aining in s a egies o p omo e psychological s eng hs, esilience, and
meaning ul goals linked o impo an alues.
The mind ulness P og am has he objec i e o dec ease dep essi e symp oma ology
using mind ulness, emphasizing he bene i s o i s he apy. The modules a e: (1) Ge ing
o know mind ulness, o explain wha mind ulness is, p ejudices abou i , he ina en ion
p oblem, and some o i s main bene i s and ecommenda ions o p ac ice i ; (2) es ablishing
o mal and in o mal p ac ices, ocused on he impo ance o he es ablishmen o o mal
and in o mal p ac ice; (3) h ough managemen , body scan p ac ice and alues, o help
people o see he impo ance o alues o keep a egula mind ulness p ac ice; and (4) Sel -
compassion. In eg a ing mind ulness in e e yday li e, o es ablish a egula p ac ice
o mind ulness o be inde ini ely kep .
Full de ails o he in e en ions a e desc ibed in Cas o e al. [35] and Gili e al. [36].
2.4. Adhe ence De ini ion
In he con ex o his analysis, adhe ence e e s o he ex en o which indi iduals
comple e he whole in e en ion in he pos - es e alua ion. The e o e, a pa icipan was
conside ed o be pa o he adhe ence g oup (comple e pa icipan ) i hey comple ed he
whole in e en ion (1 ace- o- ace session plus 4 sel -guided online he apeu ic modules) a
he pos - es assessmen . A pa icipan who did no comple e he whole in e en ion a he
pos - es was conside ed non-comple e pa icipan .
2.5. Ins umen s
Case epo o m (CRF). The pa ien ’s sociodemog aphic and clinical cha ac e is ics
we e ga he ed using a CRF: gende , da e o bi h and age, place o esidence, amily
s a us, i hey li e alone o accompanied, le el o educa ion, wo k s a us and income le el.
Psychopha macologic medica ion (yes s. no) and he numbe o physician isi s in he
las 12 mon hs we e also collec ed.
The mini In e na ional Neu opsychia ic In e iew 5.0 (M.I.N.I. 5.0) [
38
]. This diag-
nos ic in e iew was used a he sc eening o assess cu en dep ession and como bid
diso de s. This measu e is a s uc u ed diagnos ic in e iew based on he DSM-IV and he
In e na ional Classi ica ion o Diseases-10 c i e ia. The Spanish e sion was used o his
s udy [39].
Pa ien Heal h Ques ionnai e-9 (PHQ-9) [
40
]. This ins umen was used o e alua e
dep ession se e i y. Pa icipan s desc ibe hei mood o he las wo weeks p io o e al-
ua ion, wi h i ems anging om 0 o 3 deno ing “no a all,” “se e al days,” “mo e han
hal he days,” and “nea ly e e y day,” espec i ely. To al sco es ange om 0 o 27. The
Spanish e sion was used and has been shown o ha e good psychome ic p ope ies ( o
he diagnosis o any diso de , k = 0.74; o e all accu acy, 88%; sensi i i y, 87%; speci ici y,
88%) [37].
The Visual Analog Scale o he Eu oQol (VAS); [
41
]. This scale was used o assess he
esponden ’s sel - a ed heal h. The VAS is a 10-cm e ical line wi h he bes and wo s
possible heal h s a es sco e 100 and ze o, espec i ely. Spanish e sion was used in his
s udy [42].
The Sho Fo m Heal h su ey (SF-12 1) [
43
]. This scale was used as a measu e o
heal h- ela ed quali y o li e om he pa ien ’s pe spec i e. The SF-12 sco ing algo i hm
yields a physical componen scale (gene al heal h, bodily pain, ole-physical, physical unc-
ioning) and a men al componen scale (men al heal h, ole-emo ional, social- unc ioning,
i ali y). Bo h subscales we e used as con inuous a iables using Spanish no ms [
44
].
The Spanish e sion was used in his s udy and p esen s good psychome ics p ope ies
(C onbach α= 0.7) [44].
In . J. En i on. Res. Public Heal h 2021,18, 1774 5 o 15
Posi i e and Nega i e A ec Schedule (PANAS) [
45
]. This scale was used o e alua e
he posi i e and nega i e a ec . I consis s o 20 i ems ha e alua e wo independen
dimensions: Posi i e A ec (PA) (10 i ems) and Nega i e a ec (NA) (10 i ems). To al sco e
o each subscale anges om 5 o 50, using a 5-poin Like - ype scale (1 = e y sligh ly
o no a all, 5 = e y much). “T ai ” e sion was used in his s udy. The Spanish e sion
showed adequa e in e nal consis ency (C onbach’s αbe ween 0.87 and 0.91) [46].
