Journal Articles
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Item Nationwide Implementation of Unguided Cognitive Behavioral Therapy for Adolescent Depression: Observational Study of SPARX(JMIR Publications, 2024-09-03) Fleming T; Lucassen M; Frampton C; Parag V; Bullen C; Merry S; Shepherd M; Stasiak KBackground: Internet-based cognitive behavioral therapy (iCBT) interventions are effective in clinical trials; however, iCBT implementation data are seldom reported. Objective: The objective of this study is to evaluate uptake, adherence, and changes in symptoms of depression for 12-to 19-year-olds using an unguided pure self-help iCBT intervention (SPARX; Smart, Positive, Active, Realistic, X-factor thoughts) during the first 7 years of it being publicly available without referral in Aotearoa New Zealand. Methods: SPARX is a 7-module, self-help intervention designed for adolescents with mild to moderate depression. It is freely accessible to anyone with a New Zealand Internet Protocol address, without the need for a referral, and is delivered in an unguided “serious game” format. The New Zealand implementation of SPARX includes 1 symptom measure—the Patient Health Questionnaire adapted for Adolescents (PHQ-A)—which is embedded at the start of modules 1, 4, and 7. We report on uptake, the number of modules completed, and changes in depressive symptoms as measured by the PHQ-A. Results: In total, 21,320 adolescents aged 12 to 19 years (approximately 2% of New Zealand 12‐ to 19-year-olds) registered to use SPARX. Of these, 63.6% (n=13,564; comprising n=8499, 62.7% female, n=4265, 31.4% male, and n=800, 5.9% another gender identity or gender not specified; n=8741, 64.4% New Zealand European, n=1941, 14.3% Māori, n=1202, 8.9% Asian, n=538, 4.0% Pacific, and n=1142, 8.4% another ethnic identity; mean age 14.9, SD 1.9 years) started SPARX. The mean PHQ-A at baseline was 13.6 (SD 7.7) with 16.1% (n=1980) reporting no or minimal symptoms, 37.4% (n=4609) reporting mild to moderate symptoms (ie, the target group) and 46.7% (n=5742) reporting moderately severe or severe symptoms. Among those who started, 51.1% (n=6927) completed module 1, 7.4% (n=997) completed at least 4 modules, and 3.1% (n=416) completed all 7 modules. The severity of symptoms reduced from baseline to modules 4 and 7. Mean PHQ-A scores for baseline, module 4, and module 7 for those who completed 2 or more assessments were 14.0 (SD 7.0), 11.8 (SD 7.9), and 10.5 (SD 8.5), respectively; mean difference for modules 1-4 was 2.2 (SD 5.7; P<.001) and for modules 1-7 was 3.6 (SD 7.0; P<.001). Corresponding effect sizes were 0.38 (modules 1-4) and 0.51 (modules 1-7). Conclusions: SPARX reached a meaningful proportion of the adolescent population. The effect size for those who engaged with it was comparable to trial results. However, completion was low. Key challenges included logistical barriers such as slow download speeds and compatibility with some devices. Ongoing attention to rapidly evolving technologies and engagement with them are required. Real-world implementation analyses offer important insights for understanding and improving the impact of evidence-based digital tools and should be routinely reported.Item Effectiveness of a Sodium-Reduction Smartphone App and Reduced-Sodium Salt to Lower Sodium Intake in Adults With Hypertension: Findings From the Salt Alternatives Randomized Controlled Trial.(JMIR Publications, 2023-03-09) Eyles H; Grey J; Jiang Y; Umali E; McLean R; Te Morenga L; Neal B; Rodgers A; Doughty RN; Ni Mhurchu C; Buis LR; Eysenbach GBACKGROUND: Even modest reductions in blood pressure (BP) can have an important impact on population-level morbidity and mortality from cardiovascular disease. There are 2 promising approaches: the SaltSwitch smartphone app, which enables users to scan the bar code of a packaged food using their smartphone camera and receive an immediate, interpretive traffic light nutrition label on-screen alongside a list of healthier, lower-salt options in the same food category; and reduced-sodium salts (RSSs), which are an alternative to regular table salt that are lower in sodium and higher in potassium but have a similar mouthfeel, taste, and flavor. OBJECTIVE: Our aim was to determine whether a 12-week intervention with a sodium-reduction package comprising the SaltSwitch smartphone app and an RSS could reduce urinary sodium excretion in adults with high BP. METHODS: A 2-arm parallel randomized controlled trial was conducted in New Zealand (target