Culturally Informed Digital Behavioral Intervention Development for Inflammatory Bowel Disease: A Qualitative Study

May combine two claims.

Because psychosocial factors, beyond disease features, substantially affect IBD outcomes, there have been calls to add psychosocial care to medical management.

“Recognition that psychosocial factors, and not disease characteristics alone, significantly contribute to IBD outcomes has prompted calls for integrating psychosocial care to complement medical management of IBD.9”

• cites [9] Hinnant, 2024, Consensus statement on managing anxiety and depression in individuals with inflammatory bowel disease, Inflamm Bowel Dis. sourceSupported

May combine two claims.

High-quality evidence indicates some digital behavioral interventions improve psychological outcomes in IBD, but their feasibility and acceptability among racial and ethnic minority IBD patients remain unestablished.

“Although high-quality evidence suggests psychological improvement with certain digital behavioral interventions in IBD,13 feasibility and acceptability of applying such interventions among IBD patients from racial and ethnic minority groups are lacking.”

• cites [13] Peerani, 2022, A randomized controlled trial of a multicomponent online stress reduction intervention in inflammatory bowel disease, Therap Adv Gastroenterol. sourceSupported

May combine two claims.

IBD was historically viewed as mainly affecting individuals of European descent, but it is now increasingly identified in varied populations.

“Though historically, IBD was considered to affect predominantly people of European ancestry, it is now increasingly recognized in diverse groups.2”

• cites [2] Collaborators GBDIBD, 2020, The global, regional, and national burden of inflammatory bowel disease in 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017, Lancet Gastroenterol Hepatol. sourcePartly supported

  The Introduction and Discussion (page numbers unavailable) describe IBD as historically associated with high-income countries and report rising prevalence in regions that formerly had low prevalence, including parts of Asia and Africa. That supports a geographic shift, but the paper does not establish that IBD was historically considered to affect predominantly people of European ancestry or document trends by ancestry. (LLM, conf=0.86)

  Experimental — accuracy not yet measured

May combine two claims.

In IBD, co-occurring psychological distress is associated with greater use of health resources and worse health-related quality of life.

“Psychosocial care in IBD is important, given that comorbid psychological distress is linked to increased health resource utilization and poor health-related quality of life (HRQoL).6,7”

• cites [6] Lores, 2021, Integrated psychological care reduces health care costs at a hospital-based inflammatory bowel disease service, Clin Gastroenterol Hepatol. sourceNot checked — no full text of the source
• cites [7] Riggott, 2023, Novel symptom clusters predict disease impact and healthcare utilisation in inflammatory bowel disease: prospective longitudinal follow-up study, Aliment Pharmacol Ther. sourcePartly supported

  The Discussion and Table 3 (page unavailable) link the cluster with the highest gastrointestinal and psychological symptom burden to greater healthcare utilisation. Table 1 (page unavailable) shows poorer self-rated general wellbeing in that cluster, but the paper does not establish the claimed association specifically for health-related quality of life; its discussion of quality-of-life scores concerns psychological therapies reported in a meta-analysis. (LLM, conf=0.85)

  Experimental — accuracy not yet measured

Classified as probably not a substantial claim. May combine two claims.

Non-biological social and physical environmental factors mediate the link between race and health, as illustrated by health equity problems among US racial and ethnic minority groups.

“The connection between race and health is also mediated by non-biological factors that encompass the social and physical environment, as illustrated by the health equity challenges faced by racial and ethnic minority groups in the United States.3,4”

• cites [3] Chetty, 2016, The association between income and life expectancy in the United States, 2001-2014, JAMA. sourceCould not verify

  The Methods section adjusts income–life-expectancy estimates for racial and ethnic composition, while the Results and Discussion examine environmental factors in relation to income-based longevity differences. Our copy does not address whether social or physical environments mediate the relationship between race and health or explain health inequities among US racial and ethnic minority groups (pages not provided). (LLM, conf=0.74)

  Experimental — accuracy not yet measured
• cites [4] Williams, 2019, Racism and health: evidence and needed research, Annu Rev Public Health. sourceSupported

May combine two claims.