Fi e Face s mind ulness Ques ionnai e (FFMQ) [
47
]. This ques ionnai e comp ises
39 i ems, a ed on a 5-poin Like - ype scale (1 = ne e o e y a ely ue, 5 = e y o en
o always ue), and was used o assess i e ace s o ac o s o mind ulness: obse ing
( endency o a end o in e nal and ex e nal expe iences such as sensa ions, emo ions,
sounds), desc ibing ( endency o desc ibe and label hese expe iences wi h wo ds), ac ing
wi h awa eness ( endency o gi e ull awa eness and a en ion o cu en ac i i ies o
expe iences), no judging inne expe ience ( endency o a none alua i e s ance owa d
inne expe iences), and no eac ing o inne expe ience ( endency o allow hough s and
eelings o come and go, wi hou ge ing caugh up in hem). The Spanish e sion was
used in his s udy and has shown good in e nal consis ency (C onbach’s α> 0.80) [48].
The Pembe on Happiness Index (PHI) [
49
]. This index consis s o 11 i ems ela ed
o di e en domains o emembe ed well-being, each wi h an 11-poin Like - ype scale
(0 = ully disag ee, 10 = ully ag ee), and 10 i ems ela ed o expe ienced well-being, wi h
dicho omous esponse op ions (yes/no). The emembe ed well-being sco e is calcula ed
wi h he mean sco e o he 11 i ems and a ies om 0 o 10. The i ems o expe ienced well-
being a e ans o med in o a single sco e om 0 (ze o posi i e expe iences and 5 nega i e
expe iences) o 10 (5 posi i e expe iences and no nega i e expe iences). To calcula e he
o e all PHI index, which included emembe ed and expe ienced well-being, indi iduals’
sco es o he 11 i ems ela ed o emembe ed well-being plus he sum o sco es on he
expe ienced well-being we e summed; he o al sum is hen di ided by 12, so he esul ing
PHI o al mean sco e also anges om 0 o 10. The alida ed Spanish e sion showed
adequa e psychome ic p ope ies (C onbach’s α> 0.80) [49].
T ea men Expec ancy Ques ionnai e [
50
]. This ques ionnai e was used o assess he
pa ien ’s expec a ions abou he ea men ha he/she is going o ecei e. I consis s o
6 i ems sco ed be ween 0 (no hing) o 10 ( e y much). To al sco e is he sum o each i em
and he maximum a e is 60. Highe sco es mean be e expec a ions abou he ea men
ha he/she is going o ecei e.
2.6. P ocedu e
Pa ien s we e ec ui ed in Spanish P ima y Ca e se ings. When he gene al p ac-
i ione (GP) iden i ied a po en ial pa icipan du ing a isi , he o she explained o he
pa icipan he cha ac e is ics o he s udy. I he pa icipan was in e es ed on i , he o she
signed an in o med consen o m and he GP illed a e e al o m desc ibing he sociode-
mog aphic cha ac e is ics o he pa ien and a checklis o inclusion and exclusion c i e ia.
GP also ga e him o he he pa ien ’s in o ma ion shee and a handou desc ibing he s udy.
Then, he GP sen hese documen s o he local esea che . Pa icipan s we e in e iewed
a e a ew days by he esea che , which adminis e ed psychological assessmen ins u-
men s ela ed wi h inclusion and exclusion c i e ia by phone. All pa icipan s ul illed
hei assessmen s h ough a web (h ps://psicologiay ecnologia.labpsi ec.es/). Included
pa icipan s we e andomized o 1 o he 4 g oups by an independen esea che using
a compu e -gene a ed andom numbe . The E hical Re iew Boa d o he egional heal h
au ho i y app o ed he s udy (Re : IB 2144/13 PI). Mo e de ails abou he s udy design,
ec ui men , andomiza ion and da a collec ion p ocedu e a e desc ibed elsewhe e [
35
,
36
].
