Developing and evaluating MindMax: promoting mental wellbeing through an Australian Football League-themed app incorporating applied games (including gamification), psychoeducation, and social connectedness

Gamification is increasingly being used as a behavioural change strategy to increase engagement with apps and technologies for mental health and wellbeing. While there is promising evidence supporting the effectiveness of individual gamification elements, there remains little evidence for its overall effectiveness. Furthermore, a lack of consistency in how ‘gamification’ and related terms (such as ‘applied games’, an umbrella term of which gamification is one type) are used has been observed within and across multiple academic fields. This contributes to the difficulty of studying gamification and decreases its accessibility to people unfamiliar with applied games. Finally, gamification has also been critiqued by both game developers and by academics for its reliance on extrinsic motivators and for the messages that gamified systems may unintentionally convey. In this context, the aims of this thesis were fourfold: 1) to iteratively co-design and develop a gamified app for mental health and wellbeing, 2) to evaluate the eventuating app, 3) to consolidate literature on gamification for mental health and wellbeing, and 4) to synthesise findings into practical guidelines for implementing gamification for mental health and wellbeing. Chapter 2 reports the first study which addresses the first aim of this thesis. Six participatory design workshops were conducted to support the development of MindMax, an Australian Football League (AFL)-themed mobile phone app aimed at AFL fans (particularly male ones) that incorporates applied games, psychoeducation, and social connectedness. Findings from these workshops were independently knowledge translated and fed back to the software development team, resulting in a MindMax prototype. This prototype was further tested with 15 one-on-one user experience testing interviews at three separate time points to iteratively refine MindMax’s design and delivery of its content. The findings of this study suggest that broadly, participants endorsed a customisable user experience with activities requiring active user participation. These specifications were reflected in the continual software updates made to MindMax. Chapters 3 and 4 report the second and third studies which address the second aim of this thesis. As regular content, performance, and aesthetic updates were applied to MindMax (following the model of the wider tech industry), a naturalistic longitudinal trial, described in Chapter 3, was deemed to be the most appropriate systematic evaluation method. In this study, participants (n=313) were given access to MindMax and asked to use it at their leisure, and surveys were sent out at multiple time points to assess their wellbeing, resilience, and help-seeking intentions. Increases in flourishing (60-day only), sense of connection to MindMax, and impersonal help-seeking intentions were observed over 30 and 60 days, suggesting that Internet-based interventions like MindMax can contribute to their users’ social connectedness and encourage their help-seeking. The third study, described in Chapter 4, reports a secondary analysis of data collected for Chapter 3, and further explores participants’ help-seeking intentions and their links to wellbeing, resilience, gender, and age. An explanatory factor analysis was conducted on Day 1 General Help-Seeking Questionnaire (GHSQ) data (n=530), with the best fitting solution resulting in three factors: personal sources, health professionals, and distal sources. In addition to providing more evidence that younger people aged 16–35 categorise apps and technologies for mental health and wellbeing like MindMax alongside other distal social sources such as phone helplines and work or school, our findings also suggest that the best way to target individuals who are least likely to seek help, particularly men, may be through these distal sources as well. Chapter 5 reports the fourth study, which addresses the third aim. In order to consolidate literature on gamification for mental health and wellbeing, this systematic review identified 70 papers that collectively reported on 50 apps and technologies for improving mental health and wellbeing. These papers were coded for gamification element, mental health and wellbeing domain, and researchers’ justification for applying gamification to improving mental health and wellbeing. This study resulted in two major findings: first, that the current application of gamification for mental health and wellbeing does not resemble the heavily critiqued mainstream application that relies on extrinsic motivators; and second, that many authors of the reviewed papers provided little or no justification for why they applied gamification to their mental health and wellbeing interventions. While the former finding is encouraging, the latter suggests that the gamification of mental health and wellbeing is not theory-driven, and is a cause for concern. Finally, to address the final aim of this thesis, all study learnings were synthesised into practical guidelines for implementing gamification for mental health and wellbeing. First, it is important to assess the suitability of implementing gamification into the intervention. Second, this implementation should ideally be integrated at a deeper, systemic level, with the explicitly qualified intention to support users, evidence-based processes, and user engagement with these processes. Third, it is important to assess the acceptability of this gamified intervention throughout its development, involving all relevant stakeholders (particularly representative end user populations). Fourth, it is important to evaluate the impact of this gamified intervention. Fifth, and finally, comprehensive and detailed documentation of this process should be provided at all stages of this process. This thesis contributes to a growing literature on the increasing importance and relevance of Internet-based resources and apps and technologies for mental health and wellbeing, particularly for young people. Given the dominance of games in society and culture across history, and the increasing contemporary prominence of digital games (also known as video games) in particular, gamification is uniquely positioned to have the potential to make large contributions to mental health and wellbeing research. In this context, this thesis contributes a systematically derived operationalisation of gamification, an evaluation of a gamified app for mental health and wellbeing, and best practice guidelines for implementing gamification for mental health and wellbeing, thereby providing frameworks that future implementations of gamified mental health and wellbeing interventions and initiatives may find useful

