Self‐directed self‐management interventions to prevent or address distress in young people with long‐term physical conditions: A rapid review

Abstract Background Comorbid distress in adolescents and young adults with physical long‐term conditions (LTCs) is common but can be difficult to identify and manage. Self‐directed self‐management interventions to reduce distress and improve wellbeing may be beneficial. It is unknown, however, which intervention characteristics are successful in supporting young people. This rapid review aimed to identify characteristics of self‐directed self‐management interventions that aimed, in whole or part, to address distress, wellbeing or self‐efficacy in this population. Methods A systematic search was conducted for relevant controlled studies in six databases. Data on study settings, population, intervention characteristics, outcome measures, process measures and summary effects were extracted. The risk of bias was assessed using the Cochrane Risk of Bias tool v1, and the strength of evidence was rated (informed by Grading of Recommendations, Assessment, Development and Evaluations). Patient and public involvement members supported the review process, including interpretation of results. The rapid review was registered with PROSPERO (ID: CRD42021285867). Results Fourteen studies were included, all of which were randomised trials. Heterogeneity was identified in the health conditions targeted; type of intervention; outcome measures; duration of intervention and follow‐up. Three had distress, wellbeing or self‐efficacy as their primary outcome. Four modes of delivery were identified across interventions—websites, smartphone applications, text messages and workbooks; and within these, 38 individual components. Six interventions had a significant benefit in mental health, wellbeing or self‐efficacy; however, intervention characteristics were similar for beneficial and non‐beneficial interventions. Conclusions There is a paucity of interventions directly targeting distress and wellbeing in young people with physical LTCs. In those identified, the heterogeneity of interventions and study design makes it difficult to identify which characteristics result in positive outcomes. We propose the need for high‐quality, evidence‐based self‐management interventions for this population; including (1) more detailed reporting of intervention design, content and delivery; (2) robust process evaluation; (3) a core outcome set for measuring mental health and wellbeing for self‐management interventions and (4) consistency in follow up periods. Public Contribution Seven young people with an LTC were involved throughout the rapid review, from the development of the review protocol where they informed the focus and aims, with a central role in the interpretation of findings.


| BACKGROUND
Individuals with long-term physical health conditions (LTCs) are at increased risk of experiencing distress and low mood, which, if not appropriately managed, can lead to depression. 1 Distress can be defined as symptoms 'severe enough to warrant consultation', but where clinicians have not diagnosed depression or other mental health conditions. 2 Comorbid distress in individuals with physical LTCs may be particularly problematic in later adolescence and young adulthood, for example, between the ages of 16 and 29, as individuals are also undergoing major life transitions, such as moving away from home, going to college/university or beginning fulltime employment, which can make managing an LTC even more challenging. 3,4rthermore, comorbid mental health problems can be difficult to identify and manage among this population in healthcare settings, where the focus may be on the management of physical symptoms. 5,6terventions targeted at this age group that aim to prevent or reduce comorbid distress are therefore important.Given the increased pressure on healthcare services globally, self-management interventions focused on supporting young people to manage and reduce distress may be particularly beneficial. 7lf-management can be defined as 'the systematic process of learning and practicing skills which enable individuals to manage their health condition on a day-to-day basis, through practicing and adopting specific behaviours which are central to managing their condition, making informed decisions about care, and engaging in healthy behaviours to reduce the physical and emotional impact of their illness'. 8p.93)In keeping with this agenda, self-directed self-management interventions, through which young people develop knowledge and skills to manage their health without the need for ongoing direction from healthcare professionals (HCPs), could help to reduce distress in young people with physical LTCs while also helping to ease the burden on healthcare services. 7,10 is unknown, however, which characteristics of self-management interventions for young people with physical LTCs are successful in reducing distress, as well as improving wellbeing.This is the case both with interventions that directly target these outcomes and those which may have a secondary impact on distress and wellbeing.p.6)Gaining a better understanding of the characteristics and modes of delivery of interventions in this population, particularly those with positive outcomes, is important for informing the development of future research and practice development.
This rapid review aimed to identify characteristics associated with self-directed self-management interventions that aimed, in whole or part, to address distress, wellbeing or self-efficacy in young people with physical LTCs.Self-efficacy was included, as greater selfefficacy has been found to be important for positive mental health and wellbeing in younger people with LTCs. 12We aimed to identify any differences in mode of delivery and intervention components between interventions that did and did not demonstrate positive effects for these outcomes.
The review is part of a larger study-the UK National Institute for Health Research-funded Stoma Support Study, which aims to codesign with young people and HCPs, an intervention to provide support for managing distress in young people with inflammatory CORP ET AL.
| 2165 bowel disease (IBD) who have undergone stoma surgery.This is where all or part of, the large bowel, is removed resulting in an opening in the abdomen through which faeces are collected in a bag attached to the skin.One part of this intervention will be a selfdirected self-management intervention to be used by young people.This builds on earlier work which identified that distress experienced by young people after stoma surgery was often not identified or effectively addressed in healthcare settings, and young people identified a need for age-appropriate online resources to support self-management of stoma-related distress. 6,13This rapid review can therefore inform the future design of self-management interventions for young people with physical LTCs in general, and more specifically, will help to inform the design of a future Stoma Support intervention.

