JMIR Publications

ABSTRACT

Background:

There is an urgent need for scalable psychological treatments to address adolescent depression in low-resource settings. Digital mental health interventions have many potential advantages, but few have been specifically designed for, or rigorously evaluated with, adolescents in sub-Saharan Africa.

Objective:

This study had two main objectives. The first objective was to describe the user-centred development of a smartphone app that delivers Behavioural Activation (BA) to treat depression among adolescents in rural South Africa and Uganda. The second was to summarise findings from multicycle usability testing.

Methods:

An iterative user-centred agile design approach was used to co-construct the app to ensure that it was engaging, culturally relevant, and usable for the target populations. An array of qualitative methods, including focus group discussions, in-depth individual interviews, participatory workshops, usability testing, and extensive expert consultation were used to iteratively refine the app throughout each phase of development.

Results:

160 adolescents in rural South Africa and Uganda were involved in the development process. The app was built to be consistent with the principles of BA and to be supported by brief weekly phone calls from peer mentors (who would help users overcome barriers to engagement). Drawing on the findings of the formative work, we applied a narrative game format to develop the Kuamsha app. This approach taught the principles of BA using storytelling techniques and game design elements. The stories were developed collaboratively with adolescents from the study sites, and include interactive choices, character personalisation, in-app points, and notifications. The app consists of six game episodes (sessions), each covering different BA skills. Between modules, users were encouraged to work on weekly activities and report on their progress and mood as they completed these activities. Results of multicycle usability testing showed that the Kuamsha app was acceptable in terms of usability and engagement.

Conclusions:

The Kuamsha app uniquely delivered BA for adolescent depression via an interactive narrative game format tailored to the South African and Ugandan contexts. Further studies are currently underway to examine the intervention's feasibility, acceptability, and efficacy in reducing depressive symptoms. Clinical Trial: The app was developed as part of the “DoBat and Ebikolwa n’empisa” research programmes, which aim to develop scalable psychological treatments to address depression amongst adolescents in low-resource settings. The trial in South Africa was registered with the South African National Clinical Trials Registry (DOH-27-112020-5741) and the Pan African Clinical Trials Registry (PACTR202206574814636).