2.7. Ou comes and Da a Analyses
Th ee in e en ion g oups o pa icipan s we e selec ed ega ding he assigned low-
in ensi y psychological in e en ion applied by ICTs (Heal hy Li es yle P og am s. mind-
ulness P og am s. Posi i e A ec P omo ion P og am). Desc ip i e analysis examined

In . J. En i on. Res. Public Heal h 2021,18, 1774 6 o 15
he di e ences be ween g oups o adhe ence ( ea men comple e s. non-comple e ) o
each in e en ion g oup and was compu ed in e ms o mean and s anda d de ia ion o
con inuous a iables, and equency wi h pe cen age o o dinal and nominal a iables.
Disc e e a iables we e compa ed using he chi-squa e es and S uden es s we e used
o con inuous a iables compa isons. A pos -hoc analysis was conduc ed in o de o
explo e he in e en ion g oup di e ences ega ding adhe ence conside ing adhe ence
as a dicho omous a iable (comple e s s. non-comple e s) h ough chi-squa e homo-
genei y es , and as a con inuous a iable (numbe o modules comple ed) by ANOVA
es .
Logis ic
eg ession models using adhe ence as a dependen a iable we e cons uc ed
using independen p edic o a iables. Subsequen bina y logis ic eg ession analyses o
each in e en ion g oup we e conduc ed o build pa simonious models. Signi icance asso-
cia ed p obabili y o analyzed con as s we e i o 0.05, while signi icance analyses o b
coe icien s in logis ic eg essions and o Odd Ra ios we e calcula ed based on 95% CI. The
e ec s o b coe icien s o inal logis ic eg essions we e boo s apped wi h 1000 eplica ions.
The analyses we e pe o med using IBM SPSS 22 (IBM Co p, A monk, NY, USA).
3. Resul s
3.1. Sample Desc ip ion
Final analyses we e unde aken on 164 subjec s, hose who we e alloca ed in one o he
h ee in e en ion g oups, wi h 32.9% ecei ing Heal hy Li es yle P og am, 32.9% ecei -
ing mind ulness P og am, and 34.1% ecei ing Posi i e A ec P omo ion P og am. The
sample was p edominan ly emale (79.9%) and he mean age was 45.03 (SD = 11.16) yea s.
Mos we e ma ied (58%), li ed accompanied (83.4%), had p ima y/seconda y educa ional
le el (68%) and had no paid employmen (51.6%), and had an income le el p edominan ly
mo e han 2 NMW (35.6%). Wi h espec o clinical a iables, he PHQ-9 mean o he o al
sample was 12.62 (SD = 2.34) and 70.9% used psychopha macologic ea men .
Rega ding di e ences in sociodemog aphic and clinical cha ac e is ics be ween ea -
men comple e s and non-comple e s in each in e en ion g oups, analysis ound ha he
Heal hy Li es yle P og am g oup had s a is ically signi ican di e ences in Posi i e A ec
baseline sco es, sel -measu ed by he Posi i e A ec dimension om PANAS Schedule
(PA-PANAS) (mean = 23.32 s. mean = 16.25; p= 0.000), baseline sco es om “Desc ibing”
FFMQ Subscale (mean = 26.50 s. mean = 22.13; p= 0.022) and baseline global a e age PHI
(mean = 5.26 s. mean = 3.87; p= 0.007). In he Posi i e A ec P omo ion P og am, s a is i-
cally signi ican di e ences be ween ea men comple e s and non-comple e s we e ound
in baseline pe cei ed heal h, sel -measu ed by he VAS (mean = 39.44 s. mean = 56.82;
p= 0.003) and baseline sco es om “No eac ing o inne expe ience” FFMQ Subscale
(mean = 19.22 s. mean = 15.68; p= 0.013). In he mind ulness P og am, s a is ically
signi ican di e ences be ween ea men comple e s and non-comple e s we e no ound
in sociodemog aphic and clinical a iables.
The sample g oup’s sociodemog aphic cha ac e is ics and compa isons be ween bo h
g oups a e shown in Table 1.
In . J. En i on. Res. Public Heal h 2021,18, 1774 7 o 15
Table 1. Baseline sociog aphic and clinical cha ac e is ics and compa isons be ween ea men comple e s and non-comple e s.