| Patient and public involvement (PPIE)
Central to this rapid review was the role of PPIE.Our PPIE group, which we established purposefully for the associated study linked to this review, was involved at various stages of this rapid review-from the development of the review protocol where PPIE members informed the focus and aims of the review to the interpretation of the review findings.The details of this group and their contributions will be outlined later in Section 2.6.p.211)In this review, we aimed to draw strongly on this experiential expertise to both support the interpretation of the review findings, as well as to draw out their significance and implications.

| METHODS
A rapid review was conducted and reported, informed by Cochrane guidance for rapid reviews, 18 the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidance 2020 19 and Synthesis Without Meta-analysis in systematic reviews reporting guidelines. 20An a priori protocol was written and registered with the International prospective register of systematic reviews (PROSPERO ID: CRD42021285867).The search strategy utilised both subject headings and free text searching, combining terms for self-management, long-term conditions (LTCs), and controlled studies (see Supporting Information:

| Search strategy
File 1 for all database searches).In addition, the reference lists of relevant systematic reviews identified during screening were checked to identify eligible studies.
The results of each search were downloaded into Endnote™ 20 (reference management software; Clarivate Analytics, available at www.endnote.com)to facilitate deduplication, with the resulting unique records being imported into Covidence systematic review software (Veritas Health Innovation, available at www.covidence.org) for screening.

| Eligibility criteria
To be eligible for inclusion, studies needed to be of a controlled design, that is (non-)randomised controlled trials, or other designs with a control group or period (i.e., cohort studies, before-and-after studies or interrupted time series).Studies reporting self-management interventions that were self-directed were included, that is, did not involve HCPs or trained peer input as a routine part of the intervention received by all participants.Group interventions were also excluded.To capture as many self-directed interventions as possible, inclusion criteria were expanded to include studies comparing self-directed self-management to any control, rather than just usual care, no (additional) intervention or with attention control, as stipulated in the protocol.Studies were included if they reported on any self-directed self-management intervention developed for young people (16-29 years old) with long-term physical conditions, which aimed, in whole or part, to prevent or address distress/mental health needs.A scoping search revealed a paucity of studies targeting this age group, and therefore it was decided to include studies where the study population's mean age ±1 standard deviation fell within the age range of interest, or if a subgroup analysis by age was conducted so data on young people could be extracted.
Studies were included if they reported at least one of the primary outcomes of interest (psychological distress including measures of anxiety and depression, well-being including quality of life, and life satisfaction measures, confidence, self-efficacy and knowledge regarding management of distress/mental health/wellbeing).Studies reporting only secondary outcomes of interest (i.e., acceptability, preference and satisfaction), and no primary outcomes were excluded.
Given the time restraints on a rapid review, only Englishlanguage publications were included.

| Study selection
To expedite the review process, N. C. screened all titles and abstracts against eligibility criteria, with the first 150 records independently screened by a second reviewer (B.S.) to check accuracy.The agreement was 90% and after discussion, further refinement of the eligibility criteria was made.All excluded titles and abstracts were also scanned by a second reviewer (B. S. or L. B.) to ensure no studies had been excluded in error.Similarly, full texts were screened by a single reviewer, with all included and excluded full texts checked by a second reviewer.Any disagreements were resolved through discussion.Reasons for exclusion at the full-text stage were recorded.