n=326). Following a 2-week baseline period, adults who owned a smartphone and had high BP (≥140/85 mm Hg) were randomized in a 1:1 ratio to the intervention (SaltSwitch smartphone app + RSS) or control (generic heart-healthy eating information from The Heart Foundation of New Zealand). The primary outcome was 24-hour urinary sodium excretion at 12 weeks estimated via spot urine. Secondary outcomes were urinary potassium excretion, BP, sodium content of food purchases, and intervention use and acceptability. Intervention effects were assessed blinded using intention-to-treat analyses with generalized linear regression adjusting for baseline outcome measures, age, and ethnicity. RESULTS: A total of 168 adults were randomized (n=84, 50% per group) between June 2019 and February 2020. Challenges associated with the COVID-19 pandemic and smartphone technology detrimentally affected recruitment. The adjusted mean difference between groups was 547 (95% CI -331 to 1424) mg for estimated 24-hour urinary sodium excretion, 132 (95% CI -1083 to 1347) mg for urinary potassium excretion, -0.66 (95% CI -3.48 to 2.16) mm Hg for systolic BP, and 73 (95% CI -21 to 168) mg per 100 g for the sodium content of food purchases. Most intervention participants reported using the SaltSwitch app (48/64, 75%) and RSS (60/64, 94%). SaltSwitch was used on 6 shopping occasions, and approximately 1/2 tsp per week of RSS was consumed per household during the intervention. CONCLUSIONS: In this randomized controlled trial of a salt-reduction package, we found no evidence that dietary sodium intake was reduced in adults with high BP. These negative findings may be owing to lower-than-anticipated engagement with the trial intervention package. However, implementation and COVID-19-related challenges meant that the trial was underpowered, and it is possible that a real effect may have been missed. TRIAL REGISTRATION: Australian New Zealand Clinical Trials Registry ACTRN12619000352101; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=377044 and Universal Trial U1111-1225-4471.Item mHealth Technologies for Managing Problematic Pornography Use: Content Analysis.(JMIR Publications, 2022-10-13) Henry N; Donkin L; Williams M; Pedersen MBackground: Several mobile apps are currently available that purportedly help with managing pornography addiction. However, the utility of these apps is unclear, given the lack of literature on the effectiveness of mobile health solutions for problematic pornography use. Little is also known about the content, structure, and features of these apps. Objective: This study aims to characterize the purpose, content, and popularity of mobile apps that claim to manage pornography addiction. Methods: The phrase “pornography addiction” was entered as a search term in the app stores of the two major mobile phone platforms (Android and iOS). App features were categorized according to a coding scheme that contained 16 categories. Apps were included in the analysis if they were described as helpful for reducing pornography use, and data were extracted from the store descriptions of the apps. Metrics such as number of user ratings, mean rating score, and number of installations were analyzed on a per-feature basis. Results: In total, 170 apps from both app stores met the inclusion criteria. The five most common and popular features, both in terms of number of apps with each feature and minimum possible number of installations, were the ability to track the time since last relapse (apps with feature=72/170, 42.4%; minimum possible number of installations=6,388,000), tutorials and coaching (apps with feature=63/170, 37.1%; minimum possible number of installations=9,286,505), access to accountability partners or communities (apps with feature=51/170, 30%; minimum possible number of installations=5,544,500), content blocking or content monitoring (apps with feature=46/170, 27.1%; minimum possible number of installations=17,883,000), and a reward system for progress (apps with feature=34/170, 20%; minimum possible number of installations=4,425,300). Of these features, content-blocking apps had the highest minimum possible number of installations. Content blocking was also the most detected feature combination in a combinatorial analysis (with 28 apps having only this feature), but it also had the lowest mean consumer satisfaction rating (4.04) and second-lowest median rating (4.00) out of 5 stars. None of the apps reviewed contained references to literature that provided direct evidence