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| ID | Type | Description | Link |
|---|---|---|---|
| R00AA026317 | U.S. NIH Grant/Contract | View source |
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| Name | Class |
|---|---|
| National Institute on Alcohol Abuse and Alcoholism (NIAAA) | NIH |
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Sexual assault victimization is a common and particularly harmful form of trauma that is associated with increased risk for high-risk drinking and other conditions of public health concern, such as PTSD. Given evidence that sexual assault survivors who have low social support or receive negative social reactions to sexual assault disclosure are more likely to experience PTSD and drinking problems, improving social support is a novel target for intervention. The proposed study will attempt to prevent the onset of high-risk drinking and PTSD in sexual assault survivors by developing and testing a web-based early intervention aimed at increasing contact with social supporters and mitigating the harm of negative social reactions; ultimately, results will contribute to advancing the field's understanding of the potential for social support to mitigate the harm of trauma.
This study involves developing, modifying, and preliminarily testing an intervention to prevent high-risk drinking and PTSD in women who have experienced sexual assault (SA) in the past 10 weeks. In the pilot trial phase of this study, intervention feasibility will be tested in an open trial with N = 40 women with past-10-week SA histories, active drinking, and elevated distress. Participants will complete surveys at baseline, termination, and 3-month follow-up. Participants will be randomized to either the intervention (N = 20) or assessment-only control (N = 20). We hypothesize that (H1) most participants will respond positively on items assessing satisfaction with the intervention, (H2) participants will report above-average usability on a standardized measure, (H3) completion rates for daily activities will be similar to previous web-based interventions, (H4) participants will show significant learning as evidenced by increases in correct responses to knowledge questions from baseline to post, and (H5) participants in the intervention condition will evidence less high-risk drinking and PTSD at 3-month follow-up than participants in the assessment-only condition.
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| Label | Type | Description | Intervention Names |
|---|---|---|---|
| Intervention | Experimental | The THRIVE app involves 3 weeks of daily activities. Day 1 involves identification of activities to add to a "self-care activity list" with guidance around selecting activities that increase social contact, reduce alcohol use, and reduce avoidance. They will also complete an active-learning exercise about cognitive distortions and create a "stuck point to-do list" consisting of their cognitive distortions. In subsequent days, participants will be prompted to complete activities from both lists. They will also have access optional activities on topics such as asking for help, preventing isolation, deciding whether to disclose an assault, coping with negative reactions to disclosure, and thinking in helpful ways about social support. They will be prompted to complete brief daily surveys in the app, which will populate a symptom tracker. Participants in will have brief weekly phone contact with a coach to monitor safety and troubleshoot issues with app use. |
|
| Assessment-only control | No Intervention | The assessment-only control condition will involve access to a version of the app that includes daily surveys and a symptom tracker populated by these surveys, but without any of the other exercises included in the experimental version of the app. Participants in the control condition will have brief weekly phone contact with a coach to monitor safety and troubleshoot issues with app use. |
| Name | Type | Description | Arm Group Labels | Other Names |
|---|---|---|---|---|
| App-based intervention | Behavioral | A app-based cognitive-behavioral intervention to prevent the development of PTSD and high-risk drinking in recently-victimized adults |
|
| Measure | Description | Time Frame |
|---|---|---|
| Problem Drinking Scores at Baseline and 3 Weeks | Sum scores on Rutgers Alcohol Problem Index- Short Form (RAPI-S), which assesses alcohol use consequences. Range: 0-64; higher scores indicate worse outcome. | Baseline, post-intervention (3 weeks after baseline) |
| Problem Drinking Scores at Baseline and 3 Months | Sum scores on Rutgers Alcohol Problem Index- Short Form (RAPI-S), which assesses alcohol use consequences. Range: 0-64; higher scores indicate worse outcome. | Baseline, 3 month follow-up |
| Posttraumatic Stress Symptom Severity Score at Baseline and 3 Weeks | Sum scores on the Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders-5 (PCL-5), which assesses posttraumatic stress symptom severity. Range: 0-80; higher scores indicate worse outcome. | Baseline, post-intervention (3 weeks after baseline) |
| Posttraumatic Stress Symptom Severity Score at Baseline and 3 Months | Sum scores on the Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders-5 (PCL-5), which assesses posttraumatic stress symptom severity. Range: 0-80; higher scores indicate worse outcome. | Baseline, 3 month follow-up |
| Measure | Description | Time Frame |
|---|---|---|
| Anxiety | Sum scores on Generalized Anxiety Disorder-7 (GAD-7), which assesses symptoms of anxiety. Range: 0-21; higher scores indicate worse outcome. | Baseline, post-intervention (3 weeks after baseline), 3 month follow-up |
| Coping Self-efficacy |
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Inclusion Criteria:
Exclusion Criteria:
Participants who self-identify as female are eligible to participate.
