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Internet-Based Cognitive Behavioural Therapy to Treat Adolescent Anxiety: An Exploration of Intervention Designs and the User Experience
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- Author / Creator
- Radomski, Ashley D
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BACKGROUND: Internet-based cognitive behavioural therapy (iCBT) is a complex, ‘persuasive system’ as its design combines therapeutic content, technological features, and interactions between the user and the program. The design and delivery of iCBT differs across programs. While iCBT is considered effective for treating child and adolescent anxiety, how outcomes are produced remains unclear. This lack of clarity may be due to paradoxical findings such as low program usage despite high satisfaction ratings. This dissertation aimed to understand how, why and for whom iCBT works, and how iCBT is experienced by adolescent users.
METHODS: Three studies comprise this thesis. In studies 1 and 2, realist syntheses were used to explore the design and delivery features of iCBT for children and adolescents with anxiety and examine their relationship to program use (study 1) and anxiety-based outcomes (study 2). The syntheses were conducted according to recommended steps and reporting guidelines, incorporated published and grey literature, and critically appraised this literature prior to analyses. Analyses were guided by the Persuasive Systems Design (PSD) model, a framework for designing and evaluating persuasive systems. Using realist and meta-ethnographic methods, iCBT design (PSD mechanisms) and delivery features (contexts of use) were linked to outcomes. These linkages were expressed as Context-Mechanism-Outcome configurations—hypotheses for how, why and for whom iCBT programs are effective. Study 3 was a multiple method study embedded within a randomized controlled trial (RCT) comparing the effectiveness of a 6-session iCBT program for adolescents with anxiety (‘Breathe’) to anxiety-based resource webpages. Automatically captured data (intervention use) and user-reported data (anxiety symptoms, user experience using the User Experience Questionnaire for Internet-based Interventions [UEQII], global rating of change scale) were collected pre- and/or post-intervention to: describe Breathe and webpage usage; describe and compare Breathe and webpage user experiences; calculate a user-defined small, but meaningful change in Breathe users’ anxiety (minimal clinically important difference [MCID]); and explore relationships between the multiple outcomes among Breathe users. Descriptive statistics summarized outcomes, an anchor-based method was used to calculate the MCID, and independent sample t-tests and parametric and non-parametric correlations tested the relationships between usage, experience, and MCID data.
RESULTS: Realist syntheses: Forty-five documents detailing 10 iCBT programs and 63 documents detailing 15 iCBT programs were included in studies 1 and 2, respectively. In both studies, I generated hypotheses using moderate-to-high quality found across multiple iCBT programs. I developed 5 (study 1) and 11 (study 2) hypotheses that identified key PSD features and delivery contexts (adjunct program support; level of prevention programs targeted) that may lead to moderate-to-high program use (study 1) and anxiety reductions (study 2). I suggested that incorporating multiple PSD features may have additive or synergistic effects on outcomes. Multiple method study: In this study, intervention use was low for adolescents allocated to either Breathe (mean=2.2 sessions, SD=2.3; n=258) or webpages (mean=2.1 visits, SD=2.7; n=278), but was higher among the adolescents who reported on their user experience post-intervention (Breathe: median=6.0, range=1-6, n=81/258; webpages: median=2.0, range=1-9, n=148/278). The user experience was more positive for Breathe than webpage users (P<.001); for Breathe users, most user experience scores correlated with program use (P’s<.05). Adolescents who used Breathe reported barriers (time constraints, avoiding uncomfortable activities) and facilitators (liked learning about anxiety, use of videos) to their use and experience of iCBT. A user-reported MCID was calculated and, based on the estimate, 43% (n=35/81) of Breathe users were considered ‘treatment responders’. This response did not correlate with user experience scores or Breathe use (P’s>0.05).
CONCLUSIONS: This dissertation generated hypotheses about the key PSD features of iCBT thought to support desired program use, anxiety reductions, and a positive user experience. Adjunct program support may have an important role in complementing or replacing the function of PSD features across programs. The relationships between program use, program experiences, and perceived program impacts require further clarification. Future studies can validate and incorporate the novel self-report assessment tools (UEQII, MCID) and analytic approaches that I used (realist syntheses, triangulating objective and subjective data) to formally test my hypotheses and identify new avenues of research. My findings can be applied to comparisons of user experiences between Internet-based interventions, interpretations of iCBT treatment outcomes, optimization of iCBT program design and delivery, and improvement of treatment decision-making for adolescents with anxiety.
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- Graduation date
- Fall 2019
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- Type of Item
- Thesis
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- Degree
- Doctor of Philosophy
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- License
- Permission is hereby granted to the University of Alberta Libraries to reproduce single copies of this thesis and to lend or sell such copies for private, scholarly or scientific research purposes only. Where the thesis is converted to, or otherwise made available in digital form, the University of Alberta will advise potential users of the thesis of these terms. The author reserves all other publication and other rights in association with the copyright in the thesis and, except as herein before provided, neither the thesis nor any substantial portion thereof may be printed or otherwise reproduced in any material form whatsoever without the author's prior written permission.