| Data extraction and risk of bias
A customised data extraction form was developed in Excel, piloted and used to record all data required for analysis.Data from included studies were extracted on: country and healthcare setting; population characteristics; characteristics of the intervention, informed by the TIDieR checklist, 21 such as theories underpinning the intervention, delivery mode and tailoring; outcome measures; process measures (intervention adherence and fidelity) and summary effect estimates were reported.Concurrent with data extraction, the risk of bias was appraised using the Cochrane Risk of Bias tool v1. 22ta extraction was undertaken by one reviewer and checked by a second for correctness and consistency.Discrepancies were resolved through discussion.

| Data analysis and evidence synthesis
The aim of the evidence synthesis was not to estimate the overall effectiveness of self-management interventions and consequently, a meta-analysis was not conducted.Evidence was synthesised narratively and focused on identifying characteristics associated with selfdirected self-management interventions that were demonstrated to have positive effects primarily on the review's outcomes of interest, such as mode of delivery and intervention components.The synthesis began with a description of included study characteristics and main results presented in summary tables.Heterogeneity, that is, variability among studies, was informally assessed with consideration of study designs, intervention characteristics (most notably mode of delivery) and LTC of the study population.
The components making up each intervention were extracted and tabulated to facilitate comparison between different types of intervention and effective versus noneffective interventions.The narrative synthesis explored similarities and differences in the study results in relation to the characteristics of the studies, with particular reference to intervention characteristics, that is, mode of delivery and intervention components, and their methodological quality.
To rate the overall certainty of evidence associated with each intervention characteristic identified, a set of criteria was devised, inspired by the Grading of Recommendations, Assessment, Development and Evaluations methodology. 23This approach considered five factors that influence confidence in the body of evidence, and criteria were devised to identify concerns related to each (Box 1).The overall certainty of evidence for each intervention characteristic was then rated (Box 2).

| PPIE group input in interpreting results
Following the completion of the evidence synthesis, a visual summary of the review process and results were sent to members of the associated study's PPIE group (see Figure 1).A 1-h meeting was then held, via video platform, with seven PPIE members, all of whom had undergone stoma surgery due to IBD.Five members identified as female, and two as male, aged between 19 and 37 years, and lived in a range of regions in England.Initially, two members of the research team, B. S. and K. P., talked through this visual summary and then presented a lay summary of each of the studies included in the review.The research team's analysis was not presented, to ensure that group members did not feel the need to shape their interpretation of the review results according to the research teams'.
Beyond just contributing feedback, the group's input was considered integral to drawing out implications and forming conclusions.The  F I G U R E 1 Visual summary of the review process and results for patient and public involvement.Abbreviations: FAQs, frequently asked question.
PPIE group helped interpret the findings of the review, including the context around why individual interventions either were or were not successful in improving young people's outcomes.The group also had a key role in helping to identify lessons from the findings for future self-directed self-management interventions for young people with LTCs, that is, their answer to the 'so what?' question.More specifically, they helped us to identify the implications of findings for the development of a future self-management intervention to support young people with an IBD stoma.The interpretation of the results by the PPIE group is outlined later in the Discussion (Section 4.2).

| Study flow
The search identified 1944 unique records, of which 176 were included for full-text screening.Of these, 12 met the inclusion criteria and 162 were excluded for the reasons given in Figure 2. A further 21 full texts were assessed for eligibility after being identified from relevant systematic reviews picked up by the original database search.This led to the inclusion of an additional two relevant studies (Figure 2).[26][27][28][29][30][31][32][33][34][35][36][37]

| Characteristics of included studies
The study characteristics of the included studies are detailed in Table 1.There was a high level of heterogeneity in terms of the LTCs under study; type of self-directed self-management intervention; outcome measures and duration of intervention and length of followup.All included studies were either RCTs (n = 11) or pilot RCTs (n = 3).
No studies using other controlled study designs were identified.
Eleven studies (79%) used waitlist, standard care or attention controls, with the remaining three studies having active controls.
Regarding the outcomes of interest to this review, the primary outcomes of psychological distress, well-being and self-efficacy outcomes were each reported in half of the studies (n = 7), while F I G U R E 2 Preferred Reporting Items for Systematic Reviews and Meta-Analyses 2020 flow diagram.From: Page et al. 19 For more information, visit: http://www.prisma-statement.org/.
T A B L E 1 Study characteristics of included trials.secondary outcomes were reported in three studies (satisfaction n = 2, acceptability n = 1, preference n = 0).
Of the 14 interventions identified, only 6 were found to have a significant treatment benefit compared to control with respect to this review's primary outcomes of interest, 24,25,27,30,31,36 however, a further 3 interventions were shown to have a significant treatment benefit on their specified primary outcomes 29,32,33 .

