Psychosocial impact of the COVID-19 pandemic for adolescents with type-1-diabetes: a qualitative interview study involving adolescents and parents.

This study aims to investigate the psychosocial impact of the COVID-19 pandemic on adolescents with type-1-diabetes (T1D). We conducted 18 semi-structured interviews including adolescents with T1D (n = 10, 50% female, 15-18 years) and their parents (n = 8, 88% mothers). The main topics addressed were experiences during confinement regarding everyday life, lifestyle behaviors, diabetes management and treatment. We applied thematic analysis to identify common patterns of meanings. Being aware of belonging to a potential COVID-19 risk group caused worries especially in parents which resulted in strict adherence to preventive measures. Information from trustworthy sources regarding the actual risk mitigated the concerns. Digital diabetes treatment was well accepted and experienced as highly usable. The pandemic situation either facilitated or hindered the transition from parental control to diabetes self-management. While some patients managed to improve healthy lifestyle behaviors as their everyday lives seemed more predictable, others had difficulties in adapting to changed daily routines resulting in increased sedentary behavior and snacking. The perceived level of stress was directly associated with blood glucose levels. In conclusion, the implementation of psychological interventions (both for adolescents with T1D and their parents) addressing mental health literacy and media literacy seems to be important to promote positive coping skills for dealing with the pandemic situation.

Online prevention programmes for university students: stakeholder perspectives from six European countries.

BACKGROUND: Students beginning university are at a heightened risk for developing mental health disorders. Online prevention and early intervention programmes targeting mental health have the potential to reduce this risk, however, previous research has shown uptake to be rather poor. Understanding university stakeholders' (e.g. governing level and delivery staff [DS] and students) views and attitudes towards such online prevention programmes could help with their development, implementation and dissemination within university settings. METHODS: Semi-structured interviews, focus groups and online surveys were completed with staff at a governing level, university students and DS (i.e. student health or teaching staff) from six European countries. They were asked about their experiences with, and needs and attitudes towards, online prevention programmes, as well as the factors that influence the translation of these programmes into real-world settings. Results were analyzed using thematic analysis. RESULTS: Participating stakeholders knew little about online prevention programmes for university settings; however, they viewed them as acceptable. The main themes to emerge were the basic conditions and content of the programmes, the awareness and engagement, the resources needed, the usability and the responsibility and ongoing efforts to increase reach. CONCLUSIONS: Overall, although these stakeholders had little knowledge about online prevention programmes, they were open to the idea of introducing them. They could see the potential benefits that these programmes might bring to a university setting as a whole and the individual students and staff members.

Stakeholders' perspectives on online interventions to improve mental health in eating disorder patients and carers in Germany.

BACKGROUND: Eating disorders are causing severe consequences for those affected as well as a high burden for their carers. Although there is a substantial need for psychological assistance, different factors are hindering access to support. Internet-based interventions can help to overcome these barriers. To date, there is only little knowledge on attitudes of potential users, facilitators (e.g. psychologists) and decision makers (e.g. health insurances) regarding these interventions. METHODS: We conducted focus groups with potential users (N = 30) and semi-structured interviews with potential decision makers (N = 4). Potential facilitators (N = 41) participated in an online survey. Stakeholders' experiences, attitudes, and their needs regarding Internet-based interventions for eating disorder patients and carers were assessed. Furthermore, hindering and fostering factors related to reach, adoption, implementation and maintenance were analyzed. RESULTS: About two-thirds of the participating facilitators have heard or read about Internet-based interventions in general. In contrast, the other stakeholders mentioned to have no or little experience with such interventions. Factors like anonymity, availability and cost-effectiveness were seen as major advantages. Also disadvantages, e.g. lack of personal contact, limitations by disease severity and concerns on data safety, were mentioned. Stakeholders stated the need for interventions which are usable, evidence-based, tailored and provide personal support. CONCLUSION: Stakeholders considered Internet-based programmes to have more advantages than disadvantages. Effort should be put in providing systematic education to address prejudices. When offering an online intervention, stakeholders' needs, as well as a continuous evaluation and adaptation, have to be taken into account.