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| Name | Affiliation | Role |
|---|---|---|
| Emily Dworkin, PhD | University of Washington | Principal Investigator |
| Facility | Status | City | State | ZIP | Country | Contacts |
|---|---|---|---|---|---|---|
| University of Washington School of Medicine | Seattle | Washington | 98105 | United States |
| PubMed Identifier | Type | Citation | Retractions |
|---|---|---|---|
| 38376992 | Derived | Howe ES, Dworkin ER. The day-to-day relationship between posttraumatic stress symptoms and social support after sexual assault. Eur J Psychotraumatol. 2024;15(1):2311478. doi: 10.1080/20008066.2024.2311478. Epub 2024 Feb 20. | |
| 37795783 | Derived | O'Doherty L, Whelan M, Carter GJ, Brown K, Tarzia L, Hegarty K, Feder G, Brown SJ. Psychosocial interventions for survivors of rape and sexual assault experienced during adulthood. Cochrane Database Syst Rev. 2023 Oct 5;10(10):CD013456. doi: 10.1002/14651858.CD013456.pub2. |
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Participants were considered to be enrolled in the study once they provided informed consent at baseline. They completed the baseline assessment to confirm eligibility. Participants found to be eligible at baseline were automatically randomized.
Participants were recruited from January 13th, 2021 to August 24th, 2021 via mass emails sent to registered students at the University of Washington, flyers, social media ads, and provider referrals.
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| ID | Title | Description |
|---|---|---|
| FG000 | Intervention | Participants in the intervention condition completed 3 weeks of daily activities and symptom self-monitoring in the THRIVE app. Day 1 involved identification of activities to add to a "self-care activity list" with guidance around selecting activities that increase social contact, reduce alcohol use, and reduce avoidance. They also completed an active-learning exercise about cognitive distortions and created a "stuck point to-do list" consisting of their cognitive distortions. In subsequent days, participants were prompted to complete activities from both lists. They also had access to optional activities on topics such as asking for help, preventing isolation, deciding whether to disclose an assault, coping with negative reactions to disclosure, and thinking in helpful ways about social support. They were prompted to complete brief daily surveys in the app, which populated a symptom tracker. Participants had brief weekly phone contact with a coach to monitor safety and troubleshoot issues with app use. |
| FG001 | Assessment-only Control | Participants in the control condition completed 3 weeks symptom self-monitoring. They had access to a version of the app that included daily surveys and a symptom tracker populated by these surveys, but without any of the other exercises included in the experimental version of the app. Participants had brief weekly phone contact with a coach to monitor safety and troubleshoot issues with app use. |
| Title | Milestones | Reasons Not Completed | ||||||||||||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Overall Study |
|
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| ID | Title | Description |
|---|---|---|
| BG000 | Intervention | Participants in the intervention condition completed 3 weeks of daily activities and symptom self-monitoring in the THRIVE app. Day 1 involved identification of activities to add to a "self-care activity list" with guidance around selecting activities that increase social contact, reduce alcohol use, and reduce avoidance. They also completed an active-learning exercise about cognitive distortions and created a "stuck point to-do list" consisting of their cognitive distortions. In subsequent days, participants were prompted to complete activities from both lists. They also had access to optional activities on topics such as asking for help, preventing isolation, deciding whether to disclose an assault, coping with negative reactions to disclosure, and thinking in helpful ways about social support. They were prompted to complete brief daily surveys in the app, which populated a symptom tracker. Participants had brief weekly phone contact with a coach to monitor safety and troubleshoot issues with app use. App-based intervention: A app-based cognitive-behavioral intervention to prevent the development of PTSD and high-risk drinking in recently-victimized adults |