for the app’s efficacy or safety. Conclusions: There are several apps with the potential to provide low- or zero-cost real-time interventions for people struggling to manage problematic pornography use. Popular app features include blockers of pornographic content, behavior monitoring, and tutorials that instruct users how to eliminate pornography use. However, there is currently no empirical evidence to support the effectiveness and safety of these apps. Further research is required to be able to provide recommendations about which apps (and app features) are safe for public consumption.Item Recruitment and Retention of Parents of Adolescents in a Text Messaging Trial (MyTeen): Secondary Analysis From a Randomized Controlled Trial(JMIR Publications, 2021-12-20) Chu JTW; Wadham A; Jiang Y; Stasiak K; Shepherd M; Bullen CBackground: Parenting programs are well established as an effective strategy for enhancing both parenting skills and the well-being of the child. However, recruitment for family programs in clinical and nonclinical settings remains low. Objective: This study aims to describe the recruitment and retention methods used in a text messaging program (MyTeen) trial for parents of adolescents (10-15 years) and identify key lessons learned. We aim to provide insights and direction for researchers who seek to recruit parents and build on the limited literature on recruitment and retention strategies for parenting program trials. Methods: A recruitment plan was developed, monitored, and modified as needed throughout the course of the project. Strategies to facilitate recruitment were identified (eg, program content and recruitment material, staff characteristics, and study procedures). Traditional and web-based recruitment strategies were used. Results: Over a 5-month period, 319 parents or caregivers expressed interest in our study, of which 221 agreed to participate in the study, exceeding our recruitment target of 214 participants. Attrition was low at the 1-month (4.5% overall; intervention group: n=5, 4.6%; control group: n=5, 4.5%) and 3-month follow-ups (9% overall; intervention group: n=10, 9.2%; control group: n=10, 8.9%). Conclusions: The use of web-based recruitment strategies appeared to be most effective for recruiting and retaining parents in a text-messaging program trial. However, we encountered recruitment challenges (ie, underrepresentation of ethnic minority groups and fathers) similar to those reported in the literature. Therefore, efforts to engage ethnic minorities and fathers are needed. Trial Registration: Australian New Zealand Clinical Trials Registry ACTRN12618000117213; https://www.anzctr.org.au/Trial/Registration/TrialReview.aspx?id=374307Item HELP@APP: development and evaluation of a self-help app for traumatized Syrian refugees in Germany – a study protocol of a randomized controlled trial(BioMed Central Ltd, 2019-04-30) Golchert J; Roehr S; Berg F; Grochtdreis T; Hoffmann R; Jung F; Nagl M; Plexnies A; Renner A; König H-H; Kersting A; Riedel-Heller SGBackground Syrians represent the largest group among refugees in Germany. Many of them were exposed to sequential traumatizing events including war, escape and post-migration stressors, which significantly increase the risk to develop symptoms of posttraumatic stress and other mental disorders. However, there is a lack of adequate treatment options for traumatized refugees in Germany. Moreover, their access to psychosocial care is often restricted due to legal regulation, language barriers, and unclear cost coverage. We therefore aim to develop a low-threshold supportive self-help app for Syrian refugees with posttraumatic stress symptoms. By conducting a randomized controlled trial, we further aim to evaluate the apps’ efficacy, usability, acceptance, and economic health benefit/cost-effectiveness. Methods We will develop a modular, interactive self-help app in Arabic, which will be grounded on cognitive-behavioral models for the treatment of posttraumatic stress. Subsequently, screened positive (i.e., Syrian refugees, 18–65 years old, mild to moderate posttraumatic stress symptomatology as quantified by the Posttraumatic Stress Diagnostic Scale for DSM-5/PDS-5) participants (ideally up to n = 234) will be randomly allocated to an intervention (IG) and control group (CG), respectively. Participants in the IG will gain access to the self-help app for one month, while participants in the CG will receive psychoeducational reading material in form of a comprehensive brochure