Overall, all prediction models with mental health measures resulted in only a small amount of explained variance regarding substance use. Despite a mental burden that was heightened compared to normative samples and a subgroup of individuals who increased their alcohol and nicotine use, the association between mental health and substance use increase was not strong. Substance use to cope with anxiety and depression was, perhaps, not the main motive for increases in the use of alcohol and other substances. Characteristics of the sample may give an indication as to the causes for this lack of association. Women in this sample were highly educated, and their professions and occupational situations indicated a high socioeconomic status. The vast majority were not affected by job loss or short-time work and had not been indebted due to COVID-19, so existential concerns were unlikely. These results correspond with the findings from a large-scale, population-based study in the EU, which found that in the high-income groups an increase in alcohol use depended on the experience of financial distress. Individuals with a high income and no financial distress were more likely to decrease their alcohol use. The privileged baseline of the present sample may be associated with more individual resources to cope functionally with any psychological distress that arose due to COVID-19 rather than using substances. Although alcohol consumption is generally higher in the high socioeconomic status group of women than in the low/middle socioeconomic status group,mobile vertical rack the study population did not show an excessive increase in terms of alcohol consumption.
Preexisting social inequalities in health were highlighted by the COVID-19 pandemic. Epidemiological evidence shows that morbidity and mortality risk of COVID-19 is higher in individuals with a low socioeconomic status. Incidence rates were higher in districts and neighborhoods where a low socioeconomic status dominates. This correlation might be explained by the fact that more people in these populations work in jobs that involve personal contact or mobility and cannot be done from home, or they work in jobs with low social security or are easily threatened with dismissal. This leads to more contact situations with a risk for COVID-19 transmission. In addition, some non-communicable diseases are risk factors for severe COVID-19 progression and are over represented in individuals with a low socioeconomic status. These social- and health-related disadvantages played a subordinate role in this sample, which may have meant that objective and subjective threats to their own health and social situation were less pronounced in this sample. The prevention of mental disorders and hazardous substance use due to COVID-19 are of public health relevance as both lead to a high individual and societal burden. To prevent mental distress and dysfunctional coping with alcohol or other substances, groups that are more vulnerable should be focused on.The prevention of hazardous alcohol use in the course of the current or any future collective crisis should promote social support in the community. E-mental health applications also offer a broad range of opportunities to promote mental health in times of social distancing. Future e-mental health applications should also address dysfunctional substance use as an important facet of mental and physical health. The study reports on a large sample of women in the general population of Germany during the second wave of COVID-19; nevertheless, some limitations need to be considered. An online survey was used to collect the data. Thus, the possibility of selection bias needs to be considered. In addition, results may be biased in terms of socioeconomic status since high socioeconomic status was over represented. The sample does not reflect the average situation of women in Germany. It may be that the association between mental burden and substance would have been different if the sample had been more diverse.
Due to the cross-sectional design, it is not possible to interpret mental health measures without considering that they might have been heightened before COVID-19 and that the pandemic was not causative. Moreover, mental health screening instruments do not allow the proper diagnoses of mental health disorders to be made. With regard to substance use, the quantification of substance use before COVID-19 was limited, so it remains unclear as to what extent substance use increased.Heavy substance use is associated with serious physical and psychological consequences . The risk of developing a substance use disorder is heightened during reproductive years and substance use is prevalent during pregnancy. 11–15% of pregnant individuals reporting use of alcohol, tobacco, cannabis and/or illicit substances. The actual prevalence may be higher, as stigma and judgement may cause some pregnant people to be hesitant to report substance use. Heavy substance use in pregnancy has serious short and long-term consequences, including elevated risk of miscarriage, low birthweight, infant mortality, and sudden infant death syndrome. Long term outcomes for children exposed to substances in-utero vary . For example, prenatal cannabis use has been linked to reduced attention and executive functioning skills, poor academic achievement, and increased behavioural problems. Prenatal drinking has been linked to multiple long-term effects including cognitive and behavioural issues, executive functioning deficits, and poor psychosocial outcomes. Given the high prevalence of substance use in pregnancy and its serious associated harms, it is imperative that pregnant individuals receive access to evidence-based supports. Despite results which have shown the effectiveness of psychological interventions in treating substance abuse, the literature has consistently found that in the general population, people often do not seek addiction and mental health services . Potential obstacles to treatment include limited resources, time conflicts, and stigma.Pregnant individuals, especially individuals belonging to marginalized ethnic and socioeconomic groups, are also more likely to be experience arrest, prosecution, conviction and/or child removal related to substance use disclosure, contributing to increased hesitancy to seek help. Concerns about separation from family, as well as a lack of childcare are also known treatment barriers for pregnant individuals who use substances. eHealth is an emerging field that is attracting attention for a variety of mental health conditions. eHealth focuses on the delivery of health services and information through web-based programs, remote monitoring, teleconsultation, and mobile device-supported care. eHealth is a potential avenue to address substance use treatment barriers in pregnancy, particularly during COVID-19, which has disrupted a number of face-to-face psychotherapy services.
