Acupressure

We used multiple and mixed methods to involve stakeholders. In November 2011 a focus group discussion and a cross-sectional survey were conducted among female college students aged 16 to 25 years suffering from self-reported menstrual pain. Furthermore, a Stakeholder Advisory Group was implemented to design the study and a written Delphi consensus method with international acupuncture specialists was conducted to define the intervention. The aim of the focus group and the survey was to get an understanding of women’s view about their menstruation, related pain and additional symptoms, and potential treatment options such as acupressure and relaxation techniques. Additionally, women were asked whether they owned a smartphone and would use it for a study intervention. The deans of 24 colleges provided by the Berlin Chamber of Commerce were contacted by phone and informed about this pre-study. Those who were interested in participating received written information about the study and after two colleges agreed recruitment was stopped. Participants in the focus group discussion and the survey obtained informed consent. Both pre-studies were approved by the local ethics committee (Approval number: EA1/223/11).

The intervention was guided by the theoretical backdrop of the Health Action Process Approach (HAPA) [31 (link)] and the Compensatory Carry-Over Action Model (CCAM) [15 (link)]. The HAPA model suggests that the process of behavior change can be divided into two distinctive phases: the motivational and volitional stages, during which individuals may experience a dynamic process from the formation of intention to the performance of behavior. At the beginning of behavioral change, called the motivational phase, an individual develops the intention to perform a specific health behavior. During this stage, specific crucial factors such as action self-efficacy, outcome expectancies, and risk perceptions can collectively contribute to intention formation. Subsequently, once a “good intention” is initiated, the individual enters the volitional phase. During this process, the individual benefits the most from planning (e.g., action planning and coping planning), which can bridge the gap between intention and action. Before the behavior becomes a stable habit, maintenance and recovery self-efficacies and other resources (e.g., social support) play irreplaceable roles in maintaining the behavior change and avoiding relapse. To guide the simultaneous and sequential intervention components, the CCAM was employed to support the transfer of one behavior to another.
The duration of the web-based lifestyle interventions was 8 weeks (see Fig. 1) [29 (link), 32 (link), 33 (link)]. For the PA-first arm, the content included first a 4-week treatment addressing PA, and a subsequent 4-week treatment addressing FVC. For the FVC-first arm, only the sequence of intervention delivery was changed, with FVC addressed first followed by PA. The simultaneous arm had the same amount of treatments for PA and FVC as the sequential arms, but addressed these two behaviors simultaneously for 8 weeks (see Fig. 2). The treatments for the three interventions groups focused on improving social-cognitive variables related to PA and FVC behavior change, including risk perception, outcome expectancies, goal setting, self-efficacy-beliefs, action planning, coping planning and social support (see Additional file 1).
Fig. 2

Intervention variables of the web-based lifestyle intervention program

Additionally, in order to facilitate the implementation and maintenance of health behavior, behavior change techniques (BCT; e.g., provide information about health consequences, provide instruction on how to perform the behavior, barrier identification, relapse prevention, prompt review of behavioral goals, facilitating social comparison; see Additional file 2) were used in the intervention sessions based on the 93-item BCT taxonomy v1 [34 (link)]. Participants were provided with two types of feedback, including individualized feedback on past behavior, and normative feedback on whether the participants met the criterion regarding the behavioral recommendations (see Fig. 3). Furthermore, in order to maximize retention rate, multiple reminder strategies were implemented. For example, the PE lecturers reminded all to click the weekly hyperlink of the health session and follow the online instructions. Meanwhile, SMS and WeChat (a prevalent mobile social media application in China) messages were distributed to the participants weekly, prior to each intervention session in order to remind students to participate in the weekly intervention (e.g., Dear student, the new health session will start tomorrow. We kindly remind you to engage in this week’s health session by clicking the hyperlink in your computer which has been sent to you via WeChat this morning. Have a nice day!).
Fig. 3

Example of individualized and normative feedbacks on physical activity in the web-based lifestyle intervention program (translated from Mandarin)

In order to avoid the social desirability and expectation/Hawthorne effects, participants in the control group received placebo treatments which appeared in all respects to be identical to the intervention in the IGs (e.g., the intervention duration and procedure), but lacked the critical ingredients of PA and FVC treatment. In particular, participants were provided with general health information which was irrelevant for changing actual PA and FVC behaviors, such as an introduction to tourist attractions, tips on acupressure massage, and an introduction to some relaxing music and movies. All interventions were delivered on a newly updated web-site platform, through which all participants in the IGs and PCG were invited to attend the health session once per week. They were informed that the intervention would last for around 20 min per session.
Due to the randomization, only the website system could record the participants’ identity and group allocation. When students logged into the website, the system automatically linked them to the different modules according to their group allocation at baseline. With this technology, both intervention and control participants were blinded with respect to the group allocation and reminders.

