Development of a Mobile App to Support Self-management of Anxiety and Depression in African American Women: Usability Study

Author(s): Terika McCall , MBA, MPH, PhD ¹ ^, ² ^, ³ ^, , Muhammad Osama Ali , MPS ³ , Fei Yu , MPS, PhD ³ ^, ⁴ ^, ⁵ , Paul Fontelo , MPH, MD ⁶ , Saif Khairat , MPH, PhD ³ ^, ⁷ ^, ⁸

Editor(s): Gunther Eysenbach

Other contributor(s): Xianying He (Reviewer), Phoenix Kit-han Mo (Reviewer), Jorn op den Buijs (Reviewer)

Publication date (Electronic): 17 August 2021

Journal: JMIR Formative Research

Publisher: JMIR Publications

Keywords: African Americans, women, mental health, anxiety, depression, telemedicine, mHealth, mobile applications, digital health, user-centered design, mobile phone

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Abstract

Background

Anxiety and depressive disorders are the most common mental health conditions among African American women. Despite the need for mental health care, African American women significantly underuse mental health services. Previous mobile health studies revealed significant improvements in anxiety or depressive symptoms after intervention. The use of mobile apps offers the potential to eliminate or mitigate barriers for African American women who are seeking access to mental health services and resources.

Objective

This study aims to evaluate the usability of the prototype of an app that is designed for supporting the self-management of anxiety and depression in African American women.

Methods

Individual usability testing sessions were conducted with 15 participants in Chapel Hill, North Carolina. Cognitive walkthrough and think-aloud protocols were used to evaluate the user interface. Eye-tracking glasses were used to record participants’ visual focus and gaze path as they performed the tasks. The Questionnaire for User Interface Satisfaction was administered after each session to assess the participants’ acceptance of the app.

Results

Participants rated the usability of the prototype positively and provided recommendations for improvement. The average of the mean scores for usability assessments (ie, overall reactions to the software, screen, terminology and app information, learning, and app capabilities) ranged from 7.2 to 8.8 on a scale of 0-9 (low to high rating) for user tasks. Most participants were able to complete each task with limited or no assistance. Design recommendations included improving the user interface by adding graphics and color, adding a tutorial for first-time users, curating a list of Black women therapists within the app, adding details about tracking anxiety and depression in the checkup graphs, informing users that they can use the talk-to-text feature for journal entries to reduce burden, relabeling the mental health information icon, monitoring for crisis support, and improving clickthrough sequencing.

Conclusions

This study provides a better understanding of user experience with an app tailored to support the management of anxiety and depression for African American women, which is an underserved group. As African American women have high rates of smartphone ownership, there is a great opportunity to use mobile technology to provide access to needed mental health services and resources. Future work will include incorporating feedback from usability testing and focus group sessions to refine and develop the app further. The updated app will undergo iterative usability testing before launching the pilot study to evaluate the feasibility and acceptability of the prototype.

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Most cited references 51

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A brief measure for assessing generalized anxiety disorder: the GAD-7.

Robert L Spitzer, Kurt Kroenke, Janet B W Williams … (2006)

Generalized anxiety disorder (GAD) is one of the most common mental disorders; however, there is no brief clinical measure for assessing GAD. The objective of this study was to develop a brief self-report scale to identify probable cases of GAD and evaluate its reliability and validity. A criterion-standard study was performed in 15 primary care clinics in the United States from November 2004 through June 2005. Of a total of 2740 adult patients completing a study questionnaire, 965 patients had a telephone interview with a mental health professional within 1 week. For criterion and construct validity, GAD self-report scale diagnoses were compared with independent diagnoses made by mental health professionals; functional status measures; disability days; and health care use. A 7-item anxiety scale (GAD-7) had good reliability, as well as criterion, construct, factorial, and procedural validity. A cut point was identified that optimized sensitivity (89%) and specificity (82%). Increasing scores on the scale were strongly associated with multiple domains of functional impairment (all 6 Medical Outcomes Study Short-Form General Health Survey scales and disability days). Although GAD and depression symptoms frequently co-occurred, factor analysis confirmed them as distinct dimensions. Moreover, GAD and depression symptoms had differing but independent effects on functional impairment and disability. There was good agreement between self-report and interviewer-administered versions of the scale. The GAD-7 is a valid and efficient tool for screening for GAD and assessing its severity in clinical practice and research.

