Measuring Adherence Within a Self-Guided Online Intervention for Depression and Anxiety: Secondary Analyses of a Randomized Controlled Trial

BACKGROUND: Self-guided online interventions offer users the ability to participate in an intervention at their own pace and address some traditional service barriers (eg, attending in-person appointments, cost). However, these interventions suffer from high dropout rates, and current literature provides little guidance for defining and measuring online intervention adherence as it relates to clinical outcomes. OBJECTIVE: This study aims to develop and test multiple measures of adherence to a specific self-guided online intervention, as guided by best practices from the literature. METHODS: We conducted secondary analyses on data from a randomized controlled trial of an 8-week online cognitive behavioral program that targets depression and anxiety in college students. We defined multiple behavioral and attitudinal adherence measures at varying levels of effort (ie, low, moderate, and high). Linear regressions were run with adherence terms predicting improvement in the primary outcome measure, the 21-item Depression, Anxiety, and Stress Scale (DASS-21). RESULTS: Of the 947 participants, 747 initiated any activity and 449 provided posttest data. Results from the intent-to-treat sample indicated that high level of effort for behavioral adherence significantly predicted symptom change (F4,746=17.18, P<.001; and β=–.26, P=.04). Moderate level of effort for attitudinal adherence also significantly predicted symptom change (F4,746=17.25, P<.001; and β=–.36, P=.03). Results differed in the initiators-only sample, such that none of the adherence measures significantly predicted symptom change (P=.09-.27). CONCLUSIONS: Our findings highlight the differential results of dose-response models testing adherence measures in predicting clinical outcomes. We summarize recommendations that might provide helpful guidance to future researchers and intervention developers aiming to investigate online intervention adherence. TRIAL REGISTRATION: ClinicalTrials.gov NCT04361045; https://clinicaltrials.gov/ct2/show/NCT04361045