| Units | Counts |
|---|---|
| Participants |
|
| Title | Description | Population Description | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Denominator Units Selected | Denominators | Classes |
|---|---|---|---|---|---|---|---|---|---|
| Age, Categorical | Count of Participants |
| Type | Title | Description | Population Description | Reporting Status | Anticipated Posting Date | Parameter Type | Dispersion Type | Unit of Measure | Calculate Percentage | Time Frame | Units Analyzed | Denominator Units Selected | Arm/Group Information | Denominators | Classes | Analyses | |||
|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
| Primary | Problem Drinking Scores at Baseline and 3 Weeks | Sum scores on Rutgers Alcohol Problem Index- Short Form (RAPI-S), which assesses alcohol use consequences. Range: 0-64; higher scores indicate worse outcome. | Missing data are present at post-intervention | Posted | Mean | Standard Deviation | score on a scale | Baseline, post-intervention (3 weeks after baseline) |
|
3 months
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| ID | Title | Description | Deaths (Affected) | Deaths (At Risk) | Serious Events (Affected) | Serious Events (At Risk) | Other Events (Affected) | Other Events (At Risk) |
|---|---|---|---|---|---|---|---|---|
| EG000 | Intervention | Participants in the intervention condition completed 3 weeks of daily activities and symptom self-monitoring in the THRIVE app. Day 1 involved identification of activities to add to a "self-care activity list" with guidance around selecting activities that increase social contact, reduce alcohol use, and reduce avoidance. They also completed an active-learning exercise about cognitive distortions and created a "stuck point to-do list" consisting of their cognitive distortions. In subsequent days, participants were prompted to complete activities from both lists. They also had access to optional activities on topics such as asking for help, preventing isolation, deciding whether to disclose an assault, coping with negative reactions to disclosure, and thinking in helpful ways about social support. They were prompted to complete brief daily surveys in the app, which populated a symptom tracker. Participants had brief weekly phone contact with a coach to monitor safety and troubleshoot issues with app use. App-based intervention: A app-based cognitive-behavioral intervention to prevent the development of PTSD and high-risk drinking in recently-victimized adults |
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| Title | Organization | Phone | Extension | |
|---|---|---|---|---|
| Dr. Emily R. Dworkin | University of Washington School of Medicine | 206-221-6932 | edworkin@uw.edu |
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| Type | Includes Protocol | Includes SAP | Includes ICF | Document Label | Document Date | Document Uploaded Date | Document File Name |
|---|---|---|---|---|---|---|---|
| Prot_SAP_ICF | Yes | Yes | Yes | Study Protocol, Statistical Analysis Plan, and Informed Consent Form | Oct 21, 2022 | Oct 21, 2022 | Prot_SAP_ICF_000.pdf |
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| ID | Term |
|---|---|
| D013313 | Stress Disorders, Post-Traumatic |
| D000437 | Alcoholism |
| ID | Term |
|---|---|
| D040921 | Stress Disorders, Traumatic |
| D000068099 | Trauma and Stressor Related Disorders |
| D001523 | Mental Disorders |
| D019973 | Alcohol-Related Disorders |
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|
Mean scores on the Trauma Coping Self-Efficacy Scale (CSE-T), which assesses one's perceived ability to manage the demands of recovering from a potentially-traumatic event. Range: 1 to 7; higher scores indicate better outcome.