Heal hy Li es yle P og am
(n= 54)
Mind ulness P og am
(n= 54)
Posi i e A ec P omo ion P og am
(n= 56)
Sociodemog aphic and
Clinical Va iables
To al
(n= 164; 100%)
Comple e s
(n= 22; 40.75%)
Non-Comple e s
(n= 32; 59.25%)
Comple e s
(n= 28; 51.85%)
Non-Comple e s
(n= 26; 48.5%)
Comple e s
(n= 18; 32.14%)
Non-Comple e s
(n= 38; 67.85%)
Age, mean (SD) 45.03 (11.16) 41.86 (10.21) 45.69 (9.8) 48.89 (12.80) 44.65 (12.78) 48.06 (8.83) 42.29 (10.64)
Sex, n(%) 164
Male 33 (20.1) 6 (27.3) 8 (25) 4 (14.3) 3 (11.5) 6 (33.3) 6 (15.8)
Female 131 (79.9) 16 (72.7) 24 (75) 24 (85.7) 23 (88.5) 12 (66.7) 32 (84.2)
Family S a us, n(%) 157
Single 66 (42) 11 (50) 15 (51.7) 11 (39.3) 9 (40.9) 6 (33.3) 14 (36.8)
Ma ied 91 (58) 11 (50) 14 (48.3) 17 (60.7) 13 (59.1) 12 (66.7) 24 (63.2)
Educa ional Le el, n(%) 153
P ima y/Seconda y 104 (68) 15 (71.4) 24 (82.8) 15 (57.7) 13 (59.1) 13 (72.2) 24 (64.9)
Uni e si y 49 (32) 6 (28.6) 5 (17.2) 11 (42.3) 9 (40.9) 5 (27.8) 13 (35.1)
Li es, n(%) 157
Alone 26 (16.6) 5 (22.7) 5 (17.2) 6 (21.4) 5 (22.7) 1 (5.6) 4 (10.5)
Accompanied 131 (83.4) 17 (77.3) 24 (82.8) 22 (78.6) 17 (77.3) 17 (94.4) 34 (89.5)
Wo k S a us, n(%) 155
Unemploymen 80 (51.6) 11 (52.4) 15 (51.7) 18 (66.7) 10 (43.5) 8 (44.4) 18 (48.6)
Paid employmen 75 (48.4) 10 (47.6) 14 (48.3) 9 (33.3) 13 (56.5) 10 (55.6) 19 (51.4)
Income le el, n(%) 149
<NMW a48 (32.2) 7 (35) 9 (31) 8 (29.6) 7 (33.3) 5 (29.4) 12 (34.4)
1–2 NMW 48 (32.2) 7 (35) 11 (37.9) 7 (25.9) 6 (28.6) 7 (41.2) 10 (28.6)
>2 NMW 53 (35.6) 6 (30) 9 (31) 12 (44.4) 8 (38.1) 5 (29.4) 13 (37.1)
Dep ession se e i y
PHQ bBasal, mean (SD) 12.62 (2.34) 11.86 (2.7) 13.06 (2.2) 12.82 (2.19) 12.50 (2.93) 12.39 (1.97) 12.74 (2.07)
Change in dep ession se e i y, n106
PHQ-Change c, mean, SD 3.22 (5.93) 4.67 (4.33) 3.38 (4.96) 2.96 (6.82) 5.73 (6.96) 1.11 (4.56) 1.92 (7.63)
Pe cei ed Heal h, n132
Eu oQoL VAS d, mean (SD) 50.08 (22.44) 55 (24.6) 49.57 (18.46) 47.86 (24.85) 50.56 (28.38) 39.44 (18.30) ** 56.82 (16.15) **
Physical Heal h SF-12 e, mean(SD) 43.23 (11.26) 44.06 (9.18) 41.68 (9.31) 44.71 (14.32) 46.37 (13.65) 38.37 (6.67) 43.64 (11.25)
Men al Heal h SF-12, mean (SD) 27.07 (10.12) 28.56 (12.34) 27.41 (10.57) 25.36 (10.28) 27.07 (9.85) 29.23 (10) 25.61 (7.53)
In . J. En i on. Res. Public Heal h 2021,18, 1774 8 o 15
Table 1. Con .
