Systematic review and meta-analysis regarding the effectiveness of online/remote interventions for mental health in children, adolescents, and young adults after the onset of the COVID-19 pandemic (Preprint)

Abstract

BACKGROUND
The prevalence of mental illness has increased in children, adolescents, and young adults during the COVID-19 pandemic, while at the same time, access to treatment facilities has been restricted, resulting in a need for the quick implementation of remote/online interventions.

OBJECTIVE
To give an overview of randomized-control studies examining remote/online interventions for mental health in children, adolescents, and young adults and to explore the overall effectiveness of these interventions regarding different symptoms.

METHODS
A systematic literature search was conducted according to PRISMA guidelines using PubMed and Google Scholar. A meta-analysis was applied using a random effects model to calculate overall effect sizes for interventions using standardized mean differences for post-intervention scores.

RESULTS
Twelve articles with n=3833 participants could be included in the final sample, and nine were included in the quantitative analysis. The studies examined different digital interventions for several different outcomes, showing better outcomes than controls in some studies. Meta-analyses revealed significant medium overall effects for anxiety (SMD = 0.35, 95% CI: 0.06, 0.64) and social functioning (SMD = 0.42, 95% CI: -0.68, -0.17) and a small significant effect for depression (SMD = 0.21, 95% CI: 0.13, 0.30). In contrast, no significant overall treatment effect could be found for well-being, psychological distress, disordered eating, and COVID-19-related symptoms.

CONCLUSIONS
The qualitative and quantitative analyses of the included studies show some promising results regarding the effectiveness of online interventions, especially for symptoms of anxiety and depression and for training in social functioning. However, for other symptom groups, effectiveness is not apparent. All in all, more research with high-quality studies is needed.

Full text

JMIR Preprints Fischer-Grote et al
Systematic review and meta-analysis regarding the
effectiveness of online/remote interventions for
mental health in children, adolescents, and young
adults after the onset of the COVID-19 pandemic
Linda Fischer-Grote, Vera Fössing, Martin Aigner, Elisabeth Fehrmann, Markus
Böckle
Submitted to: Journal of Medical Internet Research
on: February 20, 2023
Disclaimer: © The authors. All rights reserved. This is a privileged document currently under peer-review/community
review. Authors have provided JMIR Publications with an exclusive license to publish this preprint on it's website for
review purposes only. While the final peer-reviewed paper may be licensed under a CC BY license on publication, at this
stage authors and publisher expressively prohibit redistribution of this draft paper other than for review purposes.
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
Table of Contents
Original Manuscript ....................................................................................................................................................................... 5
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
Systematic review and meta-analysis regarding the effectiveness of
online/remote interventions for mental health in children, adolescents, and
young adults after the onset of the COVID-19 pandemic
Linda Fischer-Grote1, 2; Vera Fössing3; Martin Aigner1, 4; Elisabeth Fehrmann1; Markus Böckle3
1Karl Landsteiner University of Health Sciences Krems AT
2University Hospital Krems Krems AT
3Research Centre Transitional Psychiatry Karl Landsteiner University of Health Sciences Krems AT
4Department of Psychiatry for Adults University Hospital Tulln Tulln AT
Corresponding Author:
Elisabeth Fehrmann
Karl Landsteiner University of Health Sciences
Dr.-Karl-Dorrek-Straße 30
Krems
AT
Abstract
Background: The prevalence of mental illness has increased in children, adolescents, and young adults during the COVID-19
pandemic, while at the same time, access to treatment facilities has been restricted, resulting in a need for the quick
implementation of remote/online interventions.
Objective: To give an overview of randomized-control studies examining remote/online interventions for mental health in
children, adolescents, and young adults and to explore the overall effectiveness of these interventions regarding different
symptoms.
Methods: A systematic literature search was conducted according to PRISMA guidelines using PubMed and Google Scholar. A
meta-analysis was applied using a random effects model to calculate overall effect sizes for interventions using standardized
mean differences for post-intervention scores.
Results: Twelve articles with n=3833 participants could be included in the final sample, and nine were included in the
quantitative analysis. The studies examined different digital interventions for several different outcomes, showing better
outcomes than controls in some studies. Meta-analyses revealed significant medium overall effects for anxiety (SMD = 0.35,
95% CI: 0.06, 0.64) and social functioning (SMD = 0.42, 95% CI: -0.68, -0.17) and a small significant effect for depression
(SMD = 0.21, 95% CI: 0.13, 0.30). In contrast, no significant overall treatment effect could be found for well-being,
psychological distress, disordered eating, and COVID-19-related symptoms.
Conclusions: The qualitative and quantitative analyses of the included studies show some promising results regarding the
effectiveness of online interventions, especially for symptoms of anxiety and depression and for training in social functioning.
However, for other symptom groups, effectiveness is not apparent. All in all, more research with high-quality studies is needed.
(JMIR Preprints 20/02/2023:46637)
DOI: https://doi.org/10.2196/preprints.46637
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JMIR Preprints Fischer-Grote et al
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https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
Original Manuscript
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
Systematic review and meta-analysis regarding the effectiveness
of online/remote interventions for mental health in children,
adolescents, and young adults after the onset of the COVID-19
pandemic
 !" 
#$%&'()#!
$%&(*##!
#$%&'()+,-.&&#!
/*'.&&'!$%&(*-!-!!
*!0