FitMindKit : Randomised controlled trial of an automatically tailored online program for mood, anxiety, substance use and suicidality

Purpose: Online mental health programs can be effective in reducing symptoms of depression, anxiety disorders, substance use and suicidal ideation. However, most existing e-mental health programs focus on a single domain of mental health, neglecting comorbidity. Furthermore, few programs are tailored to the symptom patterns of the individual user. FitMindKit was designed to overcome the gaps of existing e-mental health programs, providing tailored, transdiagnostic therapeutic content to address a range of comorbid mental health symptoms. A trial was conducted to test the program's efficacy. Methods: Australian adults with elevated symptoms of depression, anxiety, suicidal ideation and/or substance use were recruited through social media, with n = 194 randomised into a fully-automated trial of a 10-day brief intervention. Participants were randomly allocated to receive FitMindKit tailored to their symptoms, an untailored generic version of FitMindKit, or an attention control. Results: Mixed model repeated measures ANOVA indicated that participants in both FitMindKit and the attention control had significant reductions in symptom composite scores. Effects were not significantly greater in the FitMindKit program relative to control, either at post-test or 3-month follow-up. No effects were detected for specific decreases in depression, generalized anxiety, social anxiety, panic, suicidal ideation or alcohol/substance use. There were no significant differences between the tailored and static versions in effectiveness or adherence. Participants in the tailored and static conditions were more satisfied than in the control condition, with some evidence favouring the tailored condition. High attrition reduced power to find effects. Conclusions: FitMindKit provides a model for addressing comorbid mental health symptoms in an online program, using automated tailoring to symptom patterns. Modifications to the program are recommended, along with the need for larger trials to test the effects of tailoring on mental health outcomes.The development of FitMindKit was supported by a grant from AFFIRM, The Australian Foundation for Mental Health Research, and the John James Memorial Foundation. The development of the RCT and recruitment of young people into the RCT was supported by a grant from Australian Rotary Health. PJB and ALC are supported by NHMRC Fellowships 1083311 and 1122544 respectively

Robust estimation of bacterial cell count from optical density

Optical density (OD) is widely used to estimate the density of cells in liquid culture, but cannot be compared between instruments without a standardized calibration protocol and is challenging to relate to actual cell count. We address this with an interlaboratory study comparing three simple, low-cost, and highly accessible OD calibration protocols across 244 laboratories, applied to eight strains of constitutive GFP-expressing E. coli. Based on our results, we recommend calibrating OD to estimated cell count using serial dilution of silica microspheres, which produces highly precise calibration (95.5% of residuals <1.2-fold), is easily assessed for quality control, also assesses instrument effective linear range, and can be combined with fluorescence calibration to obtain units of Molecules of Equivalent Fluorescein (MEFL) per cell, allowing direct comparison and data fusion with flow cytometry measurements: in our study, fluorescence per cell measurements showed only a 1.07-fold mean difference between plate reader and flow cytometry data