Online interventions to prevent mental health problems implemented in school settings: the perspectives from key stakeholders in Austria and Spain.

BACKGROUND: Schools are key settings for delivering mental illness prevention in adolescents. Data on stakeholders' attitudes and factors relevant for the implementation of Internet-based prevention programmes are scarce. METHODS: Stakeholders in the school setting from Austria and Spain were consulted. Potential facilitators (e.g. teachers and school psychologists) completed an online questionnaire (N=50), policy makers (e.g. representatives of the ministry of education and health professional associations) participated in semi-structured interviews (N=9) and pupils (N=29, 14-19 years) participated in focus groups. Thematic analysis was used to identify experiences with, attitudes and needs towards Internet-based prevention programmes, underserved groups, as well as barriers and facilitators for reach, adoption, implementation and maintenance. RESULTS: Experiences with Internet-based prevention programmes were low across all stakeholder groups. Better reach of the target groups was seen as main advantage whereas lack of personal contact, privacy concerns, risk for misuse and potential stigmatization when implemented during school hours were regarded as disadvantages. Relevant needs towards Internet-based programmes involved attributes of the development process, general requirements for safety and performance, presentation of content, media/tools and contact options of online programmes. Positive attitudes of school staff, low effort for schools and compatibility to schools' curriculum were seen as key factors for successful adoption and implementation. A sound implementation of the programme in the school routine and continued improvement could facilitate maintenance of online prevention initiatives in schools. CONCLUSIONS: Attitudes towards Internet-based mental illness prevention programmes in school settings are positive across all stakeholder groups. However, especially safety concerns have to be considered.

Stakeholders' views on online interventions to prevent common mental health disorders in adults implemented into existing healthcare systems in Europe.

BACKGROUND: Online preventive interventions can help to reduce the incidence of mental disorders. Whereas knowledge on stakeholders' attitudes and factors relevant for successfully integrating online treatment into existing healthcare systems is available, knowledge is scarce for online prevention. METHODS: Stakeholders from Germany, Switzerland, Austria and Spain were surveyed. Potential facilitators/delivery staff (e.g. psychologists, psychotherapists) completed an online questionnaire (n = 183), policy makers (i.e. from the governing sector or health insurance providers) participated in semi-structured interviews (n = 16) and target groups/potential users of mental illness prevention (n = 49) participated in ten focus groups. Thematic analysis was used to identify their experiences with and attitudes and needs regarding online programmes to prevent mental disorders. Additionally, it was examined which groups they consider underserved and which factors they consider as fostering and hindering for reach, adoption, implementation and maintenance (cf. RE-AIM model) when integrating online prevention into existing healthcare systems. RESULTS: Main advantages of online mental illness prevention are perceived in low structural and psychological barriers. Lack of personal contact, security, privacy and trust concerns were discussed as disadvantages. Relevant needs are high usability and target group appropriateness, evidence for effectiveness and the use of motivational tools. CONCLUSIONS: Positive attitudes among stakeholders are the key for successful integration of online mental illness prevention into existing healthcare systems. Potential facilitators/delivery staff must receive training and support to implement these programmes; the programmes must be attractive and continuously evaluated, updated and promoted to ensure ongoing reach; and existing infrastructure and contextual factors must be considered.

Stakeholder consultation to facilitate implementation of interventions for prevention and promotion in mental health in Europe: introducing the design of the ICare Stakeholder Survey.

BACKGROUND: Online interventions to prevent mental health problems have proven to be effective. However, knowledge about their implementation in real-world practice as well as for dissemination to the target groups in different settings is scarce. The goal of the 'ICare' network is to establish a comprehensive model of eMental-health service delivery in and across different European countries. Since implementation and dissemination are influenced by many contextual factors, in the first phase of ICare a stakeholder survey was conducted. The survey aim was to explore stakeholders' experiences, needs and attitudes regarding Internet-based prevention of mental health problems and hindering and fostering factors for implementation and dissemination. This article is part of a supplement and describes the design of the stakeholder survey. Survey results are published in separate articles in the same supplement. METHODS: Based on a literature review and the individual characteristics of the ICare interventions, stakeholder groups were identified in different settings across six European countries. The RE-AIM framework guided the development of the research questions and survey instruments. A concurrent mixed methods design was applied comprising focus groups with the intended target groups of ICare interventions, an online questionnaire with potential facilitators/delivery staff and semi-structured interviews with policy makers. CONCLUSION: The challenge was to develop a design that allowed flexibility but at the same did not jeopardize the validity of the study. Implications drawn from this survey are not restricted to specific preventive interventions but will provide general information on how online mental illness prevention can be best implemented in various settings.