#$%&'()
/1#/ )23
433#/!
-56743638
1'9 11
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
Abstract
Background: - *% '           &!
! !   ,:;/8 * <          '    
!'=! *'6%1
Objective: -%%%<'>!?6%
'&!!?*%''%'
%''&*1
Methods: &!<!.+;)!!.!
)1&<**!''!% ''
>'%!>'''*%1
Results:-<%<@A**!!'*<
!=!%&1-!?''%'%''
!<!!1&%'!
%'''?&B)/@31484C,;03137317D'!B)/@3184C,;0
317A31ED''''*B)/@3184C,;031313D1;
'%''!'!'<*&
,:;/8&*1
Conclusions: -=!%=!%&'!!<*
!''%'%*&'&*'?&*
''!1(<%'&*!*''%**1
<=!&!1
Keywords
,:;/8*F6%FF?&F'!F
*F<F*&FF,:;/8)&*1
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
1. Introduction
- *%' *&     < <  
*'GHI1.&!*'<*
!' < G4I1 ,   %* '  !
*&!*%%*G7I1/!%**
%11'!*&%!%%GEI1
%<'34<<**%'
1CGI<**%!'*&'!
714CGAI!4CG8I<'*%41ACG8I1
/!,:;/8**&*%'
!%**!G3IGI&!!<
!* '  !''',:;/8 GHEI1&
%<*?&*%&*< <
      *F     '  *     
?*!<' GAI1 ) % %   '!   *%
!''<%'*GEI1
*'8733< '*?&
!G8I1-**!*!
 & ! G8I !   <  6    *&  * *&
!**&*&%GI1
(<%%*'*&'!!
'&* & ' *   * !  '  
G33I1%'*!*'*<''!!
* GI''!*'GI**GI1%
''*'<43C'<*!=! %
G4I1
-!*&'*%&
'''  *&   '* <  !   !
*!%G37HAI&&*%
&*&*  !     * G3EI1 (<%  ! < 
!!''!!'*GAI1
-!'<%%%*!'&<G3I
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
? '    < *&  G8I <  ! % '
%'%!*&*''G3I!GI1
%<%'&'!&!'
'&  '  % GI    !  <    *!            
%'<*=!'' GI1:*
     '   &&& !%& GI 
<'''GI1
**%*<*&
GI1*&  ' **   <   
'&!?*G4HAI1
(<%''%GI*& '%''
%'!1+ '!!*%*&*'
 GI1!*%%
*%&&G8I1-!*&!<*!
,:;/8!  %  ''%'    %
%'*&*<&1
)%<%!''%'%'
,:;/8*G3HI1%<&"1 G3I '!+,-?*&
 !  ,:;/8 '! < *''!  '
!1+<?%'*%
&* ?&  %< '!   GI <  1 GI '!
% ' !%*&=! !*'!
!!'',:;/8*1J!!1GI'!''&>
%'**<!!''*1
K%'%'&!'%'!'
'*&!!*'!*'!
 '%&*&*<!!
<     *1 L       &!  !      M
%NGI< *&*%%&!
*&%!%*'!11**!
G4I1
-!& %< &%%%<'!?
''%'6&%%%%!
',:;/8*'*'!&!
!1
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
2. Materials and Methods:
2.1 Search Strategy
-'&***!&33B'',:;/8*D!!
3!.'+*;')&+%<&
B.+;)D< G7I<!PubMed )1-*
*1-'&<**%!
)<1
Table 1. )*!!
Database Search parameters
.! BBB*D:+B?&D:+BD:+BD:+BD:+
B*D:+B=!&''DDK/BBB*%D:+B%D:+B,%D
:+B)%DDK/BBD:+BD:+BO!%D:+BD:+B&!D
:+B&!!D:+B!DDK/BB.&&D:+B.&*&D:+
B*&&DDK/BBD:+BD:+B%D:+BDDK/
BB''%D:+B''&DDK/BB+,-D:+B+>D:+B,
D:+B%DD
2.2 Study selection process
"'?'!  ?!  *& '  !
?!1)'!'?!*1)!<!'&
<BD%!BD*!33B'',:;/8
*DBD*%<P!BD<BD'!*&
*&*&%<%&11%***B'D
! *?&*&<=!&'
'BQDBD&!!B!*'3D1
2.3 Statistical analysis
&  <  !    ?    %R  ''%  !  >  
''B)/D!!<*<!**%
1*% )/  < !   !*  * 1
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
 ! < !* &  ! &*  *  & <   ! '  !*
B?&*<*&'!,:;/8
!D1)*&%!&GEI1''><*!
* M'NGAI+%1''<'!'
%  *> !  < ''  !1(& <
!(S;TG8I1;*'''>,SG434I1
& ''!!&<!
O";!,**, '+>,-  O
";! ,**- 'Q!?* )! G4I1& <
!+%'*!G4I1
3. Results
3.1 Sample of included studies
'8<'!*!<'
!'&1:'!!*%1<
?'!?%1:'E<?!&<<
%!<!%!*<!'331
&!?!'*!*!
&'1)!'*'!?!*1
-'*!!3!'=!%&<%@A
**1K ' !  <! =!% &1% *
+,-<!&G4I &=!?*<!*1:&!&
G44I?*&*%''1:!&G47I<*
'!!',:;/8*1
-GE4E4AI B4CD'<%!<!$)<B717ECD,G448I
!G4773I$#G77IBA1CD!&<!,G7I;&G44I
; G3I1!!!**?&B 4CD=!!''
**G3477I1;?'**GE4EH7IG44I
!&<!<'**&G47I1(''!'!
   G4444E4A77I  <      '  !  &!  !      *
G3E4748737I1
,'!!%<< '*
1
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
Table 2. Characteristics of the included studies
Study Sample size Sample
recruitment
Gender Age Study
type
Country Intervention E-Health
technology
Target Outcomes Results
/!    1
3
G4I
K@E7 :