Descriptive statistics were used for the quantitative data of baseline characteristics and the recruitment rate, attrition rate, frequency, and consistency of participants practicing the MBI. An independent-sample t test (2-tailed) was used to compare sociodemographic and baseline outcome variables between the 2 study groups. Generalized estimating equations (GEEs) were adopted to examine the outcomes of the study between the intervention and control groups across the 3 time points (T0, T1, and T2). The dependent variables were the total scores of caregivers’ health outcomes (stress, caregiver burden, sleep quality, and mindful awareness and attention) in the GEE analysis. The independent variables were the group, time points, and group × time interaction. Missing data were estimated by using multiple imputations in the GEE model. SPSS (version 23.0; IBM Macintosh) was used to analyze the data. An intention-to-treat analysis was performed.
The focus group interview was conducted by a senior research nurse asking the participants about the complexity of the teaching content, the rationality of the teaching method, the difficulties they faced during participation, the help that they needed, their satisfaction with the project, the impact of the intervention on their life, health, and other aspects; their comparisons of acupressure and MM in the intervention; other questions associated with the above aspects; and other comments. The data collected in the interviews were digitally audio-recorded, transcribed verbatim for content analysis by a research assistant, and supervised by the corresponding author. The research assistants read the text repeatedly and then summarized the content, looking for meaningful text and assigning codes, and then sorted the codes into groups to generate themes [66 (link)]. When disagreements arose, the authors continued the discussion until consensus was reached.

Convenience sampling was adopted from April 20 to July 1, 2021, to recruit community-dwelling family caregivers of frail older adults from the physical examination center of a grade III–level hospital, which receives 1.72 million annual outpatient visits in Henan province, China. Caregivers were included if they were (1) aged ≥18 years and could understand Chinese, (2) the primary family caregiver of frail older adults (≥60 years) with frailty (a score on the simple frailty questionnaire [FRAIL] of ≥3), (3) providing unpaid caregiving (helping frail older adults with activities of daily life) for at least 14 hours per week [33 (link)], and (4) using WeChat and able to study on mobile phones. Caregivers were excluded if they (1) had contraindications to acupressure or MM (eg, suspected fractures, tumors, tuberculosis, severe heart and lung disease, pregnancy, and infected skin and wounds in the selected region); (2) had an acute psychological problem; and (3) had participated in interventional studies involving acupressure, acupuncture, MM, or other MBI (eg, Tai chi and yoga) within the past 6 months.

Feasibility was defined as 80% completion of the intervention protocol and questionnaires, including daily responses to app-based surveys [58 (link)]. Usability was measured through the System Usability Scale, a 10-item scale used to assess the ease and appropriateness of the use of mobile intervention components. Responses were given on a 5-point Likert scale ranging from 1 (strongly disagree) to 5 (strongly agree).
Fidelity checking was conducted each month during the intervention period based on an intervention fidelity checklist that covered the content of each session. The checklist followed the SA protocol and was reviewed by experienced, qualified TCM specialists. The general areas of focus addressed in this pilot study are summarized in Multimedia Appendix 3. All training sessions were audio-recorded and checked against a fidelity checklist by an independent researcher. An acceptable fidelity rate of >90% was adopted [59 (link)]. Only 1 TCM and 1 MM specialist delivered all MBI sessions to minimize variations in the implementation of interventions.
Participants’ attendance in weekly training sessions and the duration of their home practice were used to determine the adherence rate and duration of the intervention. Information on their frequency of practice and the duration of their daily practice was collected through the use records of meditation software (Meditation Planet, version 2.1.10; Guangzhou Count Sheep Technology Company Limited) and their acupressure diary. The research assistant collected the adherence data weekly. The author conducted a focus group interview with 12 participants from the intervention group. A semistructured interview guide (Multimedia Appendix 4) was used to identify the impacts on the family caregivers, their difficulty in practicing the intervention, their strengths and limitations, and their perceptions of the program and intervention.