Heal hy Li es yle P og am
(n= 54)
Mind ulness P og am
(n= 54)
Posi i e A ec P omo ion P og am
(n= 56)
Sociodemog aphic and
Clinical Va iables
To al
(n= 164; 100%)
Comple e s
(n= 22; 40.75%)
Non-Comple e s
(n= 32; 59.25%)
Comple e s
(n= 28; 51.85%)
Non-Comple e s
(n= 26; 48.5%)
Comple e s
(n= 18; 32.14%)
Non-Comple e s
(n= 38; 67.85%)
PANAS ,n132
Posi i e A ec , mean (SD) 18.70 (6.22) 23.32 (6.85) *** 16.25 (3.88) *** 17.50 (4.89) 19.50 (7) 19.33 (6.94) 17.14 (5.78)
Nega i e A ec , mean (SD) 28.58 (8.29) 27.77 (7.93) 28.29 (8.13) 28.61 (7.94) 32 (9.6) 27 (8.07) 28.18 (8.95)
FFMQ g,n131
Obse ing Subscale, mean (SD) 20.69 (5.52) 21.05 (5.09) 20.17 (5.65) 21.46 (6.8) 21.50 (4.3) 20.22 (4.58) 19.59 (5.95)
Desc ibing Subscale, mean (SD) 23.43 (7.06) 26.5 (5.72) * 22.13 (6.59) * 22.61 (7.62) 24.06 (7.51) 23.28 (7.08) 22.36 (7.44)
Ac ing wi h awa eness Subscale, mean
(SD) 23.09 (6.11) 23 (7.38) 22.96 (5.64) 23.82 (5.96) 22.61 (6.83) 22.56 (4.42) 23.23 (6.53)
No judging inne expe ience Subscale,
mean (SD) 21.55 (6.92) 22.27 (6.92) 21.78 (6.26) 20.82 (8.67) 19.83 (6.26) 20.56 (5.26) 23.73 (6.89)
No eac ing o inne expe ience
Subscale, mean (SD) 18.40 (5.15) 20.64 (5.76) 18.13 (4.94) 18.43 (4.96) 18.50 (5.84) 19.22 (4.27) * 15.68 (4.22) *
Global A e age PHI h,n, mean (SD) 128
4.36 (1.83) 5.26 (1.82) ** 3.87 (1.39) ** 4.17 (1.66) 4.12 (2.34) 4.20 (1.85) 4.52 (1.83)
Physician isi s, n, mean (SD) 133
6.63 (8.89) 4.55 (5.76) 6.36 (10.19) 6.46 (7.67) 5.47 (5.33) 5.94 (6.88) 9.96 (13.12)
Psychopha macologic ea men , n(%) 127
No 37 (29.1) 9 (47.4) 5 (23.8) 10 (35.7) 4 (25) 3 (17.6) 6 (23.1)
Yes 90(70.9) 10 (52.6) 16 (76.2) 18 (64.3) 12 (75) 14 (82.4) 20 (76.9)
T ea men expec a ions, n,
mean (SD) 128
44.07 (9.54) 44.82 (8.59) 44.32 (8.75) 41.39 (13.34) 44.82 (8.41) 46.22 (7.21) 44.14 (8)
Adhe ence, n(%)
Comple e s 68 (41.5)
No-Comple e s 96 (58.5)
No es:
a
Na ional minimum Wage;
b
Pa ien Heal h Ques ionnai e 9 i ems;
c
Di e ences in PHQ-9 a baseline assessmen minus PHQ-9 sco es a pos - ea men assessmen ;
d
Visual Analog Scale o he Eu oQoL;
eSho Fo m Heal h Su ey; Posi i e and Nega i e A ec Schedule; gFi e Face s mind ulness Ques ionnai e; hThe Pembe on Happiness Index; * p< 0.05; ** p< 0.01; *** p< 0.001.
In . J. En i on. Res. Public Heal h 2021,18, 1774 9 o 15
Resul s o he pos -hoc analysis ound nei he s a is ically signi ican di e ences in he
p opo ions o comple e s and non-comple e s be ween in e en ion g oups (
χ2(2)
= 4.417;
p= 0.110), no in e ms o modules comple ed (mean = 3.01 in Heal hy Li es yle; mean= 3.37
in mind ulness P og am and mean = 2.70 in Posi i e A ec P omo ion P og am; F = 1.608;
p= 0.204).
3.2. Logis ic Reg ession Analysis Resul s
A logis ic eg ession was ca ied ou o es i he e we e in e ac ions be ween he
p edic o s a iables. Because o an e ec o in e ac ion be ween some p edic o a iables
and in e en ion a iable, models we e analyzed sepa a ely. A e ha , a bi a ia e analysis
was pe o med be ween independen baseline demog aphic and clinical a iables and
adhe ence (comple e s s. non-comple e s) as a dependen a iable in o de o iden i y
he po en ial p edic o s. No eac i i y o inne expe ience FFMQ subscale and posi i e
a ec (PA-PANAS) a iables we e signi ican ly associa ed (p< 0.10). A e a li e a u e
e iew, models we e also adjus ed by he ollowing a iables: age, sex, educa ional le el,
dep ession symp oma ology (PHQ-9), pe cei ed heal h (VAS), and ea men expec a ions.