*'
  @
4714AC
  @
1C
3  H  
&
  @31E
)/@31A
Q!
?*



!*
, :
)
'
*
  ,
  -*&
B),-D

'
&
Q!&''
?&
.*0
)'
!  '
?& !  
1  ;
Q
.
'<!*0
+!
?&  
Q
#!    1
3
G4EI
;%
!*0@7
,
!*0@
-
;
%

@48C     E
&
@41
B)/@14D
+,- $) ;.,- 
%
*!  **
!
F
0
  <
!
,&!&0  
!
=!  '
&%>
  
&
%
  
*
  *%
&
%
  <
  %
!*
!'
(!!  
13
G7I
K@E
B";@  7F
.,@D
;  
&

@C
@4EC
@A1A +,- , ";
.,
"  !*
  
%
-'
*'
?&
;
&*
"*&
  '
B".KD
;    ?  '
,:;/8
  .,0  
*  
?&  

  ";0  
!  '
".K
.%  
13
G7I
K@33
-
!*0@43
L0    @
43
%
  

@AC
@C

BD
@C
K  H  &
7  H  A
&
+,- $# :  *
!**
!
M$*'  .
)!**
-N
U
)  !*
   !
    %
L**
.&!0
  %  
*%!**
*%!**
% 
  '=!&  '
.&
!0
K ''

%
  '
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
@C !***%
  *
<
    
*
)&
!0
<
  
&*
'''&
%
''  '

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  
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
  !*
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https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
  

31A B$,D !D &!
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L,
  '&
  <


!
  @
E1EC
@1
)/@17E
+,- , '!
  