on traumatization and posttraumatic stress. Measurements are scheduled before the intervention (T0), directly after the intervention (T1, one month later) and three months after the intervention (T2). Using linear mixed effect models, we will investigate change in posttraumatic symptomatology. We will also test for changes in secondary outcomes such as depression, anxiety, and quality of life. Moreover, we will inspect the usability and user acceptance of the app. To evaluate the app in terms of its economic health benefit, the incremental cost-effectiveness ratio will be calculated. Discussion We plan to make the app freely available to the general public after evaluation. Thus, the app can help to add-on to routine care, which currently lacks sufficient and appropriate treatment options for Syrian refugees. Trial registration German Clinical Trials Register/Deutsches Register Klinischer Studien (DRKS). Registration ID: DRKS00013782. Registered: 06th of July 2018.Item Recruitment and Baseline Characteristics of Participants in the “Sanadak” Trial: A Self-Help App for Syrian Refugees with Post-traumatic Stress(MDPI (Basel, Switzerland), 2020-10) Röhr S; Jung FU; Renner A; Plexnies A; Hoffmann R; Dams J; Grochtdreis T; König H-H; Kersting A; Riedel-Heller SGMany Syrian refugees residing in Germany have been exposed to traumatizing events, while treatment options are scarce. Therefore, the self-help app “Sanadak” was developed to target post-traumatic stress in Syrian refugees. We aimed to inspect the recruitment and baseline characteristics of the participants in the trial, which is conducted to evaluate the app. Analyses were based on the recruitment sample (n = 170) and the trial sample (n = 133). Data were collected during structured face-to-face interviews in the Arabic language. Targeted outcomes included post-traumatic stress (primary; Post-traumatic Diagnostic Scale for DSM-5/PDS-5) and depressive symptoms, anxiety, resilience, among others (secondary). Recruited individuals were M = 32.8 (SD = 11.2, range = 18–65) years old; 38.8% were women. The average PDS-5 score was 23.6 (SD = 13.2) regarding trauma exposure, which was most frequently related to experiencing military- or combat-related events (32.9%). Moreover, 46.5% had major depression and 51.8% showed low resilience. Anxiety was present in 40.6% of the trial participants. Psychological distress was high in Syrian refugees residing in Germany, enrolled in a trial targeting post-traumatic stress. This underlines the need for intervention. Our results provide important figures on the mental health of a not well-studied population group in Germany.Item A Self-Help App for Syrian Refugees With Posttraumatic Stress (Sanadak): Randomized Controlled Trial(JMIR Publications, 2021-01) Röhr S; Jung FU; Pabst A; Grochtdreis T; Dams J; Nagl M; Renner A; Hoffmann R; König H-H; Kersting A; Riedel-Heller SGBackground: Syrian refugees residing in Germany often develop posttraumatic stress as a result of the Syrian civil war, their escape, and postmigration stressors. At the same time, there is a lack of adequate treatment options. The smartphone-based app Sanadak was developed to provide cognitive behavioral therapy–based self-help in the Arabic language for Syrian refugees with posttraumatic stress. Objective: The aim of this study was to evaluate the effectiveness and cost-effectiveness of the app. Methods: In a randomized controlled trial, eligible individuals were randomly allocated to the intervention group (IG; app use) or control group (CG; psychoeducational reading material). Data were collected during structured face-to-face interviews at 3 assessments (preintervention/baseline, postintervention/after 4 weeks, follow-up/after 4 months). Using adjusted mixed-effects linear regression models, changes in posttraumatic stress and secondary outcomes were investigated as intention-to-treat (ITT) and per-protocol (PP) analysis. Cost-effectiveness was evaluated based on adjusted mean total costs, quality-adjusted life years (QALYs), and cost-effectiveness acceptability curves using the net benefit approach. Results: Of 170 screened individuals (aged 18 to 65 years), 133 were eligible and randomized to the IG (n=65) and CG (n=68). Although there was a pre-post reduction in posttraumatic stress, ITT showed no significant differences between the IG and CG after 4 weeks (Posttraumatic Diagnostic Scale for DSM-5, Diff –0.90, 95% CI –0.24 to 0.47; P=.52) and after 4 months (Diff –0.39, 95% CI –3.24 to 2.46; P=.79). The