Odds a io (OR) and 95% con idence in e als o each adhe ence p edic o in each
in e en ion g oup a e shown in Table 2. Posi i e a ec (sel -measu ed by he PA-PANAS)
was a signi ican adhe ence p edic o (p= 0.005) o Heal hy Li es yle P og am and pe -
cei ed heal h (sel -measu ed by he VAS) o Posi i e A ec P omo ion P og am (p= 0.012).
Models we e signi ican i o da a o Heal hy Li es yle P og am (X
2(8)
= 23, p= 0.003) and
o Posi i e A ec P omo ion P og am (X
2(8)
= 21.628, p= 0.006) bu no o mind ulness
P og am (X2(8) = 2.479, p= 0.963).
Table 2.
Bina y logis ic eg ession o Heal hy Li es yle P og am, mind ulness P og am, and Posi i e A ec P omo ion P og am.
Heal hy Li es yle P og am Mind ulness P og am Posi i e A ec P omo ion
P og am
95% CI a95% CI 95% CI
OR bpcLowe Uppe OR pLowe Uppe OR pLowe Uppe
Sex 0.176
0.148 0.017 1.851
0.788
0.828 0.092 6.775
0.362
0.426
0.030 4.418
Age 0.981
0.704 0.891 1.081
1.029
0.353 0.969 1.092
1.083
0.155
0.970 1.208
Educa ional Le el 2.411
0.396 0.316 18.379
0.875
0.863 0.193 3.960
0.421
0.422
0.051 3.483
PHQ-9 d1.084
0.685 0.736 1.597
1.036
0.791 0.797 1.348
0.598
0.112
0.317 1.127
Eu oQoL VAS e0.968
0.293 0.912 1.028
1.010
0.537 0.979 1.042
0.869 *
0.012
0.778 0.970
Posi i e A ec (PA-PANAS)
1.456 *
0.005 1.120 1.894
0.914
0.274 0.777 1.074
1.186
0.103
0.966 1.457
No eac i i y o inne
expe ience subscale FFMQ g1.111
0.278 0.918 1.345
1.028
0.729 0.879 1.202
0.965
0.785
0.749 1.244
T ea men expec a ions 0.985
0.791 0.883 1.099
0.992
0.854 0.911 1.080
1.050
0.456
0.924 1.194
No es:
a
Con idence in e al;
b
Odds Ra io;
c
Associa ed P obabili y;
d
Pa ien Heal h Ques ionnai e 9 i ems;
e
Visual Analog Scale o he
Eu oQoL; Posi i e dimension o he Posi i e and Nega i e A ec Schedule; gFi e Face s mind ulness Ques ionnai e; * p< 0.05.
The mos pa simonious models o p edic adhe ence, based on ou sample and p e-
dic o s, a e shown in Table 3. Posi i e a ec , sel -measu ed wi h he PA-PANAS, was a
signi ican p edic o o bo h Heal hy Li es yle P og am and Posi i e A ec P omo ion
P og am. Speci ically, 1-poin inc ease was associa ed wi h 27% g ea e odds o adhe ing
o he Heal hy Li es yle P og am, while 1-poin inc ease in he Posi i e A ec P omo ion
P og am g oup was associa ed wi h 22.5% g ea e odds o adhe ence. Pe cei ed heal h,
sel -measu ed wi h he Eu oQoL VAS scale, was a signi ican nega i e p edic o o ad-
he ence o he Posi i e A ec P omo ion P og am: 1-poin dec ease in his scale was
associa ed wi h 10% g ea e odds o adhe ing o his in e en ion. These models we e
signi ican i s o da a:
χ2(1)
= 16.11, p< 0.001, o Heal hy Li es yle P og am;
χ2(2)
= 16.358,
p< 0.001 o he Posi i e A ec P omo ion P og am (Figu e 1) and co ec ly classi ied
78.3% o pa icipan s in he Heal hy Li es yle P og am and 77.5% in he Posi i e A ec
P omo ion P og am.