A sense of belonging: Pokémon GO and social connectedness

The free-to-play mobile game Pokémon GO’s (PGO) use of real-world mapping encourages play in public spaces, opening up the possibility of greater engagement with other players, local communities, and surrounds. This study conducted a series of interviews (<i>N</i> = 15) and collected online social forum reports of gameplay (<i>N</i> = 880), in order to determine what the social outcomes of play may be and what mechanisms might be facilitating the social connectedness. Thematic analysis revealed that playing PGO produced a sense of belonging, linked to a sense of place, as well as facilitating conversations with strangers and strengthening social ties. This was due to the use of accessible technology able to be integrated into daily routines, shared passion for the game, and mechanics that encouraged players out of their homes. “Shared passion” was tied to the nostalgic connection many players felt for the franchise. This study shows how gameplay can build social connectedness through real-world engagement

Flip the clinic: a digital health approach to youth mental health service delivery

UNSTRUCTURED: Mental health service demand is projected to rapidly increase as a direct and indirect result of the COVID-19 pandemic. Given that young people are disproportionately disadvantaged by mental illness and will face further challenges from COVID-19, it is crucial that the appropriate mental health care be delivered to them as early as possible. Integrating digital health solutions into mental health service delivery pathways has the potential to greatly increase efficiencies, allowing for the provision of 'right care, first time'. We propose an innovative digital health solution for demand management intended for use by primary youth mental health services, comprised of: 1) a youth mental health model of care (i.e. BMC Youth Model); and 2) a health information technology specifically designed to deliver this model of care (e.g. the InnoWell Platform), as well as an operational protocol of how this solution could be applied to primary youth mental health service delivery processes. By 'flipping' conventional service delivery models of majority in-clinic and minority online-delivered care to a model where online-delivered care is the default, this digital health solution offers a scalable way of delivering quality youth mental health care, both in response to public health crises (such as COVID-19) and ongoingly into the future

Involving end users in adapting the spanish version of the mental health eClinic for young people in Colombia : A pilot study using participatory design methodologies

ManuscritoBackground: Health information technologies (HIT) hold enormous promise for improving access to, and better quality, mental health care. However, despite rapid spread of such technologies in high-income countries, they have not yet been commonly adopted in low and middle-income countries. People living in these parts of the world are at risk of experiencing not only physical but also technological and social health inequalities. One possible solution is to utilise already available (and successfully implemented) HITs developed in other counties. Objective: Using participatory design methodologies with Colombian end users (young people, their supportive others, health professionals), this study aimed to: conduct co-design workshops to culturally adapt an online mental health clinic (MHeC) for young people; perform one-on-one user testing sessions to evaluate an alpha prototype of a Spanish version of the MHeC, and adapt it to the Colombian context; and, inform the development of a skeletal framework and alpha prototype for a Colombian version of the MHeC (MHeC-C). Methods: Utilisation of a research and development (R&D) cycle including four iterative phases: co-design workshops; knowledge translation; tailoring to language, culture and place (or context); rapid prototyping; and then, one-on-one user testing sessions. Results: Two co-design workshops were held with 18 users (young people n=7, health professionals n=11). A total of 10 participated in one-on-one user-testing sessions (young people n=5, supportive others n=2, health professionals n=3). 203 source documents were collected and 605 annotations were coded. A thematic analysis resulted in six main themes (i.e. opinions about the MHeC-C, Colombian context, functionality, content, user interface and technology platforms). Participants liked the idea of having a MHeC specially designed and adapted for Colombian young people and its five key elements were acceptable in this context (home page and triage system, self-report assessment, dashboard of results, booking and video visit system and personalized well-being plan). However, to be relevant in Colombia, participants stressed the need to develop some additional functionality (eg. phone network backup, chat, geolocation, and integration with electronic medical records, apps or e-tools) as well as adaptation of the self-report assessment. Importantly, the latter not only included language but also culture and context. Conclusions: The application of an iterative R&D cycle that also included processes for adaptation to Colombia (language, culture, context), resulted in the development of an evidence-based, language-appropriate, culturally-sensitive, context-adapted HIT that is relevant, applicable, engaging and usable in both the short- and longer-term. The resultant R&D cycle allowed for the adaptation of an already available HIT (i.e. MHeC) to the MHeC-C – a low-cost and scalable technology solution for low-tomiddle income countries such as Colombia, which has the potential to provide young people with accessible, available, affordable and integrated mental health care at the right time