Impact of COVID-19 Confinement on Adolescent Patients with Anorexia Nervosa: A Qualitative Interview Study Involving Adolescents and Parents.

COVID-19-related restrictions may have a serious impact on patients with eating disorders. We conducted semistructured interviews with female adolescent patients with anorexia nervosa (AN) (n = 13, 13-18 years) currently receiving inpatient or outpatient treatment and their parents (n = 10). We asked for their experiences during COVID-19 confinement regarding everyday life, AN symptoms, and treatment. We used thematic analysis to interpret the data. The main themes identified from the patients' interviews involved restrictions of personal freedom (i.e., leading to tension between patients and family members, reduced motivation to work on recovery), interruption of the treatment routine (emerging risks through self-monitored weight, challenges/opportunities of teletherapy), changes in AN symptoms (more exposure to triggering situations), COVID-19-related fears, and compulsions but also potential opportunities (less stress, better family relationships). The parents discussed changes in daily routines as negative (challenges in maintaining day structures) and positive (more family time, "slowing down"). They expressed reservations about reduced outpatient monitoring and increased teletherapy and discussed challenges in keeping contact with the child and clinicians during inpatient treatment. Moreover, the parents discussed deteriorations and improvements in the patients' psychopathology. Clinical implications from these in-depth insights include the importance of strengthening communication between changing staff cohorts, patients, and parents; motivational work; and joint weight monitoring with the therapist.

Usability and Engagement Evaluation of an Unguided Online Program for Promoting a Healthy Lifestyle and Reducing the Risk for Eating Disorders and Obesity in the School Setting.

Implementing integrated online prevention to reduce the risk of both obesity and eating disorders, in the school setting, is a promising approach. The challenge is to develop highly user-friendly and motivating programs, to foster adherence and effectiveness. The purpose of this study was to evaluate the usability of such a universal prevention program for students aged 14⁻19 years, and to address engagement issues. A mixed-methods approach was chosen, consisting of a think-aloud task, a semi-structured interview, and a questionnaire including items on sociodemographic characteristics and the System Usability Scale (SUS). Usability tests were conducted in two rounds, with five adolescents participating per round. Mean score in the SUS was 92.5 of 100 points (range 85⁻100), in the second round, after some adaptations from the participants' feedback. In the course of the think-aloud tasks and interviews, five major themes emerged-visual design, navigation, mode of transfer, content, and engagement conditions. Interesting headlines, gamification, and monitoring tools are crucial for engagement. Apart from the importance of using the program during school hours, the study showed that problems currently perceived as important by the target group, need to be considered and addressed, prior to offering them prevention programs, which highlights the importance of a user-centered design.

Web-based indicated prevention of common mental disorders in university students in four European countries - Study protocol for a randomised controlled trial.

BACKGROUND: Mental disorders and their symptoms are highly prevalent in the university student population, and the transition from secondary to tertiary education is associated with a rise in mental health problems. Existing web-based interventions for the prevention of common mental disorders in student populations often focus on just one disorder and have not been designed specifically for students. There is thus a need for transdiagnostic, student-specific preventative interventions that can be widely disseminated. This two-arm, parallel group randomised controlled trial aims to evaluate the effectiveness and cost-effectiveness of a web-based transdiagnostic mental health problem prevention programme (PLUS) across several universities in four countries. METHOD: Students (N = 5550) will be recruited through a variety of channels and asked to complete a personality assessment to determine whether they are at high risk for developing common mental disorders. Students at high risk will be randomly allocated to either PLUS or a control intervention, which provides practical support around issues commonly experienced at university. Students at low risk will be allocated to the control intervention. Both intervention groups will be assessed at baseline, 4 weeks, 3 months, 6 months and 12 months after randomisation. Depression and generalised anxiety, assessed using the Patient Health Questionnaire and the Generalised Anxiety Disorder scales, will form the primary outcomes in this study. Secondary outcome measures include alcohol and drug use, eating behaviour, self-esteem, and quality of life. The cost-effectiveness of the intervention will also be evaluated. CONCLUSIONS: This study will contribute to understanding the role of transdiagnostic indicated web-based interventions for the prevention of common mental disorders in university students. It will also be one of the first studies to investigate the cost-effectiveness of such interventions. TRIAL REGISTRATION: This trial was registered in the ISRCTN register (ISRCTN15570935) on 12th February 2016.