| Baseline, post-intervention (3 weeks after baseline), 3 month follow-up |
| Depression | Sum scores on the Patient Health Questionnaire-8 (PHQ-8), which assesses symptoms of depression. Range: 0-24; higher scores indicate worse outcome. | Baseline, post-intervention (3 weeks after baseline), 3 month follow-up |
| Alcohol Consumption (Quantity) | Number of drinks per week reported on the Daily Drinking Questionnaire | Baseline, post-intervention (3 weeks after baseline), 3 month follow-up |
| Alcohol Consumption (Frequency) | Number of drinking days per week reported on the Daily Drinking Questionnaire | Baseline, post-intervention (3 weeks after baseline), 3 month follow-up |
| Alcohol Consumption (Hours) | Hours spent drinking per week reported on the Daily Drinking Questionnaire | Baseline, post-intervention (3 weeks after baseline), 3 month follow-up |
| 37402144 | Derived | Dworkin ER, Schallert M, Lee CM, Kaysen D. mHealth Early Intervention to Reduce Posttraumatic Stress and Alcohol Use After Sexual Assault (THRIVE): Feasibility and Acceptability Results From a Pilot Trial. JMIR Form Res. 2023 Jul 4;7:e44400. doi: 10.2196/44400. |
| 37011153 | Derived | Dworkin ER, Schallert M, Lee CM, Kaysen D. Pilot randomized clinical trial of an app-based early intervention to reduce PTSD and alcohol use following sexual assault. Psychol Trauma. 2024 Dec;16(Suppl 3):S668-S678. doi: 10.1037/tra0001460. Epub 2023 Apr 3. |
| BG001 | Assessment-only Control | Participants in the control condition completed 3 weeks symptom self-monitoring. They had access to a version of the app that included daily surveys and a symptom tracker populated by these surveys, but without any of the other exercises included in the experimental version of the app. Participants had brief weekly phone contact with a coach to monitor safety and troubleshoot issues with app use. |
| BG002 | Total | Total of all reporting groups |
| Participants |
|
| Age, Continuous | Mean | Standard Deviation | years |
|
| Sex: Female, Male | Count of Participants | Participants |
|
| Ethnicity (NIH/OMB) | Count of Participants | Participants |
|
| Race (NIH/OMB) | Count of Participants | Participants |
|
| Race and Ethnicity Not Collected | Race and Ethnicity were not collected from any participant. | Count of Participants | Participants |
|
| Region of Enrollment | Number | participants |
|
| OG001 | Assessment-only Control | Participants in the control condition completed 3 weeks symptom self-monitoring. They had access to a version of the app that included daily surveys and a symptom tracker populated by these surveys, but without any of the other exercises included in the experimental version of the app. Participants had brief weekly phone contact with a coach to monitor safety and troubleshoot issues with app use. |
|
|
|
| Primary | Problem Drinking Scores at Baseline and 3 Months | Sum scores on Rutgers Alcohol Problem Index- Short Form (RAPI-S), which assesses alcohol use consequences. Range: 0-64; higher scores indicate worse outcome. | Missing data are present at 3 months | Posted | Mean | Standard Deviation | score on a scale | Baseline, 3 month follow-up |
|
|
|
|
| Primary | Posttraumatic Stress Symptom Severity Score at Baseline and 3 Weeks | Sum scores on the Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders-5 (PCL-5), which assesses posttraumatic stress symptom severity. Range: 0-80; higher scores indicate worse outcome. | Missing data are present at post-intervention | Posted | Mean | Standard Deviation | score on a scale | Baseline, post-intervention (3 weeks after baseline) |
|
|
|
|
| Primary | Posttraumatic Stress Symptom Severity Score at Baseline and 3 Months | Sum scores on the Posttraumatic Stress Disorder Checklist for the Diagnostic and Statistical Manual of Mental Disorders-5 (PCL-5), which assesses posttraumatic stress symptom severity. Range: 0-80; higher scores indicate worse outcome. | Missing data are present at 3 months | Posted | Mean | Standard Deviation | score on a scale | Baseline, 3 month follow-up |
|
|
|
|
| Secondary | Anxiety | Sum scores on Generalized Anxiety Disorder-7 (GAD-7), which assesses symptoms of anxiety. Range: 0-21; higher scores indicate worse outcome. | Missing data are present at post-intervention and 3 months | Posted | Mean | Standard Deviation | score on a scale | Baseline, post-intervention (3 weeks after baseline), 3 month follow-up |
|
|
|
|