Involving end users in adapting a spanish version of a Web-Based Mental Health Clinic for young people in Colombia : exploratory study using participatory design methodologies

Artículo original1-21BACKGROUND: Health information technologies (HITs) hold enormous promise for improving access to and providing better quality of mental health care. However, despite the spread of such technologies in high-income countries, these technologies have not yet been commonly adopted in low- and middle-income countries. People living in these parts of the world are at risk of experiencing physical, technological, and social health inequalities. A possible solution is to utilize the currently available HITs developed in other counties. OBJECTIVE: Using participatory design methodologies with Colombian end users (young people, their supportive others, and health professionals), this study aimed to conduct co-design workshops to culturally adapt a Web-based Mental Health eClinic (MHeC) for young people, perform one-on-one user-testing sessions to evaluate an alpha prototype of a Spanish version of the MHeC and adapt it to the Colombian context, and inform the development of a skeletal framework and alpha prototype for a Colombian version of the MHeC (MHeC-C). METHODS: This study involved the utilization of a research and development (R&D) cycle including 4 iterative phases: co-design workshops; knowledge translation; tailoring to language, culture, and place (or context); and one-on-one user-testing sessions. RESULTS: A total of 2 co-design workshops were held with 18 users-young people (n=7) and health professionals (n=11). Moreover, 10 users participated in one-on-one user-testing sessions-young people (n=5), supportive others (n=2), and health professionals (n=3). A total of 204 source documents were collected and 605 annotations were coded. A thematic analysis resulted in 6 themes (ie, opinions about the MHeC-C, Colombian context, functionality, content, user interface, and technology platforms). Participants liked the idea of having an MHeC designed and adapted for Colombian young people, and its 5 key elements were acceptable in this context (home page and triage system, self-report assessment, dashboard of results, booking and video-visit system, and personalized well-being plan). However, to be relevant in Colombia, participants stressed the need to develop additional functionality (eg, phone network backup; chat; geolocation; and integration with electronic medical records, apps, or electronic tools) as well as an adaptation of the self-report assessment. Importantly, the latter not only included language but also culture and context. CONCLUSIONS: The application of an R&D cycle that also included processes for adaptation to Colombia (language, culture, and context) resulted in the development of an evidence-based, language-appropriate, culturally sensitive, and context-adapted HIT that is relevant, applicable, engaging, and usable in both the short and long term. The resultant R&D cycle allowed for the adaptation of an already available HIT (ie, MHeC) to the MHeC-C-a low-cost and scalable technology solution for low- and middle-income countries like Colombia, which has the potential to provide young people with accessible, available, affordable, and integrated mental health care at the right time. ©Laura Ospina-Pinillos, Tracey A Davenport, Alvaro Andres Navarro-Mancilla, Vanessa Wan Sze Cheng, Andrés Camilo Cardozo Alarcón, Andres M Rangel, German Eduardo Rueda-Jaimes, Carlos Gomez-Restrepo, Ian B Hickie. Originally published in JMIR Mental Health (http://mental.jmir.org), 01.02.2020. KEYWORDS: Colombia; community-based participatory research; consumer health information; cultural characteristics; cultural competency; eHealth; ethnic groups; medical informatics; mental health; methods; patient participation; patient preference; patient satisfaction; primary health care; quality of health care; research design; telemedicin

Informing the Future of Integrated Digital and Clinical Mental Health Care: Synthesis of the Outcomes From Project Synergy