| Intervention characteristics
The  and 3; full details in Supporting Information: File 2).Three interventions incorporated automated elements such as algorithms to manage mobile text messaging, 36 to determine web-based personalised messages, 27 or to provide disease management support and access to the healthcare team if necessary. 30l but two included self-management interventions that were self-directed without any support.Of the two interventions which involved HCPs, neither provided regular, ongoing support.One included an HCP delivering an initial 45 min tutorial on installation and use of the mobile health application 33 (HCP input related to study processes rather than intervention delivery); and the second utilised an HCP to respond to health concerns of individuals when activated via SMS algorithm 30 (HCP contact separate from the main intervention, an optional extra available to the participants but not received routinely).Klee et al. 33 along with two further studies 34,36 introduced study-specific elements which our review team felt had the potential to impact study outcomes so were tentatively considered part of the interventions tested: Klee et al. 33 included a single phone call to participants after 1 month to ensure there were no technical problems and to answer any questions.Given the lack of clarity regarding what these questions concerned, it was deemed possible that outcomes may be affected so was considered integral to the intervention; Lam et al. 34 (p.3) involved a dentist 'to support study adherence', who had received  T A B L E 3 Delivery modes and components of interventions: For each section, these are presented in descending order of frequency of occurrence within interventions across studies.
Ayar et al. 24   Bell et al. 26 Chapman et al. 27 Dilorio et al. 28   Huang et al. 30 Joseph et al. 32   Lam et al. 34 Linden et al. 35 Klee et al. 33   Whiteley et al. 37 Balato et al. 25 Middleton et al. 36   Hockenmeyer and Smyth 29 Hunt et al. 31 Number of studies Intervention (columns) Ayar et al. 24   Bell et al. 26 Chapman et al. 27 Dilorio et al. 28   Huang et al. 30 Joseph et al. 32   Lam et al. 34 Linden et al. 35 Klee et al. 33   Whiteley et al. 37 Balato et al. 25 Middleton et al. 36   Hockenmeyer and Smyth 29 Hunt et al. 31 Number of studies Intervention (columns)  Bell et al. 26 Chapman et al. 27 Dilorio et al. 28   Huang et al. 30 Joseph et al. 32   Lam et al. 34 Linden et al. 35 Klee et al. 33   Whiteley et al. 37 Balato et al. 25 Middleton et al. 36   Hockenmeyer and Smyth 29 Hunt et al. 31 Number of studies Intervention (columns)  Bell et al. 26 Chapman et al. 27 Dilorio et al. 28   Huang et al. 30 Joseph et al. 32   Lam et al. 34 Linden et al. 35 Klee et al. 33   Whiteley et al. 37 Balato et al. 25 Middleton et al. 36   Hockenmeyer and Smyth 29 Hunt et al. 31 Number of studies Intervention (columns)  Bell et al. 26 Chapman et al. 27 Dilorio et al. 28   Huang et al. 30 Joseph et al. 32   Lam et al. 34 Linden et al. 35 Klee et al. 33   Whiteley et al. 37 Balato et al. 25 Middleton et al. 36   Hockenmeyer and Smyth 29 Hunt et al. 31 Number of studies Intervention (columns)  T A B L E 4 Overall certainty of evidence for intervention characteristics.Characteristics in italics involved in sensitivity analysis, where studies where the characteristic was not intended to be part of the self-directed intervention i.e. was specific to study only, were excluded and overall certainty of evidence reassessed (any changes to individual concerns and overall certainty are indicated).
interventions tested in trials on quality of life, self-management skills and self-efficacy in people with a bowel stoma. 40 behavioural change and that it can take around 10 weeks to develop 'daily habits'. 41en discussing lessons from the findings for the development of the future Stoma Support intervention, the group felt that selfmanagement workbooks may be beneficial, suggesting value in being able to work through information at their own pace, in a logical order.
A workbook intervention was used in two studies in the review, 29,31 and was found to have a positive impact on psychological distress in Hunt et al., 31 who tested an intervention for young people with IBD.
The group suggested this could be an online or physical workbook or a choice between the two.The group felt that a website or smartphone app could be beneficial for managing distress related to stoma surgery but did not feel that unsolicited text messages would be beneficial.Text messages were used in four interventions included in the review 25,30,36,37 ; three of which were found to be beneficial, though two of these combined text messages with other modes of delivery.Members of our PPIE group also suggested that receiving text messages may become irritating and are likely to be deleted, though they were more positive about receiving personalised rather than generic messages.Personalised messages were used by Chapman et al. in an intervention for individuals with IBD (though these were online rather than text messages), which had positive outcomes for psychological distress and wellbeing. 27The group felt that this tailoring of messages to focus on things important to participants might explain the positive outcomes of this trial.Overall, the ability to individualise and for interventions to be self-directed was seen as positive.
An intervention component that was highlighted as potentially beneficial was CBT techniques, which were explicitly incorporated in two of the interventions in the review. 29,31Members of the PPIE group felt that for people with an IBD stoma, the focus on psychological therapies and targeting emotions would be particularly beneficial, alongside being able to learn and use these techniques as part of a self-directed self-management intervention.