Psychological distress and IBD activity influence each other: more active IBD can cause distress, and distress can worsen IBD activity via gut-brain interaction.

“The bidirectional effects between psychological distress (ie, anxiety, depression, perceived stress) and IBD activity mean that not only does increased IBD activity trigger psychological distress, but psychological distress triggers increased IBD activity (ie, gut-brain interaction).8”

• cites [8] Gracie, 2018, Bi-directionality of brain-gut interactions in patients with inflammatory bowel disease, Gastroenterology. sourcePartly supported

  The Discussion (pp. 19, 24) reports bidirectional longitudinal associations: active IBD preceded new abnormal anxiety scores, and abnormal anxiety scores preceded higher rates of disease flare or treatment escalation. The citing sentence overstates these associations as causal “triggers” and extends the finding to perceived stress; the paper distinguishes its anxiety-and-depression study from an earlier perceived-stress study (Discussion, p. 22). (LLM, conf=0.88)

  Experimental — accuracy not yet measured

May combine two claims.

IBD behavioral trials usually do not report race and ethnicity, and when they do, most participants are White.

“While race and ethnicity are generally not presented in IBD behavioral trials, when race is included in studies, most participants are White.34”

• cites [34] McCombie, 2016, Does computerized cognitive behavioral therapy help people with inflammatory bowel disease? A randomized controlled trial, Inflamm Bowel Dis. sourcePartly supported

  Table 1 (in the Conclusions section; page unavailable) reports ethnicity for this IBD behavioral trial: 87.2% of controls and 88.5% of intervention participants were classified as solely NZ European. This supports a predominantly European sample in this trial, but the paper does not establish that IBD behavioral trials generally omit race and ethnicity or that most participants across trials are White. (LLM, conf=0.85)

  Experimental — accuracy not yet measured

Classified as probably not a substantial claim. May combine two claims.

A prior UK study reported that mental health problems were central to living with IBD, especially during flares, and that patients wanted a place to discuss physical and mental symptoms with relatable peers.

“One study explored the lived experience of racial and ethnic minorities and other marginalized groups in the United Kingdom and found that mental health issues were an important part of living with IBD, particularly during flares, and that patients desired a space to discuss their physical and mental health symptoms with others with whom they can relate.36”

• cites [36] Sheldon, 2024, Patient and public involvement in the development of health services: engagement of underserved populations in a quality improvement programme for inflammatory bowel disease using a community-based participatory approach, Health Expect. sourceSupported

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

IBD is being recognized more often in diverse groups; patients' impression of growing awareness could stem from their own changed perception since diagnosis or from rising incidence.

“IBD is increasingly recognized in diverse populations,2,32 and patients’ sense of an increase in awareness of IBD in their communities now compared to in the past may be due to their own perception of awareness since receiving their diagnosis or reflect this increasing incidence.”

• cites [2] Collaborators GBDIBD, 2020, The global, regional, and national burden of inflammatory bowel disease in 195 countries and territories, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017, Lancet Gastroenterol Hepatol. sourceSupported
• cites [32] Ng, 2017, Worldwide incidence and prevalence of inflammatory bowel disease in the 21st century: a systematic review of population-based studies, Lancet. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

This may align with the acceptance principle behind psychological approaches that show the strongest benefit in IBD and merit further investigation.

“This may resonate with the principle of acceptance, which underlies psychological approaches demonstrating the most positive effect in IBD10 and holds promise for further study.”

• cites [10] Riggott, 2023, Efficacy of psychological therapies in people with inflammatory bowel disease: a systematic review and meta-analysis, Lancet Gastroenterol Hepatol. sourceSupported

May combine two claims.

Most participants used digital technology daily and would accept a self-management resource delivered digitally.

“For most, digital technology was part of their everyday life, and a digitally delivered self-management resource would be welcome.”

May combine two claims.

Average T scores were 57 ± 7.7 for anxiety, 51 ± 8.4 for depression, and 55 ± 10.3 for perceived stress.