BACKGROUND: Globally, there are fundamental shortcomings in mental health care systems, including restricted access, siloed services, interventions that are poorly matched to service users' needs, underuse of personal outcome monitoring to track progress, exclusion of family and carers, and suboptimal experiences of care. Health information technologies (HITs) hold great potential to improve these aspects that underpin the enhanced quality of mental health care. OBJECTIVE: Project Synergy aimed to co-design, implement, and evaluate novel HITs, as exemplified by the InnoWell Platform, to work with standard health care organizations. The goals were to deliver improved outcomes for specific populations under focus and support organizations to enact significant system-level reforms. METHODS: Participating health care organizations included the following: Open Arms-Veterans & Families Counselling (in Sydney and Lismore, New South Wales [NSW]); NSW North Coast headspace centers for youth (Port Macquarie, Coffs Harbour, Grafton, Lismore, and Tweed Heads); the Butterfly Foundation's National Helpline for eating disorders; Kildare Road Medical Centre for enhanced primary care; and Connect to Wellbeing North Coast NSW (administered by Neami National), for population-based intake and assessment. Service users, families and carers, health professionals, and administrators of services across Australia were actively engaged in the configuration of the InnoWell Platform to meet service needs, identify barriers to and facilitators of quality mental health care, and highlight potentially the best points in the service pathway to integrate the InnoWell Platform. The locally configured InnoWell Platform was then implemented within the respective services. A mixed methods approach, including surveys, semistructured interviews, and workshops, was used to evaluate the impact of the InnoWell Platform. A participatory systems modeling approach involving co-design with local stakeholders was also undertaken to simulate the likely impact of the platform in combination with other services being considered for implementation within the North Coast Primary Health Network to explore resulting impacts on mental health outcomes, including suicide prevention. RESULTS: Despite overwhelming support for integrating digital health solutions into mental health service settings and promising impacts of the platform simulated under idealized implementation conditions, our results emphasized that successful implementation is dependent on health professional and service readiness for change, leadership at the local service level, the appropriateness and responsiveness of the technology for the target end users, and, critically, funding models being available to support implementation. The key places of interoperability of digital solutions and a willingness to use technology to coordinate health care system use were also highlighted. CONCLUSIONS: Although the COVID-19 pandemic has resulted in the widespread acceptance of very basic digital health solutions, Project Synergy highlights the critical need to support equity of access to HITs, provide funding for digital infrastructure and digital mental health care, and actively promote the use of technology-enabled, coordinated systems of care

Sparsentan in patients with IgA nephropathy: a prespecified interim analysis from a randomised, double-blind, active-controlled clinical trial

Background: Sparsentan is a novel, non-immunosuppressive, single-molecule, dual endothelin and angiotensin receptor antagonist being examined in an ongoing phase 3 trial in adults with IgA nephropathy. We report the prespecified interim analysis of the primary proteinuria efficacy endpoint, and safety. Methods: PROTECT is an international, randomised, double-blind, active-controlled study, being conducted in 134 clinical practice sites in 18 countries. The study examines sparsentan versus irbesartan in adults (aged ≥18 years) with biopsy-proven IgA nephropathy and proteinuria of 1·0 g/day or higher despite maximised renin-angiotensin system inhibitor treatment for at least 12 weeks. Participants were randomly assigned in a 1:1 ratio to receive sparsentan 400 mg once daily or irbesartan 300 mg once daily, stratified by estimated glomerular filtration rate at screening (30 to 1·75 g/day). The primary efficacy endpoint was change from baseline to week 36 in urine protein-creatinine ratio based on a 24-h urine sample, assessed using mixed model repeated measures. Treatment-emergent adverse events (TEAEs) were safety endpoints. All endpoints were examined in all participants who received at least one dose of randomised treatment. The study is ongoing and is registered with ClinicalTrials.gov, NCT03762850. Findings: Between Dec 20, 2018, and May 26, 2021, 404 participants were randomly assigned to sparsentan (n=202) or irbesartan (n=202) and received treatment. At week 36, the geometric least squares mean percent change from baseline in urine protein-creatinine ratio was statistically significantly greater in the sparsentan group (-49·8%) than the irbesartan group (-15·1%), resulting in a between-group relative reduction of 41% (least squares mean ratio=0·59; 95% CI 0·51-0·69; p<0·0001). TEAEs with sparsentan were similar to irbesartan. There were no cases of severe oedema, heart failure, hepatotoxicity, or oedema-related discontinuations. Bodyweight changes from baseline were not different between the sparsentan and irbesartan groups. Interpretation: Once-daily treatment with sparsentan produced meaningful reduction in proteinuria compared with irbesartan in adults with IgA nephropathy. Safety of sparsentan was similar to irbesartan. Future analyses after completion of the 2-year double-blind period will show whether these beneficial effects translate into a long-term nephroprotective potential of sparsentan. Funding: Travere Therapeutics