B(D
%
%1  
  !**
(

  
'  %
U
L,
*
.&!0
?&
*
)&
!0
'!
!**

!**
  !  
?&  
*  
  
'!
  
!** 
!*
    ''
  ?&
!
'!
%
  
  
'!
(  

*&
-    1
3
G73I
K@44 )  0
*  <
!
!  
  *  

  @
A1C
A  H  4
&
B@14
)/@1AD
+,- !

)'!
*
**
 /"-
%1*
**
<  
'
  
)*
**
B'"!&D
.&!0
  !  
&*%&
)&
!0
*
  >
?&
/
  '
  ''
'  %

!

    !*
''

https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
'& L &
!
U!  V
L3
G47I
K@33
B*,%0  
@  F  !
,:;/0    @
48D
$%&
!  
  '
%*


  @
33C
E  H  7
&
B  @
81A4  )/
@13D
+,- !

:
%
!

  %1  
%
:  '
!  
*3

  &  
'?&
'*
  '  '  '
*
%''
  '

&*
&  !
,:;/  
*,:;/
  %
%
'&
  '
*
*  

    
'
?  
''
K0@F)/@%F/"-0%*&F;.,-0;%.%,&,'-!-&F";0
'!%F.,0**&'
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
Table 3. Risk of Bias Assessment
Randomized Controlled Trials
Author True
randomization
Concealed
Allocation
Similar
groups at
baseline
Participants
/personell
/outcome
assessors
blinded to
assignment
Identical
treatment of
groups
Follow-up:
complete/
full
description
Analysis of
participants
in their
groups
Outcome
measurement:
Equal
/reliable
Appropriate
statistical
analysis
Appropriate
trial design /
deviations
accounted
for
#!  
1  3
G4EI
+>
!  '
&    

J J .*
V  *0

:!
0
&
J J J J J J
!'
(!!
  1
3
G7I
$ $ K $ J K  '<
!*
J J J K  

!*  <
%
.%
1  3
G7I
J $ J $ 

  
!*
J J J J J
.  
13
G44I
J $ J .*
V  *0

:!
0
!
J J J J J J
)
  1
3
$ $ J $ J J J J J J
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
G4AI
)
    1
3
G3I
J $ J $ J K  '<
!*
J J J J
)
    1
3
G7I
J $ J $ J J J J J J
)!''
  1
3GEI
$ J .&
:!
0
&
J J J J J J
)!1
3G48I
J $ $ .*  6