“The mean anxiety T score was 57 ± 7.7; depression 51 ± 8.4; and perceived stress 55 ± 10.3.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Eighty-one patients filled out the screening questionnaire.

“A total of 81 patients completed the questionnaire.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

About half of the patients had completed high school and had Medicaid insurance.

“Approximately half of the patients had educational attainment at a high school level and were Medicaid insured.”

May combine two claims.

The analysis produced three main themes concerning the ways race and ethnicity shape IBD experience for intervention design and content: the wide reach of racial and cultural identity; gut-brain interaction resonating with lived experience despite mental healthcare obstacles; and openness to digital technology in daily life and health.

“We identified 3 core themes regarding the influence of racial and ethnic background on IBD experience with relevance to intervention design and content: broad impact of racial and cultural identity on IBD; resonance of gut-brain interaction with personal experience notwithstanding barriers to mental healthcare; and acceptance of digital technology in everyday life and health.”

May combine two claims.

Among interviewees, 7 (28%) were foreign-born, 10 linked their culture to a non-US country, 10 (40%) were non-Hispanic Black, 11 (44%) Hispanic, and 4 (16%) Hispanic Black.

“Of those interviewed, 7 (28%) patients were born outside of the United States, 10 identified their culture with a country outside of the United States (eg, Dominican Republic, Puerto Rico, Jamaica), 10 (40%) identified as non-Hispanic Black, 11 (44%) Hispanic, and 4 (16%) Hispanic Black.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The 25 interviewees included 19 women; average age was 32 ± 14 years; 11 had Crohn's disease, 14 ulcerative colitis, and 5 active disease.

“Of the 25 participants, there were 19 females; mean age 32 ± 14 years; 11 with Crohn’s disease, 14 with ulcerative colitis; and 5 with active disease.”

May combine two claims.

Patients wanted more representation of their racial and cultural identity in resources, a need important for designing a culturally informed intervention.

“They expressed a desire for increased representation of their racial/cultural identity in resources, which is important to address in the design of a culturally informed intervention.”

May combine two claims.

Every patient said they had regular Internet access and were at ease using a mobile app.

“All patients reported having regular Internet access and feeling comfortable using a mobile application (app).”

Probably not a substantial claim: may not pass S3 (load-bearing).

Some patients perceived more IBD awareness in their social circles than in earlier years.

“At the same time, some patients sensed a shift in awareness within their social circles compared to the past.”

May combine two claims.

Patients had not encountered such a resource before, yet they were receptive to using digital technology to deliver mental health support for IBD.

“Although it was not an existing resource they had previously encountered, patients were open to the idea of digital technology in the delivery of mental health resources for IBD.”

May combine two claims. The quote only partly states this claim.

Patients gave several personal reasons for avoiding mental health professionals, such as self-management, expense, trouble expressing feelings, and fear of talking to a therapist.

“On the individual level, patients expressed various reasons for not engaging with a mental healthcare professional. A few patients cited managing on their own and “sort of do my own therapy at home” (P13) and the cost of therapy as reasons. Several others expressed that despite any theoretical benefit from engaging with a mental health professional, a barrier was having “to express my feelings to”

May combine two claims.

Even though apps were common and generally accepted, patients were unsure how to find suitable information.

“Despite the ubiquity of apps and the general acceptance of apps in daily life, patients also expressed uncertainty about finding appropriate information.”

May combine two claims.

Patients described physical symptoms like abdominal pain and fecal urgency that disrupted daily activities, caused emotional distress, and affected social interaction.

“Patients spoke of physical symptoms, such as abdominal pain and fecal urgency, that interfere with normal daily activities, lead to emotional distress, and impact their social interaction.”

May combine two claims.

Patients recognized their condition as chronic yet identified diet and stress as triggers that could worsen disease activity at times.

“While patients acknowledged the timeline of their condition to be chronic, they also noted temporal triggers of increased disease activity due to diet and stress.”

May combine two claims.

Most patients used digital technology daily, including patient portals to contact their IBD team, social media, and online searches for IBD information.