Healthy Teens @ School: Evaluating and disseminating transdiagnostic preventive interventions for eating disorders and obesity for adolescents in school settings.

BACKGROUND: The worldwide prevalence of overweight and obesity is at alarming levels. Nearly one in three children in Europe is overweight or obese. Disordered eating and body image concerns are equally widespread and increase risk for more chronic and severe weight-related problems. Research has shown that online interventions that address both healthy weight regulation and body image can reduce risk for eating disorders and obesity simultaneously and are feasible to implement in school settings. To date, evaluation and dissemination of such programs in Europe is scant. METHODS: The Healthy Teens @ School study is a multi-country cluster-randomized controlled trial (RCT) comparing the effectiveness of an unguided, online, multi-level intervention for promoting a healthy lifestyle and reducing problematic eating behavior, eating disorder and obesity risk among students aged 14 to 19 years with control condition. As part of the Horizon 2020 funded project ICare (GA No. 634757) the trial is conducted in Austria and Spain. Cluster randomization by school is used. The intervention is an adapted version of an evidence-based program developed in the USA (StayingFit). Participants of the intervention group are assigned to one of two possible program tracks based on the results of the initial online-assessment: Overweight adolescents are assigned to the "Weight Management" track emphasizing balanced eating and exercise for weight maintenance, and all other individuals are assigned to the "Healthy Habits" track which aims at promoting healthy habits related to e.g., nutrition, physical activity, sleep. The participants of both tracks work on ten modules (one 20-30 min module per week) during school hours and/or at home. Assessments are conducted at pre- and post-intervention, and at 6- and 12-months after baseline assessment. The primary outcome is intuitive eating, secondary outcomes are eating disorder symptomatology, body image concerns, body mass index, food intake, physical activity, self-esteem, stress coping, depression, and anxiety. Following the initial assessment, individuals in the control group do not have access to the prevention program but continue as normal and are only prompted to the assessments at all time points. At the end of the 12-month study they will get access to the program. DISCUSSION: The results from this study will add to the understanding of how to address eating and weight related problems in adolescents and will shed light on the feasibility of implementing online prevention programs in school routine in Austria and Spain. As part of the larger ICare project this RCT will determine how an adapted version of StayingFit is disseminated within Europe.

The Mental Health in Austrian Teenagers (MHAT) Study: design, methodology, description of study population.

Profound epidemiological data on the prevalence of mental health disorders and respective risk and protective factors is a prerequisite for adequate prevention, intervention and service planning. Children and adolescents are regarded as high priority groups for prevention in this field because of the high chronicity and individual burden of mental health disorders. The Mental Health in Austrian Teenagers (MHAT)-Study is the first epidemiological study based on a large representative sample of adolescents (N > 3700) in Austria in order to obtain the prevalence of a wide range of behavioral problems and psychiatric disorders. Adolescents are recruited from multiple settings (schools, course providers for early school leavers and psychiatric clinics) in order to enhance the representativity of the sample. A "gold-standard" two-stage design (screening questionnaire and diagnostic interviews) is used to obtain psychiatric diagnoses that are based on the 5th edition of the Diagnostic and Statistical Manual of Mental Disorders which was published by the American Psychiatric Association in 2013. This paper aims at presenting the study design and methodology of the MHAT study, describing the study population as well as discussing relevant strengths and limitations.

