Utility of ACT based apps in healthcare
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Background: There are significant psychological challenges faced by people throughout their lives and many of these challenges can be readily understood from a contextual behavioural science perspective, and Acceptance and Commitment Therapy (ACT) shows promise as a theoretically and practically relevant intervention. Some problems faced in delivering such an intervention are volume and access to healthcare. A potential solution to this is to design theoretically driven interventions which can be delivered through technology. These need to be interactive, individually shaped and will combine mindfulness, acceptance and values. Such interventions need to be evaluated scientifically according to acceptability, quality, safety and effectiveness. Aims: This thesis has two sections. Firstly, a systematic review aiming to assess the acceptability and effectiveness of using technology to deliver ACT. Secondly, an empirical research study aiming to analyse the experiences of using an ACT based app for young people with type 1 diabetes (TD1). Methods: The review searched 11 databases, and a related website. Included studies were required to use a form of technology to deliver ACT, with no real-time therapist. Two independent researchers determined inclusion of articles into the review and rated the studies according to the quality criteria. Where there was uncertainty a third reviewer was used. For the empirical study, individual interviews of 9 young people aged 13-22 years with TD1 were asked about their experiences of using the ACT based app. Framework analysis was used to determine themes. Results: The review search yielded 18 studies which met inclusion criteria. Findings highlighted that generally these interventions were seen as acceptable and satisfactory. All of these interventions were conducted in an adult population, and qualitative data was not robustly accounted for. The empirical research found two main themes: ‘Desire for apps to represent my needs’ and ‘How diabetes impacts me and how this could potentially be addressed in an app’. Discussion: Both the review and empirical study found that participants were positive about the use of technology to deliver ACT. Developmental progress needs to be made in the app to truly represent the needs of young people with TD1. These interventions could enhance the availability of psychological therapies. This has been highlighted as a government objective in several countries. Methodological weaknesses limit conclusions, such as underpowered studies. As this is a fast growing body of research it is hoped that future studies could be more similar methodologically. It would still be interesting to determine whether asynchronous contact enhances the cost-effectiveness of this form treatment. This thesis has provided me with the opportunity to design an ACT protocol for young people with type 1 diabetes (TD1). It has helped me to fully understand the undertaking which goes into designing apps and the scope of how responsive apps can be. It has given me the chance to communicate with people from different professional backgrounds to create a shared language, an opportunity to lead and manage a project and much more. With the help of my supervisor in my first year of training, we established links with the informatics department to see if students would be able to help with the programming of such an app. We had to create a synopsis of the proposed study to entice students to undertake the project as part of their degree. An interested student was assigned the project and meetings were held to determine our expectations and to establish the scope of what could be created. A second student took on the project during my second year or training. During this time my supervisor and I created a protocol of the content for the app. This was based on previous ACT protocols and tools we were aware of, which we thought might be helpful. A lot of thought had to go into trying to keep the content concise, including different modes of delivery (MP3s, video, animation etc), making the content applicable to young people with TD1 based on previous literature, and thinking about how interactive the app could be. Friends were also relied on to create graphics for the app. I went to different health boards across Scotland to meet with Diabetes teams to inform them about the project and to gather advice on the appropriateness of the diabetes information within the content of the app, and to determine whether they were interested in taking part in the study. I tested the initial prototype and glitches were ironed out. The next stage was to test the app on professionals working in the field, and to gather their feedback through focus groups. Adaptations to the app were made based on this. The app was initially made for Android phone devices based on general market research indicating that there was little evidence that one platform was more popular in adolescents. The diabetes teams and I tried to recruit young people with TD1 from their usual diabetes clinics. Initial barriers to recruitment were that at least 50% of young people had iPhones so could not download the app, and others did not seem interested in downloading the app to take part in the study. Funding of 10 Android tablets was agreed by the University. I attended the usual diabetes clinics in NHS Lothian and young people with TD1 started to volunteer to take part in the study. Originally it was hoped a trial of the effectiveness of the app would be carried out, but the difficulties in recruitment meant that instead I decided to use a qualitative methodology to explore young people’s experiences of using the app.