Game for Health: Development and Evaluation of eHealth Interventions for Addressing the Psychological Needs of Children and Young People with Long-Term Physical Conditions

Abstract

Background: Around 10%–12% of children and young people experience long-term physical conditions (LTPC or chronic illness) and are at greater risk of developing psychological problems, especially anxiety and depression. These psychological problems are often under-recognised and access to face-to-face treatment is limited. This thesis examines the most effective therapeutic modalities for addressing these problems and the role of eHealth interventions in better supporting the needs of this population. Methods: Six key studies were performed: 1. A qualitative study to identify the psychological needs of New Zealand children and young people with LTPC and the views of these individuals, their families and clinicians regarding the role of eHealth interventions. Eleven children (7–12 years), eleven young people (13–18 years), seven parents, eleven paediatricians and ten general practitioners (GPs) participated in a series of seven semi-structured digitally recorded focus groups. A general inductive approach was used to analyse interview data. 2. A systematic review of randomised controlled trials (RCTs), cluster-randomised trials and cross-over trials of psychological therapies for treating anxiety or depression in children and young people with LTPC. Data sources were Ovid MEDLINE, Embase, PsycINFO, the Cochrane Central Register of Controlled Trials (CENTRAL), Web of Science (Core Collection), relevant conference proceedings, reference lists of included articles, and grey literature. 3. A systematic review of randomised controlled trials (RCTs), cluster-randomised trials and crossover trials of eHealth interventions for treating anxiety or depression in children and young people with LTPC. Data sources were the same as for the previous review. 4. A systematic review of RCTs, cluster-randomised trials and crossover trials of biofeedback interventions for treating anxiety or depression in children and young people with LTPC was undertaken via Ovid-MEDLINE, EMBASE, PsycINFO, CINAHL and the Cochrane Central Register of Controlled Trials databases.5. A narrative review of co-design processes for the development of eHealth interventions with children and young people that informed my development of a prototype cognitive behaviour therapy (CBT) and biofeedback-based eHealth game for treating anxiety called ‘Starship Rescue’. 6. An open trial with 24 children and young people with LTPC aged 10–17 years to evaluate the acceptability, usability and effectiveness of Starship Rescue. Results: 1. Anxiety was the most common psychological issue identified by New Zealand children and young people with LTPC. Along with their families and clinicians, there was an openness to the use eHealth interventions with which to address this issue provided they were engaging and reliable. 2. Twenty-eight RCTs and one cross-over trial with 1349 participants were included in the review. For the primary outcome of treatment efficacy, short-term depression (versus any control), there was low-quality evidence from 16 trials involving 1121 participants suggesting that psychological therapies, especially those based on cognitive behaviour therapy (CBT), may be more effective than control therapies (SMD -0.31, 95% CI -0.59 to -0.03; I2=79%). For the primary outcome of treatment efficacy, short-term anxiety (versus any control), there was inadequate evidence of moderate-quality from 13 studies involving 578 participants to determine whether psychological therapies were more effective than control conditions (SMD -0.26, CI -0.59 to 0.07, I2=72%). 3. Five trials of three interventions (Breathe Easier Online, Web‐MAP, and multimodal cognitive behavioural therapy (CBT)) with 463 participants were included in this review. There was limited evidence of the effectiveness of eHealth interventions for treating anxiety and depression in this population. For the primary outcome of change in depression symptoms versus any control, there was very low‐quality evidence meaning that it could not be determined whether eHealth interventions were clearly better than any comparator (SMD ‐0.06, 95% CI ‐0.35 to 0.23; 5 RCTs, 441 participants). For the primary outcome of change in anxiety symptoms versus any comparator, there was very low‐quality evidence meaning that it could not be determined whether eHealth interventions were clearly better than any comparator (SMD ‐0.07, 95% CI ‐0.29 to 0.14; 2 RCTs, 324 participants). For the primary outcome of treatment acceptability, there was very low‐quality evidence that eHealth interventions were less acceptable than any comparator (SMD 0.46, 95% CI 0.23 to 0.69; 2 RCTs, 304 participants). 4. Nine studies (4 RCTs, 5 non-RCTs; of which all measured changes in anxiety and three of which measured changes in depression) were included in the final analysis. Due to the heterogeneity of study design and reporting, risk of bias was judged as unclear for all studies and a meta-analysis of findings was not undertaken. Heart rate variability (HRV), biofeedback-assisted relaxation therapy and electroencephalography were found to be effective in reducing symptoms of anxiety. HRV was also found to be effective in reducing symptoms of depression in two studies. 5. Adapted co-design processes are feasible for research with children and young people. Starship Rescue was developed via a 3-stage co-design process involving children and young people with LTPC. 6. Starship Rescue was an acceptable, usable and clinically effective, co-designed eHealth game for treating anxiety in children and young people with LTPC. Users gave it an overall rating of 5.9 out of 10 (range 3–10 and a mean score of 71 out of 100 (SD 11.7; min 47.5; max 90) on the System Usability Scale (SUS). Significant reductions in anxiety were noted between the start and end of the game on the Generalized Anxiety Disorder – 7 item (GAD-7) scale (-4.6 (p=0.000)), the Spence Childhood Anxiety Scale (SCAS) (-9.6 (p=0.005)), and a combined Likert/visual analogue scale (-2.4 (p=0.001)). Quality of life also improved on the Pediatric Quality of Life (PedsQL) scale (+4.3 (p=0.042)). All changes were sustained at 3-month follow-up. Conclusion: eHealth interventions, particularly those based on CBT, can be used to address psychological problems faced by children and young people with LTPC. Starship Rescue is a newly co-designed CBT and biofeedback-based eHealth game that shows promise for treating anxiety in this group. Further research into its effectiveness is required.