| Implications for future design and testing of self-directed self-management interventions
A key finding in this rapid review is the paucity of interventions directly targeting distress and wellbeing in young people with physical LTCs.Six of the included studies targeted condition-specific outcomes, with mental health, wellbeing and self-efficacy being secondary outcomes, and five did not clearly specify the difference between their primary and secondary outcomes.Only 3 of the 14 studies explicitly targeted mental health, wellbeing and/or selfefficacy as a primary outcome.Given the well-established psychological impact of long-term physical illness on mental health and wellbeing in this population, 42 there is clearly a need for the development of high-quality, evidence-based self-management interventions for this population that target mental health and wellbeing as primary outcomes.
In the review, we identified a lack of consistency in the way self- | 2187 intervention components are operationalised and delivered.This would allow for a clearer picture of whether individual components led to improved outcomes, or whether this was down to how they were designed and delivered.This was a point raised in the discussion by our PPIE group, which has also been expressed elsewhere in the literature. 17Linked to this, and in line with UK Medical Research Council guidance, 43 there is the need for robust process evaluations within trials of self-management interventions, including qualitative research that explores participants' experiences and perceptions of which components and modes of delivery were acceptable and felt to be most beneficial.
In to intervention evaluation, there is a need for the development of a core outcome set for measuring mental health and wellbeing outcomes in this population, that would allow for comparison in evaluating trial results.This would be a useful area for future research.Consistency is also needed in the time period for measuring outcomes, another point that was highlighted by our PPIE group.We would suggest the incorporation of PPIE input in deciding follow-up periods; our PPIE group highlighted 12 weeks as a minimum time period in their experience, to bring about meaningful change.

| Strengths and limitations
A clear strength of this review was the inclusion of PPIE members in helping to interpret the review findings and drawing out the key implications.p.1)A limitation of the study is that the shorter timeframe for this rapid review when compared to a traditional systematic review meant that we were unable to include articles not written in English, and as a result may have excluded potentially relevant articles.

| CONCLUSION
We have found a lack of studies testing self-directed self-management interventions for young people with physical LTCs that directly target mental health and wellbeing outcomes.In those that were identified, it was not possible to conclude which components or modes of delivery resulted in beneficial outcomes.However,

A
comprehensive search strategy was designed and conducted by an information specialist (N.C.) to identify eligible studies.Six electronic bibliographic databases were searched: MEDLINE (OVID), EMBASE (OVID), Cochrane CENTRAL, HMIC (OVID), CINAHLPlus (EBSCO) and PsycINFO (EBSCO) from database inception to 18 October 2021.

