Adolescent Health Promotion Interventions Using Well-Care Visits and a Smartphone Cognitive Behavioral Therapy App: Randomized Controlled Trial

Abstract

Background: Adolescent health promotion is important in preventing risk behaviors and improving mental health. Health promotion during adolescence has been shown to contribute to the prevention of late onset of the mental health disease. However, scalable interventions have not been established yet.

Objective: This study was designed to test the efficacy of two adolescent health promotion interventions: a well-care visit (WCV) with a risk assessment interview and counseling and self-monitoring with a smartphone cognitive behavioral therapy (CBT) app. Our hypothesis was that participants who had received both WCV and the CBT app would have better outcomes than those who had received only WCV or those who had not received any intervention. We conducted a prospective multi-institutional randomized controlled trial.

Methods: Participants were 217 adolescents aged 13-18 years. They were randomly divided into two intervention groups (WCV group and WCV with CBT app group) and a nonintervention group. WCV comprised a standardized physical examination along with a structured interview and counseling for youth risk assessment, which was designed with reference to the Guideline for Health Supervision of Adolescents of Bright Futures. A smartphone-based CBT program was developed based on the CBT approach. The CBT app comprised a 1-week psychoeducation component and a 1-week self-monitoring component. During the CBT program, participants created several self-monitoring sheets based on the CBT model with five window panels: event, thoughts, feelings, body response, and actions. The primary outcome was the change in scores for depressive symptoms. Secondary outcomes included changes in scores for self-esteem, quality of life, self-monitoring, and an adolescent health promotion scale. These outcomes were evaluated at baseline and at 1, 2, and 4 months after baseline. The exploratory outcome was the presence of suicidal ideation during the observation period. Intervention effects were estimated using mixed effect models.

Results: In total, 94% (204/217) of the participants completed the 4-month evaluation. Both intervention groups showed a significant effect in the form of reduced scores for depressive symptoms at 1 month in high school students; however, these effects were not observed at 2 and 4 months. The intervention effect was significantly more predominant in those scoring above cutoff for depressive symptoms. There was significantly less suicidal ideation in the intervention groups. As for secondary outcomes, there was significant increase in health promotion scale scores at the 4-month follow-up among junior high school students in the WCV group. Moreover, the CBT app was significantly effective in terms of obtaining self-monitoring skills and reducing depressive symptoms.

Conclusions: Although adolescent health promotion interventions may have short-term benefits, the frequency of WCV and further revision of the CBT app should be considered to evaluate long-term effectiveness.

Trial registration: University Hospital Medical Information Network Clinical Trials Registry UMIN 000036343; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000041246.

Keywords: RCT; app; cognitive behavioral therapy; health promotion; mobile phone; randomized controlled trial; well-care visit.

Figure 1

Participant flow chart. CBT: cognitive behavioral therapy; WCV: well-care visit.

Figure 2

Screenshots of the smartphone cognitive behavioral therapy app.

Figure 3

Changes in Depression Self-Rating Scale for Children (DSRS-C) scores in the intervention and nonintervention groups during the follow-up period; a: There were significant differences in the changes in DSRS-C scores from baseline to 1 month between the WCV group and the nonintervention group (P=.045); b: there were significant differences in the changes in DSRS-C scores from baseline to 1 month between the WCV with CBT app group and the nonintervention group (P=.004). Vertical bars show the SE. CBT: cognitive behavioral therapy; WCV: well-care visit.

Figure 4

Changes in Depression Self-Rating Scale for Children (DSRS-C) scores for participants in the intervention groups by the DSRS-C cutoff score; a: the mean DSRS-C score for participants scoring >16 in the intervention groups was significantly decreased at 1 month compared with the mean score at their first visit (P=.004); b: the mean DSRS-C score for participants scoring >16 in the intervention groups was significantly decreased at 4 month compared with the mean score at their first visit (P=.03). Vertical bars show SE.

Figure 5

Correlation between the number of self-monitoring sheets created by participants and the changes in Depression Self-Rating Scale for Children (DSRS-C) scores in the well-care visit with cognitive behavioral therapy app group. Significant negative correlation was observed between the changes in DSRS-C scores and number of self-monitoring sheets created by participants at 4 months.

Figure 6

Changes in Adolescent Health Promotion Short Form (AHP-SF) scores in the intervention and nonintervention groups during the follow-up period; a: the changes in AHP-SF scores from baseline to 4 months were significantly different between the WCV group and the nonintervention group (P=.046). Vertical bars show the SE. CBT: cognitive behavioral therapy; WCV: well-care visit.

Figure 7

Correlation between the number of self-monitoring sheets created by participants and the changes in self-monitoring scores in the well-care visit with cognitive behavioral therapy app group. Significant positive correlation was observed between changes in self-monitoring scores and number of self-monitoring sheets created by participants at the 1-month visit.