0&
B'D
J J J J J J
-  
1  3
G73I
J J J J J J J J J J
U!  V
L
3G47I
J $ J $ J $ J J J )*  >
%6

!
Quasi-Experimental Studies
Author Clear
distinction
cause / effect
Similar
participant
in
comparison
Similar
treatment
of
comparison
group
Control
group
Multiple
measurement
of outcome
pre /post
intervention
Complete
follow-up
or
description
Equal
measurement
of
participants
in
comparisons
Reliable
measurement
of outcomes
Appropriate
statistical
analysis
/!  
1  3
G4I
J K
**
K
**
K $ J K
**
J J
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
3.2 Characteristics of online interventions used in the included
studies
  '    !  ! G4H4E487H7I **  ''  %  '  %'
&&<%<%&BD1;%
&!&B;.,-D  #! 1 G4EI **!%
% %1  .%    1   *  '    !* ! &  !
 !L**'  *  !** G7I1-'!
  B(D %  & )!  1  <  !** &  L, 
*G48I1:%%&%%'<:)
'  *    ,  -*&  B),-D G4I  '!  %
G77I**&'B.,D G7I % *& ' -! & G44I
%!G47I1
K?        %  <  '  &  <  !  **  '
    %1  )    1 G4AI ?    %  '
*%  &*    )    1 G3I   ,:;/8  ?&  <  '
 %  1-?< 
% ' <*&!<**!&& )!''1 GEI 
!**'B)-(D1:!&G73I!***B'"!&D
%*&B/"-D!1
:&'<!*'&*&'%1-<
<% '!  %   ' G4EI  * G4E4AI    < 
' G3I   *      !* *  
!*G48I1
3.3 Effectiveness of Online Intervention Regarding Mental Health
Outcomes
 ! %   !  !B   D  !?&
*    <    '! ,:;/8  &*  &!&
-!&!*&1
3.3.1 Anxiety
)%!*!?&G3E4444877I1-*?&<
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
 ! '     !* G3487I1 ;   '! & *
'' G4AI=! '' '' <!* G4473I1 .*& ' 
B.,D<'!%'*?&'!B";D!&
G7I1&'%!<?>?&
?&  <   %  '  *% '' ' %  !       '
&*B)>!'')/@31484C,;3137317; @7CD1!
<'*'%!1
3.3.2 Depression
+!&*'*<'!%!GE444A48I<!*&'
%!*'!GE444AI1-!!&)!1G48I)
1 G7I  - 1 G73I '!!*'' *%&*& 
!*1K%&''%!'!''B)/@3184C
,;31313;@313C1D-%!*'*'!1
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
3.3.3 Mental well-being, quality of life, agency/self-efficacy
<<'!%!GE4E77I1Q!&''<'!
'<!*!&G4I1)'''&&<
! G4A7I <  !& '!  '' GEI1 :& < ! G737I <  ' 
&&>''<1(<%'''<<
&B'!D1
3.3.4 Other main outcomes
!&&!&&%!* G4EI<
<*!  !**% *
< %   ! G7I1-  %*!%
&*          <  -!  &  <  =!&  !  %
%'''%G44I1"&!***!&<
!!'&G73I!&
'*!<''<'!G47I1
&  <  !  '  %  '    !1  +    
*& B'!D% ! 6?&B'!4D   '
''!'!!<'!''B)/@3184C
,;317A31E;@313CD<'!'%'!!
GE487IB'!D1!<'!<
'&*%&1
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