BOX 1
Concerns relating to five factors influencing confidence primary mode of delivery for self-management interventions was web-based (n = 8), with the remaining interventions' main mode of delivery equally distributed between mobile device apps (n = 2), text messages (n = 2) and workbooks (n = 2).However, most interventions utilised multiple modes of delivery (n = 9) which included one or more of the following additional modes: web-based group/peer discussion; phone calls; emails; text messages; audiovisual recordings; an initial face-to-face meeting and a complementary workbook (see Tables 2

2 -
day training on internet-based cognitive behavioural therapy (CBT) to provide email, phone or asynchronous chat support to individuals with chronic temporomandibular pain disorder.While Middleton et al. 36 introduced a study-specific SMS portal where participants had the option to send questions about diabetes and its management to the study team which included healthcare professionals.When synthesising the findings, these specific intervention characteristics were included in a sensitivity analysis to establish what if any effect their inclusion/exclusion had on the overall strength of evidence (see below).T A B L E 1 (Continued)

2 1
Mode used as both primary and secondary modes across interventionsText messageNumber of modes utilised for interventionCombination of modes Abbreviations: CBT, cognitive behavioural therapy; CF, cystic fibrosis; HCP, healthcare professional; IBD, inflammatory bowel disease; T1DM, type 1 diabetes mellites; T2DM, type 2 diabetes mellites; TMD, temporomandibular disorder; WebEase, Web Epilepsy Awareness, Support and Education.aPrimary mode.bIntervention intended to be used without guidance, during the study only, the support provided (to aid study adherence).
management interventions for young people with physical LTCs have been developed and evaluated, which may be in part due to the variation in conditions targeted.This presents challenges in developing a core body of evidence to guide the design of future interventions for this population.One way of addressing this can be through more detailed and transparent reporting of intervention design, content and delivery which could help with future intervention design by allowing a more thorough assessment of how CORP ET AL.
significant incorporation of PPIE input enabled the development of future recommendations, including the need for more detailed and transparent reporting of self-management intervention design, content and delivery and robust process evaluation to enable a better understanding of which components and modes of delivery brought about change.Additionally, there is a need for a core outcome set for measuring mental health and wellbeing outcomes in relation to self-management interventions in this population, and consistency in follow-up periods.These findings can have implications for future research and intervention design and will also inform the next stages of the Stoma Support Study in which we will work with young people with a stoma and healthcare professionals to co-design the content and format of a self-management intervention for young people with an IBD stoma.
Underlined intervention-indicates a significant intervention effect on outcomes of interest compared to control.Underlined outcome-indicates outcome where significant treatment effect detected (p < .05).Abbreviations: ART, antiretroviral treatment; BMI, body mass index; BMQ, Beliefs about Medicine Questionnaire; BSA, body surface area; FEV1, forced expiratory volume in the first second; GSRS, Gastrointestinal Symptom Rating Scale; HADS, Hospital Anxiety and Depression Scale; HBI, Harvey-Bradshaw Index; IPQ, Brief Illness Perception Questionnaire; IQR, interquartile range; LSSS-3, Liverpool Seizure Severity Scale; MARS, Medication Adherence Report Scale; n, sample size at randomisation; NR, not reported; PAM, Patient Activation Measure; PASI, Psoriasis Area and Severity Index; PGA, Physicians Global Assessment; PSM, Perceived Sensitivity to Effects of Medicines; QoL, Quality of life; RCT, randomised controlled trial; SAPASI, Self-Administered Psoriasis Area Severity Index; SD, standard deviation; SIBDQ, Short Inflammatory Bowel Disease Questionnaire; SIMS AU, Satisfaction with Information about Medicines Action and Usage Subscale; SIMS PP, Satisfaction with Information about Medicines Potential Problems Subscale; SM, self-management; SOC-13, 13-item Sense of Coherence Questionnaire; TRAQ, Transition Readiness Assessment Questionnaire; VASA, Adherence Visual Analogue deviation estimated from median and range or IQR after Luo et al 2018 and Wan et al 2014, respectively, using https://www.math.hkbu.edu.hk/~tongt/papers/median2mean.html.Italicised modes of delivery/intervention providers indicate an element reported as specific to the study rather than integral to the intervention itself.Abbreviations: CBT, cognitive behavioural therapy; CF, cystic fibrosis; IBD, inflammatory bowel disease; mHealth apps, mobile health applications; N/A, not applicable; NR, not reported; QoL, quality of life; SM, self-management; SMS, short message service; T1DM, type I diabetes mellitus; T2DM, type II diabetes mellitus; TMD, temporomandibular disorder; WebEase, Web Epilepsy Awareness, Support and Education.
a Mean and standard b Primary study outcomes.c Significance regarding proportion of individuals recording favourable change in score from baseline, not actual/change in score.CORP ET AL. | 2173 T A B L E 2 Characteristics of interventions.