Digital health interventions (DHIs), including computer-assisted therapy, smartphone apps and wearable technologies, are heralded as having enormous potential to improve uptake and accessibility, efficiency, clinical effectiveness and personalisation of mental health interventions. It is generally assumed that DHIs will be preferred by children and young people (CYP) given their ubiquitous digital activity. However, it remains uncertain whether: DHIs for CYP are clinically and cost-effective, CYP prefer DHIs to traditional services, DHIs widen access and how they should be evaluated and adopted by mental health services. This review evaluates the evidence-base for DHIs and considers the key research questions and approaches to evaluation and implementation. We conducted a meta-review of scoping, narrative, systematic or meta-analytical reviews investigating the effectiveness of DHIs for mental health problems in CYP. We also updated a systematic review of randomised controlled trials (RCTs) of DHIs for CYP published in the last 3 years. Twenty-one reviews were included in the meta-review. The findings provide some support for the clinical benefit of DHIs, particularly computerised cognitive behavioural therapy (cCBT), for depression and anxiety in adolescents and young adults. The systematic review identified 30 new RCTs evaluating DHIs for attention deficit/hyperactivity disorder (ADHD), autism, anxiety, depression, psychosis, eating disorders and PTSD. The benefits of DHIs in managing ADHD, autism, psychosis and eating disorders are uncertain, and evidence is lacking regarding the cost-effectiveness of DHIs. Key methodological limitations make it difficult to draw definitive conclusions from existing clinical trials of DHIs. Issues include variable uptake and engagement with DHIs, lack of an agreed typology/taxonomy for DHIs, small sample sizes, lack of blinded outcome assessment, combining different comparators, short-term follow-up and poor specification of the level of human support. Research and practice recommendations are presented that address the key research questions and methodological issues for the evaluation and clinical implementation of DHIs for CYP.

https://nottingham-repository.worktribe.com/preview/835825/Hollis%20et%20al%202016%20-%20accepted%20publication.pdf

Annual Research Review: Digital health interventions for children and young people with mental health problems – a systematic and meta‐review

Can smartphone mental health interventions reduce symptoms of anxiety? A meta-analysis of randomized controlled trials.

Background - The Mobile Application Rating Scale (MARS) provides a reliable method to assess the quality of mobile health (mHealth) apps. However, training and expertise in mHealth and the relevant health field is required to administer it. Objective - This study describes the development and reliability testing of an end-user version of the MARS (uMARS). Methods - The MARS was simplified and piloted with 13 young people to create the uMARS. The internal consistency and test-retest reliability of the uMARS was then examined in a second sample of 164 young people participating in a randomized controlled trial of a mHealth app. App ratings were collected using the uMARS at 1-, 3,- and 6-month follow up. Results - The uMARS had excellent internal consistency (alpha = .90), with high individual alphas for all subscales. The total score and subscales had good test-retest reliability over both 1-2 months and 3 months. Conclusions - The uMARS is a simple tool that can be reliably used by end-users to assess the quality of mHealth apps.

/pdf/development-and-validation-of-the-user-version-of-the-mobile-7nxm5cwykg.pdf

Development and Validation of the User Version of the Mobile Application Rating Scale (uMARS)

The potential of smartphone apps to improve quality and increase access to mental health care is increasingly clear. Yet even in the current global mental health crisis, real-world uptake of smartphone apps by clinics or consumers remains low. To understand this dichotomy, this paper reviews current challenges surrounding user engagement with mental health smartphone apps. While smartphone engagement metrics and reporting remains heterogeneous in the literature, focusing on themes offers a framework to identify underlying trends. These themes suggest that apps are not designed with service users in mind, do not solve problems users care most about, do not respect privacy, are not seen as trustworthy and are unhelpful in emergencies. Respecting these current issues surrounding mental health app engagement, we propose several solutions and highlight successful examples of mental health apps with high engagement. Further research is necessary to better characterise engagement with mental health apps and identify best practices for design, testing and implementation.

Clinical review of user engagement with mental health smartphone apps: evidence, theory and improvements.