same was true for PP. Regarding secondary outcomes, ITT indicated a treatment effect for self-stigma: after 4 weeks (Self-Stigma of Mental Illness Scale/SSMIS–stereotype agreement: d=0.86, 95% CI 0.46 to 1.25; stereotype application: d=0.60, 95% CI 0.22 to 0.99) and after 4 months (d=0.52, 95% CI 0.12 to 0.92; d=0.50, 95% CI 0.10 to 0.90), the IG showed significantly lower values in self-stigma than the CG. ITT showed no significant group differences in total costs and QALYs. The probability of cost-effectiveness was 81% for a willingness-to-pay of €0 per additional QALY but decreased with increasing willingness-to-pay. Conclusions: Sanadak was not more effective in reducing mild to moderate posttraumatic stress in Syrian refugees than the control condition nor was it likely to be cost-effective. Therefore, Sanadak is not suitable as a standalone treatment. However, as the app usability was very good, no harms detected, and stigma significantly reduced, Sanadak has potential as a bridging aid within a stepped and collaborative care approach. Trial Registration: German Clinical Trials Register DRKS00013782; https://www.drks.de/drks_web/navigate.do?navigationId=trial.HTML&TRIAL_ID=DRKS00013782 International Registered Report Identifier (IRRID): RR2-10.1186/s12888-019-2110-yItem Social isolation, mental health, and use of digital interventions in youth during the COVID-19 pandemic: A nationally representative survey(Cambridge University Press on behalf of the European Psychiatric Association, 2021) Rauschenberg C; Schick A; Goetzl C; Roehr S; Riedel-Heller SG; Koppe G; Durstewitz D; Krumm S; Reininghaus UBackground Public health measures to curb SARS-CoV-2 transmission rates may have negative psychosocial consequences in youth. Digital interventions may help to mitigate these effects. We investigated the associations between social isolation, COVID-19-related cognitive preoccupation, worries, and anxiety, objective social risk indicators, and psychological distress, as well as use of, and attitude toward, mobile health (mHealth) interventions in youth. Methods Data were collected as part of the “Mental Health And Innovation During COVID-19 Survey”—a cross-sectional panel study including a representative sample of individuals aged 16–25 years (N = 666; Mage = 21.3; assessment period: May 5, 2020 to May 16, 2020). Results Overall, 38% of youth met criteria for moderate or severe psychological distress. Social isolation worries and anxiety, and objective risk indicators were associated with psychological distress, with evidence of dose–response relationships for some of these associations. For instance, psychological distress was progressively more likely to occur as levels of social isolation increased (reporting “never” as reference group: “occasionally”: adjusted odds ratio [aOR] 9.1, 95% confidence interval [CI] 4.3–19.1, p < 0.001; “often”: aOR 22.2, CI 9.8–50.2, p < 0.001; “very often”: aOR 42.3, CI 14.1–126.8, p < 0.001). There was evidence that psychological distress, worries, and anxiety were associated with a positive attitude toward using mHealth interventions, whereas psychological distress, worries, and anxiety were associated with actual use. Conclusions Public health measures during pandemics may be associated with poor mental health outcomes in youth. Evidence-based digital interventions may help mitigate the negative psychosocial impact without risk of viral infection given there is an objective need and subjective demand.Item Young People's Attitudes and Motivations Toward Social Media and Mobile Apps for Weight Control: Mixed Methods Study(JMIR Publications, 2019-10-10) Nikolaou CK; Tay Z; Leu J; Rebello SA; Te Morenga L; Van Dam RM; Lean MEJBACKGROUND: Effective prevention at a young enough age is critical to halt the obesity epidemic. Mobile health (mHealth) apps would potentially reach large numbers at low-cost. While there is already a profusion of lifestyle apps, they are mostly non-evidence-based and evidently ineffective against rising obesity prevalence. OBJECTIVE: The aim of this study was to explore preferences and usage of lifestyle apps among young people in 6 countries. METHODS: A mixed methods study was conducted among young people aged 13 to 24 years residing in the United Kingdom, Belgium, Finland, Greece, Singapore, and New Zealand. Participants were recruited from Web advertisements on Facebook, asking for volunteers interested in mobile apps in general, not specific to lifestyle or health, to complete a short survey