Factors influencing workplace health promotion intervention: a qualitative systematic review.

Although workplace health promotion (WHP) has evolved over the last 40 years, systematically collected knowledge on factors influencing the functioning of WHP is scarce. Therefore, a qualitative systematic literature review was carried out to systematically identify and synthesize factors influencing the phases of WHP interventions: needs assessment, planning, implementation and evaluation. Research evidence was identified by searching electronic databases (Scopus, PubMed, Social Sciences Citation Index, ASSIA, ERIC, IBBS and PsycINFO) from 1998 to 2013, as well as by cross-checking reference lists of included peer-reviewed articles. The inclusion criteria were: original empirical research, description of WHP, description of barriers to and/or facilitators of the planning, implementation and/or evaluation of WHP. Finally, 54 full texts were included. From these, influencing factors were extracted and summarized using thematic analysis. The majority of influencing factors referred to the implementation phase, few dealt with planning and/or evaluation and none with needs assessment. The influencing factors were condensed into topics with respect to factors at contextual level (e.g. economic crisis); factors at organizational level (e.g. management support); factors at intervention level (e.g. quality of intervention concept); factors at implementer level (e.g. resources); factors at participant level (e.g. commitment to intervention) and factors referring to methodological and data aspects (e.g. data-collection issues). Factors regarding contextual issues and organizational aspects were identified across three phases. Therefore, future research and practice should consider not only the influencing factors at different levels, but also at different phases of WHP interventions.

A Guided Online and Mobile Self-Help Program for Individuals With Eating Disorders: An Iterative Engagement and Usability Study.

BACKGROUND: Numerous digital health interventions have been developed for mental health promotion and intervention, including eating disorders. Efficacy of many interventions has been evaluated, yet knowledge about reasons for dropout and poor adherence is scarce. Most digital health intervention studies lack appropriate research design and methods to investigate individual engagement issues. User engagement and program usability are inextricably linked, making usability studies vital in understanding and improving engagement. OBJECTIVE: The aim of this study was to explore engagement and corresponding usability issues of the Healthy Body Image Program-a guided online intervention for individuals with body image concerns or eating disorders. The secondary aim was to demonstrate the value of usability research in order to investigate engagement. METHODS: We conducted an iterative usability study based on a mixed-methods approach, combining cognitive and semistructured interviews as well as questionnaires, prior to program launch. Two separate rounds of usability studies were completed, testing a total of 9 potential users. Thematic analysis and descriptive statistics were used to analyze the think-aloud tasks, interviews, and questionnaires. RESULTS: Participants were satisfied with the overall usability of the program. The average usability score was 77.5/100 for the first test round and improved to 83.1/100 after applying modifications for the second iteration. The analysis of the qualitative data revealed five central themes: layout, navigation, content, support, and engagement conditions. The first three themes highlight usability aspects of the program, while the latter two highlight engagement issues. An easy-to-use format, clear wording, the nature of guidance, and opportunity for interactivity were important issues related to usability. The coach support, time investment, and severity of users' symptoms, the program's features and effectiveness, trust, anonymity, and affordability were relevant to engagement. CONCLUSIONS: This study identified salient usability and engagement features associated with participant motivation to use the Healthy Body Image Program and ultimately helped improve the program prior to its implementation. This research demonstrates that improvements in usability and engagement can be achieved by testing and adjusting intervention design and content prior to program launch. The results are consistent with related research and reinforce the need for further research to identify usage patterns and effective means for reducing dropout. Digital health research should include usability studies prior to efficacy trials to help create more user-friendly programs that have a higher likelihood of "real-world" adoption.

Prevalence of Eating Disorder Risk and Associations with Health-related Quality of Life: Results from a Large School-based Population Screening.