4. Discussion
4.1 Principal results
-<% ! !  <   '   ,:;/8*  !! 3  <
 ' !    & %<   &  ? ''% '
6 %  '  ''   !       &!
!< !''!%!,:;/8*1
;!'!''     ' !!
&%%1
%G3E44H7I!'<%!<>!&
!&*%''% G44I1K%
?* !        '  '  !    % &  % <    
*  =! < '&!1-
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
!&'!=!'''%G44I1
L '  ! !   <  % !* G34777I
*'' '% G7I   ! ''!*
GE4EH73I <    *    *&  '  !    ''%  '
%1'!!!%'&!%**
%<%***&'%&1
&  ''%& ''*%&*
!''?&<'!1-!6
%<*!%%1,*%
&*&GE4A48I''%!*%&**&!1;
*<G4473I*%&**&&!<
''%'''%&*1
,%*!!0%*%<
!*&       %  *& &*   
<'''!&1:!<%&
'<!   <   '  !1 :& <  !!  !   
& <1 : !  >% '!  * !** G7I
<      **    **    !  !   G73I1  -!  ?    ''  
%!'' '6**!
'  <''&?* !'!'' =!  ''<<
!<?* ''%''1
.&  < &>  <  ! GE73IF     ! '  
&'%'%!G34AI1-<<''!
!<!0G4AI?%8!<G3I'!
,:;/8?&1 (<%  & %< & "  1 G3I '! 
=!&!<<!''%8&* ?&
*%&*!*% G7I?< '%G7477IF
<6%%'!**1
+ '%''!!
*&'&*1
=!**   !  *!&
  * G7EI1   *%!  &  '!    !  <    <
''% '%'  G7AI1- !& & U!L G47I
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
*&*'',:;/8!,:;/8'!&*
! *! '%!*1L
&'?&*'!
**'%'*!*1
'%<%''!'!!
        '      !      ''%  '  6
%<1
-&%%*&'
! ,:;/8*<''&
*!'%!'&!
!?*!<%*&1-!%
%*< % G37AI1K%%'%  *  
0 '< * '''!G3I  *
!**<%G3AI1 +%*'!
% !  <  *% ''  & ! *  !*    %* *
G4EI&!*%G7AI1
(<%!*%* ''
0   & %> !  !   '!  G4EI  &!
** '%% GEI1.%
!'**! G4I<'!*<
=!&''G78I1
4.2 Limitations
L*&  !  %<'  *   '''
%'&!!!*'
&%<&%*1:'!!+,-
G4I1(<%!'!&&**%&&!
&1,!*!'''%!
!'*F%   *%&'!    
''%'%*1; '%
''''***
6!1 **>&**B
 D1 -  !   =!& '  ! !1 %   ! ?%!
!!'' '6 ''6%
*<!?%1-*%&
%*>'!!*<&>=!%&1L!
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
<!%!<!!
<&%1
4.3 Comparison with prior work
-&%<&?%%'
*&&*&!!''
,:;/8*1&%<&"1G3I'!<!!
%,:;/8&* ?&*%&*1)
!&!&1:%<!!
!'   * GI & ! '   ' ,:;/8 GI1-
''%'%<&'!=!!*GI 
%<*!'=!&!''!!!G3H
I1  )&  %<  !  '    *      %    *%
* '   GE3I   * *'& GEI  &!  ** % <
*!  *&  !=!% ! !   '  ?% =!&
% '  *1 K      &! !   %<
*''%%*&'*'!=!''%
GEI1
4.4 Conclusion
!!<*!*'**
%'!'&!!'
<*%'*&!*!
'  !,:;/8*1(<%
=!&'''%<*&1
5. Acknowledgements
-!  <  **   !  ' KW !!  & '
$%&(* <!'*%>'< !
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
1-&    <     <  !** '    :* .!! ' #
$%&'()#!1
6. Conflicts of interest
K
7. Abbreviations
,;0'%
K60!
Q0Q!&''
)/0>''
8. References