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While considerable attention has focused on improving the detection of depression, assessment of severity is also important in guiding treatment decisions. Therefore, we examined the validity of a brief, new measure of depression severity. The Patient Health Questionnaire (PHQ) is a self-administered version of the PRIME-MD diagnostic instrument for common mental disorders. The PHQ-9 is the depression module, which scores each of the 9 DSM-IV criteria as "0" (not at all) to "3" (nearly every day). The PHQ-9 was completed by 6,000 patients in 8 primary care clinics and 7 obstetrics-gynecology clinics. Construct validity was assessed using the 20-item Short-Form General Health Survey, self-reported sick days and clinic visits, and symptom-related difficulty. Criterion validity was assessed against an independent structured mental health professional (MHP) interview in a sample of 580 patients. As PHQ-9 depression severity increased, there was a substantial decrease in functional status on all 6 SF-20 subscales. Also, symptom-related difficulty, sick days, and health care utilization increased. Using the MHP reinterview as the criterion standard, a PHQ-9 score > or =10 had a sensitivity of 88% and a specificity of 88% for major depression. PHQ-9 scores of 5, 10, 15, and 20 represented mild, moderate, moderately severe, and severe depression, respectively. Results were similar in the primary care and obstetrics-gynecology samples. In addition to making criteria-based diagnoses of depressive disorders, the PHQ-9 is also a reliable and valid measure of depression severity. These characteristics plus its brevity make the PHQ-9 a useful clinical and research tool.

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The efficacy of smartphone-based mental health interventions for depressive symptoms: a meta-analysis of randomized controlled trials.

Joseph Firth, John Torous, Jennifer Lynn Nicholas … (2017)

The rapid advances and adoption of smartphone technology presents a novel opportunity for delivering mental health interventions on a population scale. Despite multi-sector investment along with wide-scale advertising and availability to the general population, the evidence supporting the use of smartphone apps in the treatment of depression has not been empirically evaluated. Thus, we conducted the first meta-analysis of smartphone apps for depressive symptoms. An electronic database search in May 2017 identified 18 eligible randomized controlled trials of 22 smartphone apps, with outcome data from 3,414 participants. Depressive symptoms were reduced significantly more from smartphone apps than control conditions (g=0.38, 95% CI: 0.24-0.52, p<0.001), with no evidence of publication bias. Smartphone interventions had a moderate positive effect in comparison to inactive controls (g=0.56, 95% CI: 0.38-0.74), but only a small effect in comparison to active control conditions (g=0.22, 95% CI: 0.10-0.33). Effects from smartphone-only interventions were greater than from interventions which incorporated other human/computerized aspects along the smartphone component, although the difference was not statistically significant. The studies of cognitive training apps had a significantly smaller effect size on depression outcomes (p=0.004) than those of apps focusing on mental health. The use of mood monitoring softwares, or interventions based on cognitive behavioral therapy, or apps incorporating aspects of mindfulness training, did not affect significantly study effect sizes. Overall, these results indicate that smartphone devices are a promising self-management tool for depression. Future research should aim to distil which aspects of these technologies produce beneficial effects, and for which populations.

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Author and article information

Contributors

Terika McCall:

ORCID: https://orcid.org/0000-0002-8143-5393

Center for Medical InformaticsYale School of Medicine300 George StreetSuite 501New Haven, CT, 06511United States1 203 737 5379terika.mccall@yale.edu

Journal

Journal ID (nlm-ta): JMIR Form Res

Journal ID (iso-abbrev): JMIR Form Res

Journal ID (publisher-id): JFR

Title: JMIR Formative Research

Publisher: JMIR Publications (Toronto, Canada )

ISSN (Electronic): 2561-326X

Publication date Collection: August 2021

Publication date (Electronic): 17 August 2021

Volume: 5

Issue: 8

Electronic Location Identifier: e24393

Affiliations

[1 ] Center for Medical Informatics Yale School of Medicine New Haven, CT United States

[2 ] Division of Health Informatics Department of Biostatistics Yale School of Public Health New Haven, CT United States

[3 ] Carolina Health Informatics Program University of North Carolina at Chapel Hill Chapel Hill, NC United States

[4 ] School of Information & Library Science University of North Carolina at Chapel Hill Chapel Hill, NC United States

[5 ] Health Sciences Library University of North Carolina at Chapel Hill Chapel Hill, NC United States

[6 ] National Library of Medicine Bethesda, MD United States

[7 ] School of Nursing University of North Carolina at Chapel Hill Chapel Hill, NC United States

[8 ] Cecil G. Sheps Center for Health Services Research University of North Carolina at Chapel Hill Chapel Hill, NC United States

Author notes

Corresponding Author: Terika McCall terika.mccall@ 123456yale.edu

Author information

Terika McCall https://orcid.org/0000-0002-8143-5393

Muhammad Osama Ali https://orcid.org/0000-0002-2139-6425

Fei Yu https://orcid.org/0000-0003-1079-1590

Paul Fontelo https://orcid.org/0000-0003-3186-3215

Saif Khairat https://orcid.org/0000-0002-8992-2946

Article

Publisher ID: v5i8e24393

DOI: 10.2196/24393

PMC ID: 8408754

PubMed ID: 34133313

SO-VID: 0cb49e8c-ff23-4fa6-928d-18bd9f17a024

License:

This is an open-access article distributed under the terms of the Creative Commons Attribution License ( https://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work, first published in JMIR Formative Research, is properly cited. The complete bibliographic information, a link to the original publication on https://formative.jmir.org, as well as this copyright and license information must be included.

History

Date received : 21 September 2020

Date revision requested : 7 November 2020

Date revision received : 28 February 2021

Date accepted : 15 June 2021

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