“For most patients, digital technology was part of their everyday life, from using an electronic health record patient portal to communicate with their IBD team to social media and Internet searches for IBD-specific information.”

May combine two claims.

Patients said greater racial and cultural representation in IBD mattered and wanted someone relatable with whom to discuss their experience.

“Nevertheless, patients expressed that increased racial/cultural representation of IBD was important and desired someone who they could relate to about their experience.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Some felt that mental healthcare disapproval varied by generation: older people saw it as a sign something was wrong, while younger people were more open.

“There was also a sentiment that disapproval of mental healthcare differed by generation, where “the older generation look at it like there’s something wrong with you, like, ‘Get over it,’ you know. ‘Figure it out. You don’t need to go see a doctor.’…But I feel like my generation and the younger we are becoming and are so open with our feelings and reaching out.” (P7).”

May combine two claims. The quote only partly states this claim.

Every patient identified as Black/African American and/or Hispanic/Latino, and some additionally described themselves as American or New Yorker.

“All patients identified their race and/or ethnicity as either Black/African American and/or Hispanic/Latino”

May combine two claims.

Few had used an app for health management, but many would accept a resource delivered digitally.

“Although few had experience using an app to help manage a health condition, many would welcome a digitally delivered resource”

Probably not a substantial claim: may not pass S3 (load-bearing).

Behavioral interventions are thought to change illness perception-how a person cognitively and emotionally interprets and reacts to their condition.

“It is believed that these behavioral interventions alter illness perception, or the way an individual cognitively and emotionally thinks about and responds to their illness.11,12”

• cites [11] Knowles, 2011, Preliminary examination of the relations between disease activity, illness perceptions, coping strategies, and psychological morbidity in Crohn’s disease guided by the common sense model of illness, Inflamm Bowel Dis. sourceNot checked — no full text of the source
• cites [12] Kantidakis, 2021, Psychological mediators of psychological distress and quality of life in inflammatory bowel disease, J Psychosom Res. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing). The quote only partly states this claim.

The final codes and representative excerpts were reviewed collectively by RG, AP, and LK.

“Final selection of codes and data extracts representative of themes were shared between RG, AP, and LK.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Enrollment and interviewing proceeded together until no new data were emerging.

“Recruitment and data collection occurred simultaneously until data saturation was achieved.”

Probably not a substantial claim: may not pass S3 (load-bearing).

The paper describes team members' backgrounds and relationships with participants as factors that may shape how findings are received.

“As any researcher will have their own personal background and perspective, the following statements of positionality regarding research team members’ characteristics and relationship to the research participants may be relevant to how the study findings are perceived.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

Among 50 eligible patients, 25 (50%) were interviewed; 21 did not respond to follow-up, 3 withdrew, and 1 interview was incomplete because of technical problems.

“Of the 50 patients who completed the screening questionnaire and were eligible to participate in a semi-structured interview, 25 (50%) completed an interview, 21 did not follow up with the interview invitation, 3 withdrew, and 1 had an incomplete interview due to technical issues.”

Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

The research team checked transcripts against the audio recordings for errors and removed identifying details.

“RG conducted semi-structured interviews among eligible patients via video teleconferencing with audio transcription and error-checked all transcripts by listening to the original audio while reading through transcript files, redacting any identifiers.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Before the study, the interview guide was tested with one patient.

“The interview guide was pilot tested with a patient prior to use in the study.”

Classified as probably not a substantial claim. May combine two claims.

RG and AP independently coded every transcript with an initial CSM framework, then met to discuss codes and themes and settle the final framework.

“RG and AP, a gastroenterology fellow with previous experience in qualitative research, separately analyzed all transcripts using a preliminary CSM framework of codes and subcodes. RG and AP then discussed codes, emerging themes, descriptive labels, and finalized the framework.”

Probably not a substantial claim: may not pass S3 (load-bearing).

Reporting followed the COREQ checklist.

