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A Gamified Digital Intervention Using Behavioural Activation for Adolescent Depression in Rural South Africa: A Pilot Randomised Controlled Trial (the DoBAt Study)
25 Pages Posted: 15 Nov 2024
More...Abstract
Background: Effective and scalable interventions to address depression amongst adolescents are urgently needed. We evaluated the feasibility, acceptability, and preliminary efficacy of digitally delivered Behavioural Activation, the Kuamsha app, for adolescents with depression in rural South Africa.
Methods: A pilot randomised controlled trial was conducted in rural northeastern South Africa. Adolescent males and females aged 15-19 years with symptoms of mild-to-moderately severe depression on the Xitsonga Patient Health Questionnaire Adolescent Version (PHQ-A) were recruited from 11 high schools. Participants were randomly assigned (1:1) to receive the Kuamsha app, which delivers Behavioural Activation through an interactive narrative game supported by low-intensity telephone guidance, or a control app. Our first co-primary objective was to assess the feasibility and acceptability of the Kuamsha app using a mixed-methods design. Our second co-primary objective was to assess the preliminary efficacy of the intervention in reducing symptoms of depression compared to the control. The trial is registered with the Pan African Clinical Trials Registry (PACTR202206574814636).
Findings: Between April and September 2022, 195 adolescents were randomised. Primary outcome data were available on 195 (100%) adolescents. In the Kuamsha group, 77 (80.2%) adhered to the treatment protocol (defined as completing at least 4 of 6 app modules), indicating favourable engagement. In-depth interviews and questionnaire responses revealed high acceptability. Reductions in depressive symptoms were modest, with no significant between-group differences at 11 weeks (AMD: -0·37, 95% CI -1·96, 1·22) or 24 weeks (AMD: -0·11, 95% CI -1·70, 1·48). Exploratory analyses suggested greater efficacy amongst participants who met a cut-off for ‘moderate’ baseline depression symptoms (PHQ-A≥10) and greater app engagement.
Interpretation: The Kuamsha app is a feasible and acceptable treatment for depression amongst adolescents in rural South Africa. Following adaptations, a larger trial is warranted to definitively assess its effectiveness in reducing symptoms of depression.
Trial Registration: The trial is registered with the Pan African Clinical Trials Registry (PACTR202206574814636).
Funding: Research reported in this publication received financial support from the South African Medical Research Council with funds received through the MRC Newton Fund UK-South Africa Joint Initiative on Mental Health (MR/S008748/1). We received additional funding from a UKRI ODA Institutional grant supplement to the University of Oxford. The study was conducted within the SAMRC/Wits Rural Public Health and Health Transitions Research Unit and Agincourt Health and socio-Demographic Surveillance System, a node of the South African Population Research Infrastructure Network (SAPRIN), which is supported by the Department of Science and Innovation, the University of the Witwatersrand, and the Medical Research Council, South Africa, and previously the Wellcome Trust, UK (grants 058893/Z/99/A; 069683/Z/02/Z; 085477/Z/08/Z; 085477/B/08/Z). BM received funding support from the SAMRC (MR/S008748/1), and Oppenheimer Memorial Trust Award (OMT Ref. 2022-1268). JRP received funding support from MRC UK (MR/S008748/1), Wellspring Philanthropic Fund, and NIMH (5R01MH121632-02). CL is supported by the National Institute for Health Research (NIHR) (using the UK’s Official Development Assistance (ODA) Funding) and Wellcome (grant number: 221940/Z/20/Z) under the Department of Health and Social Care (DHSC)-Wellcome Partnership for Global Health Research. HOM received funding from the National Institute for Health Research (NIHR: grant numbers: 151099, 17/49/38). MGC receives payments from Oxford University Press, the American Psychological Association, and from Elsevier (as Editor-in-Chief of Behaviour Research and Therapy) and payment for editorial work for UpToDate,Inc. MGC receives funding for her research from NIMH, Wellcome Trust and Wellcome Leap. TS is supported by the National Research Foundation of South Africa (Grant Number: 150571). SJB is funded by Wellcome (grant number WT107496/Z/15/Z), the MRC, the Jacobs Foundation, the Wellspring Philanthropic Fund and the University of Cambridge. KK and ST’s research is supported by Wits University, the SAMRC, and Dept of Science and Innovation, South Africa; Institutes of the NIH, USA; and the Joint Global Health Trials Scheme, UK. AS received support from the Joint Global health Trials Scheme (MRC/Wellcome/FCDO ) (MR/P006965/1), the MRC Newton Fund ((MR/S008748/1), the ESRC (ES/T003936/1), and the Wellspring Philanthropic Fund and a UKRI ODA Institutional grant supplement to the University of Oxford.
Declaration of Interest: The authors declare no competing interests.
Ethical Approval: Ethical approval was provided by the University of the Witwatersrand Human Research Ethics Committee (MED20-05-011) and the Oxford Tropical Research Ethics Committee (OxTREC 34-20).
Keywords: adolescent mental health, depression, digital, app, gamification, peer support, pilot trial, South Africa
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