comprising 18 questions on demographics, weight gain, and mobile app preferences and then to join English-language online focus groups, which were held during 2017, in password-protected Web rooms, moderated by an experienced researcher. Descriptive statistics were carried out for the survey, and thematic analysis was applied to transcripts. RESULTS: A total of 2285 young people (610 adolescents aged 13-17 years and 1675 young adults aged 18-24 years) responded and completed the survey, with 72.0% (1645) reported being concerned about weight gain for themselves or friends. Later, 807 young people (376 adolescents and 431 young adults) were selected based on age and country to participate in 12 online focus groups, with 719 young people completing. Analysis revealed 4 main themes: (1) feelings toward personal weight; (2) perception of lifestyle apps and desired content for weight gain prevention; (3) social media apps, lifestyle apps, and motivation for downloading and retaining; and (4) data safety and data usage and confidentiality. Young people are interested in evidence-based advice in programs incorporating their preferences. CONCLUSIONS: Young people are commonly, and consistently across 6 countries, concerned about weight gain and obesity and would welcome evidence-based mHealth programs, provided the views of young people themselves are incorporated in the program content.Item A Co-Designed, Culturally-Tailored mHealth Tool to Support Healthy Lifestyles in Māori and Pasifika Communities in New Zealand: Protocol for a Cluster Randomized Controlled Trial(JMIR Publications, 22/08/2018) Verbiest M; Borrell S; Dalhousie S; Tupa'i-Firestone R; Funaki T; Goodwin D; Grey J; Henry A; Hughes E; Humphrey G; Jiang Y; Jull A; Pekepo C; Schumacher J; Te Morenga L; Tunks M; Vano M; Whittaker R; Ni Mhurchu CBACKGROUND: New Zealand urgently requires scalable, effective, behavior change programs to support healthy lifestyles that are tailored to the needs and lived contexts of Māori and Pasifika communities. OBJECTIVE: The primary objective of this study is to determine the effects of a co-designed, culturally tailored, lifestyle support mHealth tool (the OL@-OR@ mobile phone app and website) on key risk factors and behaviors associated with an increased risk of noncommunicable disease (diet, physical activity, smoking, and alcohol consumption) compared with a control condition. METHODS: A 12-week, community-based, two-arm, cluster-randomized controlled trial will be conducted across New Zealand from January to December 2018. Participants (target N=1280; 64 clusters: 32 Māori, 32 Pasifika; 32 clusters per arm; 20 participants per cluster) will be individuals aged ≥18 years who identify with either Māori or Pasifika ethnicity, live in New Zealand, are interested in improving their health and wellbeing or making lifestyle changes, and have regular access to a mobile phone, tablet, laptop, or computer and to the internet. Clusters will be identified by community coordinators and randomly assigned (1:1 ratio) to either the full OL@-OR@ tool or a control version of the app (data collection only plus a weekly notification), stratified by geographic location (Auckland or Waikato) for Pasifika clusters and by region (rural, urban, or provincial) for Māori clusters. All participants will provide self-reported data at baseline and at 4- and 12-weeks postrandomization. The primary outcome is adherence to healthy lifestyle behaviors measured using a self-reported composite health behavior score at 12 weeks that assesses smoking behavior, fruit and vegetable intake, alcohol intake, and physical activity. Secondary outcomes include self-reported body weight, holistic health and wellbeing status, medication use, and recorded engagement with the OL@-OR@ tool. RESULTS: Trial recruitment opened in January 2018 and will close in July 2018. Trial findings are expected to be available early in 2019. CONCLUSIONS: Currently, there are no scalable, evidence-based tools to support Māori or Pasifika individuals who want to improve their eating habits, lose weight, or be more active. This wait-list controlled, cluster-randomized trial will assess the effectiveness of a co-designed, culturally tailored mHealth tool in supporting healthy lifestyles. TRIAL REGISTRATION: Australia New Zealand Clinical Trials Register ACTRN12617001484336; http://www.ANZCTR.org.au/ACTRN12617001484336.aspx (Archived by WebCite at http://www.webcitation.org/71DX9BsJb). REGISTERED REPORT IDENTIFIER: RR1-10.2196/10789.