1 ,O!) #1.%/%*
' .& /   ,   1   .&&  33!
F73BAD0AEHA1031336*&1731A1AE
1 !    #<!> 1  *  *&  )!    #  !
O!0%X!"Y !/1
!*&3E)*FBD087H3103133E633E3A?
1   #+K ! # +,1 *& '    
1/!,K!-&VF338FBD0EH
31031AAE6/,K)1338116  
1 .>& )!)!&),&+1!%<0
&'<<*%'1O
,.&.&&L&:&F34F47BD04H741
41 L)( "#-!;L1'!'
P*%0<*&'!!!1
.&34F4BD0434H410313E6)338E3373
71 /  +    K"  L    )!  "1  ;*  '  %  
'%***%1K!3AF44BE78D0H431
0313A6!4EE3
E1 ,+-&O+.>K1/%*K!!&'%
0  ,  . ' !&1  O  .&&
.&.!F33O!F73B7D03H341031E76**1P*1731713
A1 .**OUL  # -!)/YL #<!>#L1
.%'%*!*&
!'*%1).&&.&*3A
/F4BD04HE103133E633E3A4A7&
81 L    U    L  #  .**  O  -!  ) /Y  L  -! O
#<!>#1   * ! 0  < <
*  !&  **&  /)4  1  !  ,    .&&  3E
/F7BD0AH88103133E633EAE3E38887
31 ,1:*&*U,*1.&*!
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
3&F77BD084H3103133E633EA3333A3
1 K+OJ+*++,:!&O1+ 
.%'.*%,(!,:;/
8.1OJ!3OF43BD0H4E103133E63873338
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'&  1  ;  O  %  +  .!  (  3  *  FABED07E81  0
31836P*A3E7E8
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**%S0*',:;/8**&!*
*'*&1,(OL&V)F
3)*FEBD0HE103161A
1 W>Y U#:/L>-,, !<
 &#&-1/.',:;/8.(%;'!
(L"'J!.*[,)!)!&1
;O%+.!(3FABD1031836P*AE84
41 .,...-/+(!1'('(
) )!  /!  )  /   +  ) /!   ,:;/8
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31336P< *131A77
71 .!)(*((*'-()O#*
L+-L&)#1*,:;/8*0
    P&  &  !  !  $#  1    .&&  3
O!FABED073H781031376)4377BD3347
E1 ) +K!*O! ))((-O+%)$
"&#1 ,       S   **! 
&!,:;/8*H+!'*%<1+#;!F
3/F03147763E7
A1 .$)>.,.,!
..1-*',:;/8 <0&
%<1!,.&&3!AF03133E633EAE33A47<
81  ,!   ()<&K +& ))' +  "
&,!K"< ,,<&1+*)&+%<0-;*'
);     (' ,  
,?',:;/81O,.&&33K%F48BD0A811
031376P1P1331341338
31 )  +  !!  )  ,!  1    %%
%  '  ,:;/8  ?&0    >    1  -  .&&
.&\].=!+)!F3&F0H4310
31E776E73A8333347
1 !-&W>Y U.*<, &#&-1
* '      <   <!     !  % 
  !1  ,    .&&    (  38  /FBD041  0
31A76338384&
1 (/.*/1M%,N,#(*.0;%!,
  .  -*1  O  ,    ,    .&&  37F4BD0AH1
.;/0E8
1 )*)+,1-*!%'*&*&0
%<0      %'  *&*&1  !  O  +!  (  3
/FB7D0A3H8810316P18
1 %%))<O(O."! #+1P/*
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
  K  ,&  )!%&H  )!**0  .%  ,  
-1  O      ,    .&&  34  O  F4BD0E11  0
31376P1P1313133
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0)&+%<'$1)1.%%)%- 1;
37F7B4D01031E76448
71 )1'Y!!13F81
E1 :1;!!.&*0' '!%
.&*!^!#^1.&!3/F4BHD04H10
3133E633E8333A7
A1 U!( )1:*&*'&0$#<!%&
    '  ,:;/81  ;  O    -  33  :  F4BD07HE1  0
313A36E4A1331A4
81 '      1  >  !        *_
.& 1    #   3  O!F78BED07AH71  0  3133E633
33A&
31 )!>K1'' %!)*&;
"!133EFA1
1 " !U+**+"U!/+-*K
O-*  )+1 ' *&*&0& %<1 .&  )%  3
&F8BD0H10313E633E8
1 .!,,/,&/1J!.*S:(*) 
(  /''!0  )&  K%  +%<1  O    ;  +  38  K%
8FBD0AE1031876AE
1 K!O"-!O#1)(0
"' +   :**! ' +   .1  O - "% ) 33
)*F4BD04H4E103133E6E3333?
1  + .  O  )  .1    (   ** '  .  
0   )&  +%<1  O    ;  +  3E  &  4F8B4D0E71  0
31876P1E
41 -<(-( )&)1,'(;%L
,    J!  .*1    .&&  3A  :  AF80A1  0
31A86'*&13A133A
71 O  )< ) _,!  , ) " "  1 ,
< .."! 'Y O!  "* :
.':.K1.&!  3/F4BHD04H73103133E633E83
33AA>
E1 )<))/'-) "" 1.
,,%*':.!K< B:.KD'!