“Results are reported according to the Consolidated criteria for Reporting Qualitative research (COREQ) checklist.31”

• cites [31] Tong, 2007, Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups, Int J Qual Health Care. sourceNot checked — no full text of the source

Probably not a substantial claim: may not pass S3 (load-bearing).

Selection bias may have occurred because participants had to be willing to discuss mental health.

“Another potential limitation is that selection bias for patients willing to discuss the topic of mental health may also exist.”

Classified as probably not a substantial claim.

That earlier study recommended encouraging activities that reduce stress.

“In identifying stress as an important aspect of the IBD experience, this previous study proposed promoting stress-reducing activities.”

• cites [37] Scott, 2021, Coping behaviors of african americans with inflammatory bowel disease: a focused ethnography, J Transcult Nurs. sourceNot checked — no full text of the source

May combine two claims.

All patients had low-to-middle socioeconomic status, healthcare access, and an IBD physician, limiting broader generalization to other Black and/or Hispanic groups.

“Finally, all patients were of low-to-middle socioeconomic status, had health care access, and were under the care of an IBD physician, which limits drawing broader generalizations to other groups of Black and/or Hispanic patients.”

May combine two claims.

The study shows how racial and cultural background shape illness perceptions in IBD and how these insights can guide GI clinicians' use of digital behavioral interventions and researchers' content and design choices for a culturally informed digital mind-body program.

“In sum, this study highlights how racial and cultural background impact illness perceptions among people living with IBD and how these insights can directly inform how GI clinicians may approach utilizing digital behavioral interventions, as well as how researchers can consider the content and design of a culturally informed digital mind-body intervention.”

Classified as probably not a substantial claim. May combine two claims.

Another study of coping among African Americans with IBD identified themes including long bathroom time, restrictive eating around time and food, avoiding cultural foods, chronic stress and racial injustice, and seclusion to handle urgency and emotions like fear, anxiety, and embarrassment.

“Another previous study on coping behaviors among African Americans with IBD focused on their beliefs and experiences and found themes of spending time living in the bathroom, time and food restrictive eating practices and cultural food avoidance, dealing with chronic stress and racial injustice, and the practice of seclusion to manage bathroom urgency and emotions of fear, anxiety, and embar”

• cites [37] Scott, 2021, Coping behaviors of african americans with inflammatory bowel disease: a focused ethnography, J Transcult Nurs. sourceNot checked — no full text of the source

Classified as probably not a substantial claim. May combine two claims.

Because many patients already use cultural remedies or prayer, digital behavioral interventions can be framed as complementary to conventional medical care.

“At the same time, just as many patients may already have cultural remedies or prayer to cope with their condition, digital behavioral interventions can be presented as complementary to traditional medical management.”

Probably not a substantial claim: may not pass S3 (load-bearing).

A digital format may also ease the IBD-specific concern about finding a bathroom when going somewhere in person.

“A digital format may also help the IBD-specific worry over needing to find a bathroom when traveling somewhere in person.”

Classified as probably not a substantial claim.

Few studies have examined such a diverse patient population.

“Few studies focus on such a diverse population of patients.”

• AssumptionRests on an assumption: Few studies focus on such a diverse population of patients.

May combine two claims.

The sample was mostly female, which may restrict generalizability to all sexes.

“Most participants were female, which may limit generalizability across all sexes.”

Classified as probably not a substantial claim.

This study is novel in examining whether digital behavioral medicine is acceptable as psychosocial support for IBD in this population.

“Furthermore, this study is unique in exploring the acceptability of digital behavioral medicine as a potential mode of IBD psychosocial support in this population.”

May combine two claims.

A strength was a well-characterized IBD sample in a large city, with almost one-third born outside the US.

“Strengths of this study include a well-characterized group of patients with IBD in a large metropolitan city, with nearly a third of patients born outside of the United States.”

May combine two claims.

Digital behavioral interventions could deliver psychosocial care through a mobile app and thereby bypass cultural obstacles to seeing a mental health professional.

“Digital behavioral interventions may have the advantage of providing psychosocial care via a mobile health application and so overcome cultural barriers that may exist in seeing a mental healthcare professional.”