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Optimizing Digital Cardiac Rehabilitation Using the Multiphase Optimization Strategy: Mixed Methods Feasibility Study

<strong>Background:</strong> Cardiac rehabilitation (CR) is an evidence-based, multicomponent intervention. However, participation in and reach of CR remain suboptimal globally. Digital CR is a promising alternative to traditional center-based CR, with the potential to increase intervention reach and efficiency. However, efforts to increase the efficiency of digital CR require an understanding of the relative effectiveness of the components of CR, which is currently lacking. The Multiphase Optimization Strategy provides a framework to evaluate the effects of individual components within complex interventions. <strong>Objective:</strong> This mixed methods study explored the feasibility and acceptability of implementing the procedures of a factorial design and delivering multiple intervention components in preparation for an optimization randomized controlled trial of a digital CR intervention. <strong>Methods:</strong> Patients attending CR in a community setting were randomized to 1 of 8 experimental conditions in a 2 × 2 × 2 (2<sup>3</sup>) factorial trial design. Each condition received a different combination of three intervention components over a 6-week study period (1) goal setting and self-monitoring, (2) education, and (3) feedback messages. Feasibility was assessed through intervention fidelity (eg, usage statistics) and outcome measure data completeness. Acceptability was measured using the System Usability Scale, a questionnaire, and semistructured interviews based on the Theoretical Framework of Acceptability. <strong>Results:</strong> A total of 8 participants were recruited and retained in the study. The mean age was 75 (SD 5.6) years, and the majority were female (5/8, 62.5%). The digital CR intervention demonstrated good usability (System Usability Scale score 72.1, SD 19.1), and 83.3% (5/6) of participants found the digital technology acceptable. However, only half (2/4, 50%) found the feedback messages acceptable. Fidelity was high for goal setting/self-monitoring and feedback but lower for education. Qualitative findings indicated that participants held positive attitudes toward the intervention and reported improvements in physical activity, although many expressed a preference for more tailored feedback and 2-way communication. Of the 3 prespecified progression criteria, usability met the “Go” criterion, whereas intervention fidelity, acceptability, and outcome measure data completeness met the “Amend” threshold. <strong>Conclusions:</strong> This study demonstrated the feasibility of implementing a factorial design and delivering multiple intervention components within a digital CR intervention. While the intervention was generally acceptable, modifications to the education and feedback components are necessary prior to conducting a pilot optimization randomized controlled trial.
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SleepPathfinder: A Socratic Questioning and Self-Decision–Based Chatbot to Support User Engagement in Digital CBT-I: Usability and Feasibility Study

Background: Chronic insomnia is a highly prevalent sleep disorder that adversely affects quality of life and mental health. Cognitive behavioral therapy for insomnia (CBT-I) is internationally recommended as the first-line treatment, and digital CBT-I (dCBT-I) has been developed to improve accessibility and scalability. While existing dCBT-I systems effectively support structured behavioral training through standardized protocols, they provide relatively limited support for users’ cognitive exploration and meaning-making processes, particularly in helping users reflect on and internalize the rationale behind CBT-I practices in daily life. These limitations may contribute to challenges in sustained engagement and long-term adherence. Objective: This study aimed to examine the usability and feasibility of SleepPathfinder, a conversational CBT-I support chatbot that integrates Socratic questioning and a self-decision mechanism to support users’ understanding of and engagement with CBT-I practices. Methods: SleepPathfinder was designed around a 4-stage conversational flow: education on CBT-I techniques, Socratic cognitive exploration, self-decision, and advice provision. We conducted (1) a single-session pilot usability study (n=45) to assess system stability and user experience and (2) a 5-day condition-based comparative experiment (n=30) consisting of daily sessions, comparing an exploratory dialogue condition with a directive, protocol-guided dialogue condition. Quantitative measures assessed usability, cognitive appraisals related to sleep problems, autonomy-related experiences, and behavioral readiness, while qualitative feedback and conversational log analyses were used to examine interaction patterns and engagement characteristics. Results: In the comparative experiment, the exploratory dialogue condition showed a tendency toward reduced perceived threat and severity appraisal of sleep problems compared with the directive condition, accompanied by moderate effect sizes in cognitive perception measures. Autonomy-related experiences, including perceived choice and engagement, demonstrated suggestive upward trends in the exploratory condition. Behavioral intention changes were comparable across conditions, while overall readiness for change increased across participants. Conversational log analyses indicated that greater depth and volume of user self-narrative were associated with larger shifts in cognitive appraisals, whereas the frequency of chatbot questions alone was not. The pilot usability study indicated generally positive evaluations of system usability and content credibility, while identifying areas for improvement in emotional responsiveness and conversational naturalness. Conclusions: These findings suggest that a Socratic questioning–based and self-decision–based conversational structure is usable and feasible as a supportive interaction layer within dCBT-I systems. Rather than altering the directive behavioral structure of CBT-I, such an approach may complement existing protocols by facilitating cognitive exploration and supporting user-perceived autonomy. This study provides design-oriented evidence to inform the refinement of dialogue-supported digital CBT-I systems aimed at enhancing user engagement with CBT-I practices.
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New national action plan targets gaps at the intersection of mental health and criminal justice.