| Secondary | Coping Self-efficacy | Mean scores on the Trauma Coping Self-Efficacy Scale (CSE-T), which assesses one's perceived ability to manage the demands of recovering from a potentially-traumatic event. Range: 1 to 7; higher scores indicate better outcome. | Missing data are present at post-intervention and 3 months | Posted | Mean | Standard Deviation | score on a scale | Baseline, post-intervention (3 weeks after baseline), 3 month follow-up |
|
|
|
|
| Secondary | Depression | Sum scores on the Patient Health Questionnaire-8 (PHQ-8), which assesses symptoms of depression. Range: 0-24; higher scores indicate worse outcome. | Missing data are present at post-intervention and 3 months | Posted | Mean | Standard Deviation | score on a scale | Baseline, post-intervention (3 weeks after baseline), 3 month follow-up |
|
|
|
|
| Secondary | Alcohol Consumption (Quantity) | Number of drinks per week reported on the Daily Drinking Questionnaire | Missing data are present at post-intervention and 3 months | Posted | Mean | Standard Deviation | drinks per week | Baseline, post-intervention (3 weeks after baseline), 3 month follow-up |
|
|
|
|
| Secondary | Alcohol Consumption (Frequency) | Number of drinking days per week reported on the Daily Drinking Questionnaire | Missing data are present at post-intervention and 3 months | Posted | Mean | Standard Deviation | drinking days per week | Baseline, post-intervention (3 weeks after baseline), 3 month follow-up |
|
|
|
|
| Secondary | Alcohol Consumption (Hours) | Hours spent drinking per week reported on the Daily Drinking Questionnaire | Missing data are present at post-intervention and 3 months | Posted | Mean | Standard Deviation | drinking hours per week | Baseline, post-intervention (3 weeks after baseline), 3 month follow-up |
|
|
|
|
| 0 |
| 20 |
| 0 |
| 20 |
| 0 |
| 20 |
| EG001 | Assessment-only Control | Participants in the control condition completed 3 weeks symptom self-monitoring. They had access to a version of the app that included daily surveys and a symptom tracker populated by these surveys, but without any of the other exercises included in the experimental version of the app. Participants had brief weekly phone contact with a coach to monitor safety and troubleshoot issues with app use. | 0 | 21 | 0 | 21 | 0 | 21 |
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| D019966 | Substance-Related Disorders |
| D064419 | Chemically-Induced Disorders |
| Unknown or Not Reported |
|
| Native Hawaiian or Other Pacific Islander |
|
| Black or African American |
|
| White |
|
| More than one race |
|
| Unknown or Not Reported |
|
| 3 months |
|
|
| Cohen's D |
| -0.01 |
| 2-Sided |
Between-group Cohen's d; calculated as within-group d(intervention) - within group d(control). Standardized using the standard deviation of the change scores. Negative values favor intervention and positive values favor control. |
| Superiority |
| Post-intervention |
|
|
| Cohen's D |
| -0.15 |
| 2-Sided |
Between-group Cohen's d; calculated as within-group d(intervention) - within group d(control). Standardized using the standard deviation of the change scores. Negative values favor intervention and positive values favor control. |
| Superiority |
| 3 months |
|
|
| Cohen's D |
| -0.70 |
| 2-Sided |
Between-group Cohen's d; calculated as within-group d(intervention) - within group d(control). Standardized using the standard deviation of the change scores. Negative values favor intervention and positive values favor control. |
| Superiority |
| Post-intervention |
|
|
| 3 months |
|
|
Baseline to 3 months |
| Mixed Models Analysis |
| .64 |
| Slope |
| -0.90 |
| Standard Error of the Mean |
| 1.90 |
| 2-Sided |
3 month condition x time interaction coefficient from mixed-effect model using negative binomial distribution. Intervention = 1 and control = 0. |
| Superiority |
| Baseline to post-intervention only | Cohen's D | -0.10 | 2-Sided | Post-intervention between-group Cohen's d; calculated as within-group d(intervention) - within group d(control). Standardized using the standard deviation of the change scores. Negative values favor intervention and positive values favor control. | Superiority |
| Baseline to 3 months | Cohen's D | 0.02 | 2-Sided | 3 month between-group Cohen's d; calculated as within-group d(intervention) - within group d(control). Standardized using the standard deviation of the change scores. Negative values favor intervention and positive values favor control. | Superiority |
| Post-intervention |
|
|
| 3 months |
|
|
Baseline to 3 months |
| Mixed Models Analysis |
| .34 |
| Slope |
| 0.29 |
| Standard Error of the Mean |
| 0.30 |
| 2-Sided |