1/(3O!7F0A3371031A86'131A337
A1 )<)O_) ""  !1*H
  .."!  'Y  O!1  -  U!_  !  * 
!1  $%_  'Y  L!  #  V  !P!1F  3F  0
31A6A.O"8)A
81 U!#K( )1-*&/L0;%
+%<',!.!!/1.&3*AF04844710
31A86'*&1317333E3
31 ":LJ  # O` #( , )!JL!J"!'' O-
 )+/"-;-)-/J>"
,)) )-! "-"/1''',:;/8
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
(;%,!KQ!
$-/!  ,:;/8;'0)&+%< '  +
,-1,O.&&).!;F3&F7EB4D07H4310
31EE63E37EE3E37A
1 ,+!)L.",+>,*+
Oa+)'O1L?%'*<*%
?&0&%<'>1">O.&&
3K%FBD0H1.;/0A43
1   U  (  )) J!    "<  "O    O  (  ,  (  ,1
;*' -)%  -K!%*
/0  )&  +%<1  O    ;  +  3  O  3FBD0781  0
3187678
1 J!!LL(L:$*&&)!#*
- +  - #''-)! 1  /> ,% "% ;%'
/*%)&*/!.&0)&+%<1O;+3
FBD0E1031876E
1 ,  -      /    #  (  -1  &      *[  /
!**'%1.&$)F3FEEBD0A7H841
.;/08787EA
41 ,  ))  )  "#1  )*  !    *        
!#0.%< %!1(.&:*
)  .!  F  3A  O  F4BD034438AE44371  0
31EE634438AE4437
71 /->''O/1.'+*;')&
+%<&0-.+;))1;,'
.&F338!AF4BD07H781031E76333A843383AA3334
E1 )!''  "    -   <>  /   <>      "  "  /1
*&'''/;%)!**
('J!!-,0.+>,-1O;+
+3:F4B3D0E1031876E
A1 !L1 ,! &  + <   ' . 1 O  )
)'<33!4F7BD0HA1031A7E6P1%3713
81 (  O.-1  !  &    &1  "O  33  )*
7FEBED044EH473103176P1E1E144E
431 , O1 ) *< &  '  % 1( K1O10  1
!F8AA1;)"K08EA3A34A3A
41 )1;*'''0*'1
.-.+%O!$)F33A/FBD0E33HE1.;/08E4334
41 -!'!, !  U   ,* O (** 1  ,*  0  )&
%<'''%1;0!U1O";+%
3E1
41 +,-1+0!%'*!10+
!'),*!F31%'0*066<<<1+*P1
41 /!L#J"!(!Q,U!QUO1-  :  )
;'*  , -*&,:;/8''1
+  )  L  .  )  .!  ;F  3  &  FBD074HE1  0
31EE638E437EE3
441 . ! K ,  , " + +>> +1
+>  ,  -  ,* '  %1    /%&  '
"%-*& ' J! L-!)&   -' ,:;/81 
.&&3&F0A71.;/047A7A8
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
471 U!JL-/1-*',:;/8&''!%&
!1;O/3F4BED0AHAA103133614
4E1 #! +/!).OK!K++++#+&1
,&!&  "  .%  ;%  '      ;0  .
+>  ,  -1  O;+    (  3  )*  4FAB8D07381  0
31876738
4A1 )O! &,?#+/)''(+!,1
>  '  % ' * !
,:;/81K(!"%K!.!!*F3F7BD04AH7A10313A6
473343
481 )!)/))U,.Q)"<O! :*/1
'!  B(D %   *&& 
!%&!=!!,:;/8*0>
1O,!.&$)0.&F  3F78BD04EHE1 0
313E6!333347A
731 - (  O%& L QL):S/ " ,
,(1 - '''   *! * ** !  
&!!0'>!1-1
.:)3&F8B4D0338EA1031E6P!1*1338EA
71 .%+-(<"<" (
< O!/:<..<+.');.)!**J!
.*S%&!*1:  *!**   * S 
!** &!,:;/80+
=!%%!1!,.&&3EF03133E633EAE3
383
71 )  : ">:)/  )"1'''<   
'!*?&*!%&!!,:;/80
>    1  .&&  +  3  K%  F3401  0
31376P1*&131
71 !'(!!,b-!O!(,,
K'\/,,"!cd-&e1.*&'
 '! !,:;/80  +! ' > ! 
*   &  !1. K!*&*"
.&&3*3F3E03731031376P1***131373
71 L!-?,/:'f!#f)**Pg"*%
#1"':,%"%!;%'/&'!L&
+,:;/8.0+,-1.&.&
3F83BD08H8810314863334A
741 ## K!&+, K,<&O!
+)#+-)1'''&*/%*&!.'
-*,/*?&!/!,:;/
8.0+>  ,-1O.&&  3O!FEAB7D0771 0
31336P*&&1313
771 -"/#< %""!!(&+)%L()
-,"!/! / /&" # +/"
L!> K!O-!#hiK,!+K(<)
.)")OO! ))"1'''
!'!  !*** ?& &* ** <
&?&!,:;/8B).;K,(-D0<**&
      1    +!  3  O!FB7D0EHE1  0
31376)77488BD333737
https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]

JMIR Preprints Fischer-Grote et al
7E1 L "-! ,  & / )& + .#1-' "!
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**%%1OJ!)*F34FBD083H1
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https://preprints.jmir.org/preprint/46637 [unpublished, non-peer-reviewed preprint]