Beyond COVID-19, eHealth initiatives have the potential for broad scale health promotion for substance use. eHealth is accessible, vertical grow rack which may make it more appealing to those in remote locations. Additionally, it is cost-effective, and can be flexibly incorporated into one’s schedule. Given the accessible nature of eHealth interventions, some pregnant individuals may prefer to use eHealth interventions as opposed to traditional face to face treatment. Treatment preference is important to consider because matching patients to their treatment preferences has been shown to result in greater reduction of substance use behaviours. Moreover, patient centered care is one of the techniques that has been recommended to improve the quality of substance use disorder treatment—and a key aspect of patient centered care is shared decision making. A number of meta-analyses of eHealth interventions for treatment of substance use disorders in the general population have been conducted, with promising results; however, the literature in for eHealth interventions treating substance use in pregnancy has yet to be integrated as a review. Accordingly, the primary objective of this systematic review and meta-analysis was to evaluate the effectiveness of randomized controlled trials on eHealth interventions delivered during pregnancy with the goal of reducing substance use, where substance use was defined broadly to include any kind of reported alcohol, tobacco, or other drugs. This definition, which includes a variety of substances at varying levels of use was justified by guidelines suggesting that all substance use should be avoided during pregnancy. Substance use was measured by self-reported and objective reports of abstinence. Two team members independently extracted data into a Microsoft Excel file and conflicts were resolved by consensus with the coders and the first and second authors. Extracted data included authors’ names, publication years, country, sample demographics, pregnancy characteristics, substance use parameters, intervention characteristics and administration, and mental health assessments for all groups. Sample characteristics that were extracted when provided included sample size, age, gestational age, ethnicity, race, and gender breakdown. Study characteristics that were extracted when provided included the name of intervention, description, method of administration, degree of interactivity , degree of guidance, and participant time spent on the intervention. The outcomes extracted were odds ratios measuring substance use outcomes post-intervention. Corresponding authors of included articles were contacted if studies had missing or incomplete data. A random effects meta-analysis was conducted using Comprehensive Meta-Analysis Software. Most studies reported ORs, and these were used to calculate meta-estimates of substance use post-intervention in the intervention groups compared to the control groups. Ref. was the only study to report chi-squares, which were transformed to ORs through the CMA software. Some studies had several post tests and outcomes . To meet the assumption of independence, effect sizes from the same study were aggregated in CMA and the single effect size estimate for each study was used to calculate pooled ORs.
A forest plot was also created to display the ORs for each individual study as well as the pooled OR from all the studies. To test for publication bias, the Begg and Mazumdar rank correlation test as well as the Egger’s regression test were performed to assess bias by regressing standardized effect size to the studies precision. A significant test indicates publication bias, or significant funnel plot asymmetry . Meta-regression analyses were originally planned to explore significant moderators and explore secondary outcomes; however, not enough studies were included to complete these analyses. Sensitivity analyses were also completed to assess the robustness of the synthesized results.To assess the quality of the RCT studies, the Cochrane Risk of Bias Tool for randomized trials was used. This tool assesses literature based on seven potential sources of bias within the general categories of selection bias , performance and detection bias , attrition bias and selective reporting bias. Bias was judged individually by a team member and then cross-referenced by the judgment of another team member to complete a 100% check. Total scores range from 0 , to 7 . Higher scores indicate lower study quality and a higher risk of biased results. The study informally defined scores from 0–2 as low risk, scores from 3–5 as moderate risk, and scores between 6–7 as high risk. The current review aimed to determine whether eHealth interventions delivered during pregnancy reduced substance use when compared to a control group. Substance use was measured using self-reports of frequency and quantity of substances taken, as well as self-report measures of abstinence and objective measures of abstinence. Objective forms of abstinence were defined as a biochemical measure of substance use. For example, in certain studies where smoking was the outcome, carbon monoxide readings and/or saliva samples were tested for a certain amount of cotinine. This search was originally conducted with an associated study , which reviewed eHealth interventions in pregnancy for treatment of depression, anxiety, and insomnia. A wider search was conducted to include substance use for the purposes of this paper. The search identified 5505 relevant articles, with 2945 duplicates removed. In total, 2367 of the articles were excluded after title and abstract review and 193 articles were reviewed at the full-text level. A total of 6 articles met inclusion criteria for this review. See Figure 1 for the PRISMA diagram. Table 1 provides characteristics of the included studies. Participant baseline age ranged from 18–37 years old. Gestational age ranged from 4–23 weeks. Of the four studies which reported ethnicity, three studies had a total sample where >85% of participants were of European descent . With respect to the type of eHealth interventions, most of the interventions were created in a way that communication of services took place through the use of technology , rather than the use of a specific app to reduce substance use behaviours. Four of the eHealth interventions were delivered via computer or the internet, one was delivered through text message and one was delivered via telephone. The types of interventions that were delivered included: motivational interviewing in one study, the use of general health advice in three studies , and psychoeducation in two studies.