OBJECTIVE: The objective of this study was to investigate the prevalence of eating disorder (ED) risk as well as associated psychopathology and health-related quality of life (HrQoL) in a large population sample of Austrian adolescents. METHOD: A sample of 3610 adolescents aged 10-18 years was recruited from 261 schools representative for the Austrian population. The SCOFF questionnaire was used to identify participants at risk for EDs, and the Youth Self-Report and KIDSCREEN were used to assess general psychopathology and HrQoL. RESULTS: In total, 30.9% of girls and 14.6% of boys were screened at risk for EDs. SCOFF scores were significantly associated with internalising and externalising behavioural problems as well as HrQoL after controlling for sex, age and body mass index. The SCOFF score further turned out to be an independent predictor of HrQoL. DISCUSSION: The high prevalence of ED risk among Austrian adolescents points out the need for prevention in this field. Variables indicating eating pathology should be included in general mental health screenings.

The Mental Health in Austrian Teenagers (MHAT)-Study: preliminary results from a pilot study.

BACKGROUND: No epidemiological data on prevalence rates of mental disorders based on a representative sample are available for Austrian adolescents up to now. However, the knowledge of psychiatric disorders, related risk and protective factors is of great significance for treatment and prevention. The purpose of the MHAT-Study (Mental Health in Austrian Teenagers), the first epidemiological study on mental health in Austria, is to obtain prevalence rates of mental disorders and to examine risk factors, protective factors and quality of life in a representative sample of adolescents aged 10-18. Aims of this pilot study were to evaluate the feasibility and acceptability of the screening instruments, pre-estimate the frequency of mental health problems and estimate possible non-responder bias. METHODS: Twenty-one schools in eastern Austria were asked to participate. Data on mental health problems were derived from self-rating questionnaires containing standardized screening measures (Youth Self-Report, measuring emotional and behavioral problems and the SCOFF, indicating eating problems. Quality of life as well as related risk and protective factors were also obtained. RESULTS: Four hundred and eight adolescents of five schools were recruited. The prevalence of mental health problems was 18.9 % [CI 95 %: 14.9-22.7]. Moreover, emotional and behavioral problems were highly correlated with quality of life measures. A Non-Responder Analysis indicated that non-responders (16.7 %) differ from responders with regard of school related problems. CONCLUSIONS: The results demonstrate that mental health problems affect approximately one fifth of the adolescents. A Non-Responder Analysis suggests that the prevalence of behavioral and emotional problems is underestimated.

Participation by different stakeholders in participatory evaluation of health promotion: a literature review.

Participatory evaluation has been increasingly used in health promotion (HP) and various forms of participatory evaluation have been put into practice. Simultaneously, the concept of participation has become more important for evaluation research in general, which is equally diverse and the subject of various discourses. This study addresses the issue of how the concept of participation has been established in HP evaluation practice. An analytical framework was developed, which served as a basis for a literature review, but can also be used as a general framework for analyzing and planning the scope of participation by various stakeholders within different phases of participatory evaluation. Three dimensions of participation, which refer to decision making (decision power, deliberation) and action processes are distinguished. The results show that only a few articles discussed participatory evaluation processes and participatory (evaluation) research was largely put forth by participatory (action) research in communities. The articles analyzed referred mostly to three stakeholder groups - evaluators, program staff and beneficiaries - and to participation processes in the initial evaluation phases. The application of the framework revealed that decision power seems to be held predominantly by program staff, evaluators seem to be more involved in action processes and beneficiaries in deliberation processes.

Implementing school health promotion in Austria: experiences from a pilot training course.

A pilot training course on school health promotion in Austria focused on supporting teachers and school heads during the implementation of the health-promoting school (HPS) concept. The participants talked about their experiences during the implementation phase in focus groups held in a feedback seminar at the end of the training course. The focus groups were analyzed by using an inductive approach. A coding method for thematic analysis was applied. Compatibility of the training course with the school setting was examined and supporting and hindering structures and processes pertaining to the schools and the training course are described. The results can be displayed in a model showing connections between the themes. Internal and external collaboration structures were identified as central aspects in the implementation phase. Particularly collaboration within the faculty is shown to be of importance when implementing the HPS approach. Voluntary cooperation especially of teachers, which is often connected with work in their spare time, is another aspect influencing the sustainability and therefore also the compatibility of the training course with the school setting. For future designs of teacher training courses in health promotion, the aspects of collaboration, teamwork, and collective commitment have to be taken into consideration.