FOR IMMEDIATE RELEASE

OTTAWA, ON – The Mental Health Commission of Canada (the Commission) today released “Finding New Pathways: An action plan for criminal justice and mental health in Canada”. The plan provides an evidence-based roadmap to address systemic gaps in care, coordination, and community supports, recognizing the impact of mental health on the criminal justice system.

Many are working to improve outcomes but needs remain high and progress is uneven. This action plan is a practical pan-Canadian reference point that seeks to contribute to the mental health and wellbeing of all individuals who interact with the criminal justice and forensic mental health systems, including those who work within them.

Developed through a rigorous five-year process, the action plan was shaped by input from national subject matter experts, research, and the lived and living experiences of justice-involved individuals and system workers. The action plan comes at a critical time, as individuals experiencing mental health challenges currently comprise roughly three-quarters of all federally incarcerated people in Canada.

“Meaningful and sustainable transformation is within reach for Canada,” said Lili-Anna Pereša, President and CEO of the Mental Health Commission of Canada. “While these transformative changes cannot be implemented overnight or by one group alone, this action plan serves as a starting point. It centralizes evidence-based approaches designed to break the cycle of recidivism and prioritize prevention, diversion, end-to-end supports and continuity of care.” The action plan stands on three strategic pillars:

  • Care, not criminalization: Ensuring all people in Canada have access to supports that help prevent involvement with the criminal justice system, and prioritizing diversion for those with mental illnesses.
  • Care during criminal justice involvement: Providing access to high-quality, trauma-informed, and culturally safe health and social supports for those within the system.
  • Care after criminal justice involvement: continuity of care and seamless integration into community-based mental health
    and substance use services upon release.

“Finding New Pathways” identifies 68 specific recommendations across individual, community, institutional, systemic, and societal levels. It pays particular attention to priority populations, including people from First Nations, Inuit, and Métis, and African, Caribbean, and Black, and other equity-deserving groups who are currently overrepresented in the justice system and face distinct mental health needs.

The action plan further highlights the critical importance of supporting the psychological health and safety of workers within the criminal justice and forensic mental health systems, noting that public safety personnel are significantly more likely to experience symptoms consistent with mental disorders than the general population.

Howard Sapers, current executive director of the Canadian Civil Liberties Association, former Correctional Investigator of Canada, and project advisor for the action plan, emphasized the necessity of these reforms: “ or too long, Canada’s criminal justice system has been asked to shoulder responsibilities it was never designed to carry. The over representation of people with mental health needs in police encounters, courts, and correctional facilities is a predictable consequence of systemic gaps in care, coordination, and community supports. The Mental Health Commission of Canada’s National Action Plan offers something we have been missing for years: a coherent, evidence-based roadmap that prioritizes health, human rights, and dignity.”.

Media Contact:

For English requests, please contact Josie Sabatino at jsabatino@summa.ca; 250-649-6856.

For French requests, please contact Carlene Variyan, cvariyan@summa.ca; 613-601-7456.

About the Mental Health Commission of Canada

The Commission is a national organization committed to recognizing and contributing to a new and equitable relationship with First Peoples, with its head office located on the unceded traditional territory of the Algonquin Anishinaabe Nation in Ottawa.

As an independent, not-for-profit with charitable status, the Commission collaborates with leading experts and organizations nationally and internationally, including with people with lived and living experience, to develop national guidelines, standards and strategies, promote innovation and best practices, reduce stigma, increase mental health literacy, develop and deliver training through our Opening Minds division and support all levels of government to improve mental health outcomes for everyone living in Canada.   

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