BACKGROUND Understanding patterns of real-world usage of mental health apps is key to maximizing their potential to increase public self-management of care. Although developer-led studies have published results on the use of mental health apps in real-world settings, no study yet has systematically examined usage patterns of a large sample of mental health apps relying on independently collected data. OBJECTIVE Our aim is to present real-world objective data on user engagement with popular mental health apps. METHODS A systematic engine search was conducted using Google Play to identify Android apps with 10,000 installs or more targeting anxiety, depression, or emotional well-being. Coding of apps included primary incorporated techniques and mental health focus. Behavioral data on real-world usage were obtained from a panel that provides aggregated nonpersonal information on user engagement with mobile apps. RESULTS In total, 93 apps met the inclusion criteria (installs: median 100,000, IQR 90,000). The median percentage of daily active users (open rate) was 4.0% (IQR 4.7%) with a difference between trackers (median 6.3%, IQR 10.2%) and peer-support apps (median 17.0%) versus breathing exercise apps (median 1.6%, IQR 1.6%; all z≥3.42, all P<.001). Among active users, daily minutes of use were significantly higher for mindfulness/meditation (median 21.47, IQR 15.00) and peer support (median 35.08, n=2) apps than for apps incorporating other techniques (tracker, breathing exercise, psychoeducation: medians range 3.53-8.32; all z≥2.11, all P<.05). The medians of app 15-day and 30-day retention rates were 3.9% (IQR 10.3%) and 3.3% (IQR 6.2%), respectively. On day 30, peer support (median 8.9%, n=2), mindfulness/meditation (median 4.7%, IQR 6.2%), and tracker apps (median 6.1%, IQR 20.4%) had significantly higher retention rates than breathing exercise apps (median 0.0%, IQR 0.0%; all z≥2.18, all P≤.04). The pattern of daily use presented a descriptive peak toward the evening for apps incorporating most techniques (tracker, psychoeducation, and peer support) except mindfulness/meditation, which exhibited two peaks (morning and night). CONCLUSIONS Although the number of app installs and daily active minutes of use may seem high, only a small portion of users actually used the apps for a long period of time. More studies using different datasets are needed to understand this phenomenon and the ways in which users self-manage their condition in real-world settings.

/pdf/objective-user-engagement-with-mental-health-apps-systematic-12krodm4vh.pdf

Objective User Engagement With Mental Health Apps: Systematic Search and Panel-Based Usage Analysis.

Background: The use of mobile apps for health and well being promotion has grown exponentially in recent years. Yet, there is currently no app-quality assessment tool beyond “star”-ratings. Objective: The objective of this study was to develop a reliable, multidimensional measure for trialling, classifying, and rating the quality of mobile health apps. Methods: A literature search was conducted to identify articles containing explicit Web or app quality rating criteria published between January 2000 and January 2013. Existing criteria for the assessment of app quality were categorized by an expert panel to develop the new Mobile App Rating Scale (MARS) subscales, items, descriptors, and anchors. There were sixty well being apps that were randomly selected using an iTunes search for MARS rating. There were ten that were used to pilot the rating procedure, and the remaining 50 provided data on interrater reliability. Results: There were 372 explicit criteria for assessing Web or app quality that were extracted from 25 published papers, conference proceedings, and Internet resources. There were five broad categories of criteria that were identified including four objective quality scales: engagement, functionality, aesthetics, and information quality; and one subjective quality scale; which were refined into the 23-item MARS. The MARS demonstrated excellent internal consistency (alpha = .90) and interrater reliability intraclass correlation coefficient (ICC = .79). Conclusions: The MARS is a simple, objective, and reliable tool for classifying and assessing the quality of mobile health apps. It can also be used to provide a checklist for the design and development of new high quality health apps.

/pdf/mobile-app-rating-scale-a-new-tool-for-assessing-the-quality-4l93hi29up.pdf

Mobile App Rating Scale: A New Tool for Assessing the Quality of Health Mobile Apps

Background There is growing evidence for the positive impact of mindfulness on wellbeing. Mindfulness-based mobile apps may have potential as an alternative delivery medium for training. While there are hundreds of such apps, there is little information on their quality. Objective This study aimed to conduct a systematic review of mindfulness-based iPhone mobile apps and to evaluate their quality using a recently-developed expert rating scale, the Mobile Application Rating Scale (MARS). It also aimed to describe features of selected high-quality mindfulness apps. Methods A search for “mindfulness” was conducted in iTunes and Google Apps Marketplace. Apps that provided mindfulness training and education were included. Those containing only reminders, timers or guided meditation tracks were excluded. An expert rater reviewed and rated app quality using the MARS engagement, functionality, visual aesthetics, information quality and subjective quality subscales. A second rater provided MARS ratings on 30% of the apps for inter-rater reliability purposes. Results The “mindfulness” search identified 700 apps. However, 94 were duplicates, 6 were not accessible and 40 were not in English. Of the remaining 560, 23 apps met inclusion criteria and were reviewed. The median MARS score was 3.2 (out of 5.0), which exceeded the minimum acceptable score (3.0). The Headspace app had the highest average score (4.0), followed by Smiling Mind (3.7), iMindfulness (3.5) and Mindfulness Daily (3.5). There was a high level of inter-rater reliability between the two MARS raters. Conclusions Though many apps claim to be mindfulness-related, most were guided meditation apps, timers, or reminders. Very few had high ratings on the MARS subscales of visual aesthetics, engagement, functionality or information quality. Little evidence is available on the efficacy of the apps in developing mindfulness.

