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.

A systematic review of reach, adoption, implementation and maintenance of Internet-based interventions to prevent eating disorders in adults.

BACKGROUND: There is a growing body of research and evidence for the efficacy of Internet-based eating disorder (ED) prevention interventions for adults. However, much less is known about the reach, adoption, implementation and maintenance of these interventions. The RE-AIM (reach, efficacy/effectiveness, adoption, implementation, maintenance) model provides a framework to systematically assess this information. METHODS: A literature search was conducted in PubMed, Web of Science and PsycINFO for articles published between 2000 and 2019. Additionally, reference lists of the studies included and existing reviews published until the end of 2020 were searched. Sixty original articles describing 54 individual studies fulfilled inclusion criteria. Data were extracted for a total of 43 RE-AIM indicators for each study. Fostering and hindering factors for reach, adoption, implementation and maintenance were assessed qualitatively. RESULTS: Overall reporting rates were best for the RE-AIM dimensions reach (62.6%), implementation (57.0%) and effectiveness (54.2%), while adoption (24.2%) and maintenance (21.5%) had comparatively low overall reporting rates. Reporting on indicators of internal validity, such as sample size, effects or description of interventions was better than indicators relevant for dissemination and implementation in real-world settings, e.g. characteristics of non-participants, characteristics and representativeness of settings, and data to estimate cost. CONCLUSIONS: Because most Internet-based ED prevention interventions are provided in a research-funded context, little is known about their public health impact. Better reporting of factors determining external validity is needed to inform dissemination and implementation of these interventions.

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.

Students' perceptions of an online mental health intervention: a qualitative interview study.

BACKGROUND: University students are at a heightened risk of developing mental health disorders. Online interventions are becoming increasingly popular in this target group, both to prevent the development of mental health disorders and to treat existing ones. The PLUS (Personality and Living of University Students) programme is a web-based targeted prevention intervention which has been tested across two European countries. Completion of this programme has been relatively poor. Understanding university students' opinions, experiences and perceptions of the PLUS programme can lead to future improvements in intervention design, engagement and dissemination. METHODS: Semistructured interviews were conducted with university students from the UK (n = 10) and Austria (n = 14) who had previously had access to PLUS. Students were asked about their perception and experiences of the programme, and how it could be improved. Results were analysed using thematic analysis. RESULTS: Experience of online prevention programmes in general were limited and as a result of this, few had specific expectations of the PLUS programme before signing up. The lack of guidance and accountability due to the online nature of the programme made engagement challenging for many, however, frequent reminder emails helped mitigate this. In terms of positives of the programme, participants found the flexibility suitable for students and many noticed that the programme created change in how they thought or behaved. CONCLUSION: Overall, the PLUS programme was well received by students, despite study retention being poor. Although PLUS was viewed as a useful tool to integrate into the university setting, several improvements were suggested to increase engagement. By considering this feedback, uptake and intervention completion can be improved for future preventative interventions.

Evaluating reach, adoption, implementation and maintenance of Internet-based interventions to prevent eating disorders in adolescents: a systematic review.

BACKGROUND: Past research has yielded promising results on the effectiveness of Internet-based interventions to prevent eating disorders (EDs) in adolescents, but further information is needed to evaluate the public health impact of their large-scale dissemination. This article used an established framework to systematically review the extent to which indicators of the reach, effectiveness, adoption, implementation and maintenance [cf. Reach-Effectiveness-Adoption-Implementation-Maintenance (RE-AIM)-framework] of universal and targeted online ED prevention programmes are reported in the literature, in order to estimate their future dissemination potential. METHODS: The literature search was conducted on PubMed, Web of Science and PsycINFO, and complemented by searching existing reviews and the reference lists of the studies included. Twenty-two studies published between 2000 and April 2019 met the inclusion criteria. We extracted data on a total of 43 indicators, within RE-AIM dimensions for each article, including qualitative coding of fostering and hindering factors. RESULTS: Reach (55.0%) and implementation (54.0%) were the dimensions reported on most frequently, followed by effectiveness (46.8%), adoption (34.7%) and maintenance (18.2%). While internal validity indicators were frequently reported (e.g. sample size, effects and intervention intensity), most studies failed to report on elements of external validity, such as representativeness of participants and settings, adoption rates, implementation costs and programme sustainability. CONCLUSIONS: Evidence indicates that Internet-based ED prevention programmes can reach a large number of adolescents and can be feasibly implemented in school settings. However, given the paucity of large-scale dissemination studies available for review, the degree to which schools are willing to adopt preventive interventions, as well as the transferability of programmes to different settings and geographical regions remains unclear.

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.