3 month condition x time interaction coefficient from mixed-effect model using negative binomial distribution. Intervention = 1 and control = 0. |
| Superiority |
| Baseline to post-intervention only | Cohen's D | 0.92 | 2-Sided | Post-intervention between-group Cohen's d; calculated as within-group d(intervention) - within group d(control). Standardized using the standard deviation of the change scores. Positive values favor intervention and negative values favor control. | Superiority |
| Baseline to 3 months | Cohen's D | 0.68 | 2-Sided | 3 month between-group Cohen's d; calculated as within-group d(intervention) - within group d(control). Standardized using the standard deviation of the change scores. Positive values favor intervention and negative values favor control. | Superiority |
| Post-intervention |
|
|
| 3 months |
|
|
Baseline to 3 months |
| Mixed Models Analysis |
| .24 |
| Slope |
| -1.94 |
| Standard Error of the Mean |
| 1.64 |
| 2-Sided |
3 month condition x time interaction coefficient from mixed-effect model using negative binomial distribution. Intervention = 1 and control = 0. |
| Superiority |
| Baseline to post-intervention only | Cohen's D | -0.41 | 2-Sided | Post-intervention between-group Cohen's d; calculated as within-group d(intervention) - within group d(control). Standardized using the standard deviation of the change scores. Negative values favor intervention and positive values favor control. | Superiority |
| Baseline to 3 months | Cohen's D | -0.23 | 2-Sided | 3 month between-group Cohen's d; calculated as within-group d(intervention) - within group d(control). Standardized using the standard deviation of the change scores. Negative values favor intervention and positive values favor control. | Superiority |
| Post-intervention |
|
|
| 3 months |
|
|
Baseline to 3 months |
| Mixed Models Analysis |
| .96 |
| Slope |
| 0.01 |
| Standard Error of the Mean |
| 0.25 |
| 2-Sided |
3 month condition x time interaction coefficient from mixed-effect model using negative binomial distribution. Intervention = 1 and control = 0. |
| Superiority |
| Baseline to post-intervention only | Cohen's D | -0.15 | 2-Sided | Post-intervention between-group Cohen's d; calculated as within-group d(intervention) - within group d(control). Standardized using the standard deviation of the change scores. Negative values favor intervention and positive values favor control. | Superiority |
| Baseline to 3 months | Cohen's D | 0.003 | 2-Sided | 3 month between-group Cohen's d; calculated as within-group d(intervention) - within group d(control). Standardized using the standard deviation of the change scores. Negative values favor intervention and positive values favor control. | Superiority |
| 3 months |
|
Baseline to 3 months |
| Mixed Models Analysis |
| .64 |
| Slope |
| -0.12 |
| Standard Error of the Mean |
| 0.27 |
| 2-Sided |
3 month condition x time interaction coefficient from mixed-effect model using negative binomial distribution. Intervention = 1 and control = 0. |
| Superiority |
| Baseline to post-intervention only | Cohen's D | -0.12 | 2-Sided | Post-intervention between-group Cohen's d; calculated as within-group d(intervention) - within group d(control). Standardized using the standard deviation of the change scores. Negative values favor intervention and positive values favor control. | Superiority |
| Baseline to 3 months | Cohen's D | -0.16 | 2-Sided | 3 month between-group Cohen's d; calculated as within-group d(intervention) - within group d(control). Standardized using the standard deviation of the change scores. Negative values favor intervention and positive values favor control. | Superiority |
| Post-intervention |
|
|
| 3 months |
|
|
Baseline to 3 months |
| Mixed Models Analysis |
| .55 |
| Slope |
| -0.22 |
| Standard Error of the Mean |
| 0.36 |
| 2-Sided |
3 month condition x time interaction coefficient from mixed-effect model using negative binomial distribution. Intervention = 1 and control = 0. |
| Superiority |
| Baseline to post-intervention only | Cohen's D | -0.04 | 2-Sided | Post-intervention between-group Cohen's d; calculated as within-group d(intervention) - within group d(control). Standardized using the standard deviation of the change scores. Negative values favor intervention and positive values favor control. | Superiority |
| Baseline to 3 months | Cohen's D | -0.39 | 2-Sided | 3 month between-group Cohen's d; calculated as within-group d(intervention) - within group d(control). Standardized using the standard deviation of the change scores. Negative values favor intervention and positive values favor control. | Superiority |