/pdf/review-and-evaluation-of-mindfulness-based-iphone-apps-3q8n29lyes.pdf

Review and Evaluation of Mindfulness-Based iPhone Apps.

Background

There is growing evidence for the positive impact of mindfulness on wellbeing. Mindfulness-based mobile apps may have potential as an alternative delivery medium for training. While there are hundreds of such apps, there is little information on their quality.

Objective

This study aimed to conduct a systematic review of mindfulness-based iPhone mobile apps and to evaluate their quality using a recently-developed expert rating scale, the Mobile Application Rating Scale (MARS). It also aimed to describe features of selected high-quality mindfulness apps.

Methods

A search for “mindfulness” was conducted in iTunes and Google Apps Marketplace. Apps that provided mindfulness training and education were included. Those containing only reminders, timers or guided meditation tracks were excluded. An expert rater reviewed and rated app quality using the MARS engagement, functionality, visual aesthetics, information quality and subjective quality subscales. A second rater provided MARS ratings on 30% of the apps for inter-rater reliability purposes.

Results

The “mindfulness” search identified 700 apps. However, 94 were duplicates, 6 were not accessible and 40 were not in English. Of the remaining 560, 23 apps met inclusion criteria and were reviewed. The median MARS score was 3.2 (out of 5.0), which exceeded the minimum acceptable score (3.0). The Headspace app had the highest average score (4.0), followed by Smiling Mind (3.7), iMindfulness (3.5) and Mindfulness Daily (3.5). There was a high level of inter-rater reliability between the two MARS raters.

Conclusions

Though many apps claim to be mindfulness-related, most were guided meditation apps, timers, or reminders. Very few had high ratings on the MARS subscales of visual aesthetics, engagement, functionality or information quality. Little evidence is available on the efficacy of the apps in developing mindfulness.

Review and evaluation of mindfulness-based iPhone apps

Smartphone technology provides free or inexpensive access to mental health and wellbeing resources. As a
result the use of mobile applications for these purposes has increased significantly in recent years. Yet, there is
currently no app quality assessment alternative to the popular ‘star’-ratings, which are often unreliable. This
presentation describes the development of the Mobile Application Rating Scale (MARS) a new measure for
classifying and rating the quality of mobile applications. A review of existing literature on app and web quality
identified 25 published papers, conference proceedings, and online resources (published since 1999), which
identified 372 explicit quality criteria. Qualitative analysis identified five broad categories of app quality rating criteria: engagement, functionality, aesthetics, information quality, and overall satisfaction, which were refined into the 23-item MARS. Independent ratings of 50 randomly selected mental health and wellbeing mobile apps
indicated the MARS had excellent levels of internal consistency (α = 0.92) and inter-rater reliability (ICC = 0.85).

The MARS provides practitioners and researchers with an easy-to-use, simple, objective and reliable tool for
assessing mobile app quality. It also provides mHealth professionals with a checklist for the design and
development of high quality apps.

The Mobile Application Rating Scale (MARS): A new tool to measure the quality of health mobile applications

University students can experience low levels of quality of life (QoL). Previous research has indicated a positive relationship between spirituality and QoL. The objective of this study was to examine the association between QoL and spirituality in Indian post-graduate university students. It was hypothesised that higher levels of QoL would be associated with higher levels of spiritual beliefs, spiritual practices, sense of purpose/connectedness and sense of hope/control after adjusting for a range of demographic variables and perceived social support. A group of 475 post-graduate university students (241 males and 234 females) from Pondicherry, India, participated in this cross-sectional study. Data was collected by using demographics, as well as the World Health Organisation’s QoL-BREF Questionnaire and the Spirituality Attitude Inventory. The results indicated that religiosity was not associated with QoL in this sample. However existential wellbeing was independently associated with Physical Health QoL, Psychological QoL, and Environmental QoL; while a sense of hope/control was independently associated with Physical Health QoL, Social QoL and Environmental QoL. Negative religious coping had the strongest association with all of the measures of QoL. These results provide evidence that higher levels of spirituality are associated with higher levels of QoL in Indian university students. The findings of the study support the need for further interventional studies examining the promotion of spirituality in Indian university students in order to improve their QoL.

/pdf/quality-of-life-and-spirituality-in-indian-university-3gutx793ms.pdf

Madhavan Mani

Papers

Mobile App Rating Scale: A New Tool for Assessing the Quality of Health Mobile Apps

Review and Evaluation of Mindfulness-Based iPhone Apps.

Review and evaluation of mindfulness-based iPhone apps

The Mobile Application Rating Scale (MARS): A new tool to measure the quality of health mobile applications

Quality of Life and Spirituality in Indian University Students