Publications by authors named "Megan Jones Bell"

8 Publications

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Online interventions to prevent mental health problems implemented in school settings: the perspectives from key stakeholders in Austria and Spain.

Eur J Public Health 2021 07;31(31 Suppl 1):i71-i79

Ferdinand Porsche FernFH-Distance Learning University of Applied Sciences, Wiener Neustadt, Austria.

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.
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July 2021

A randomized controlled trial of a smartphone-based application for the treatment of anxiety.

Psychother Res 2021 04 14;31(4):443-454. Epub 2020 Jul 14.

Department of Psychiatry, Stanford University, Stanford, CA, USA.

Generalized anxiety disorder (GAD) is prevalent among college students. Smartphone-based interventions may be a low-cost treatment method. College students with self-reported GAD were randomized to receive smartphone-based guided self-help ( = 50), or no treatment ( = 50). Post-treatment and six-month follow-up outcomes included the Depression Anxiety Stress Scales-Short Form Stress Subscale (DASS Stress), the Penn State Worry Questionnaire (PSWQ-11), and the State-Trait Anxiety Inventory-Trait (STAI-T), as well as diagnostic status assessed by the GAD-Questionnaire, 4th edition. From pre- to post-treatment, participants who received guided self-help (vs. no treatment) experienced significantly greater reductions on the DASS Stress ( = -0.408) and a greater probability of remission from GAD ( = -0.445). There was no significant between-group difference in change on the PSWQ-11 ( = -0.208) or STAI-T ( = -0.114). From post to six-month follow-up there was no significant loss of gains on DASS Stress scores ( = -0.141) and of those who had remitted, 78.6% remained remitted. Yet rates of remitted participants no longer differed significantly between conditions at follow-up (= -0.229). Smartphone-based interventions may be efficacious in treating some aspects of GAD. Methods for improving symptom reduction and long-term outcome are discussed.
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April 2021

Evaluation of the Computer-Based Intervention Program Brazil to Promote Healthy Eating Habits: The Results from a School Cluster-Randomized Controlled Trial.

Int J Environ Res Public Health 2019 05 14;16(10). Epub 2019 May 14.

Departamento de Ciências da Nutrição, Escola de Nutrição, Universidade Federal da Bahia, Av. Araújo Pinho, 32, Canela, Salvador, BA 40.110-150, Brazil.

Interventions via the Internet are promising regarding the promotion of healthy habits among youth. The objective of this study was to evaluate the effect of an adapted version of StayingFit to promote healthy eating habits and the measurement adequacy of anthropometric markers among adolescents. A web school-based 12-month cluster-randomized controlled trial examining 7th to 9th grade students was conducted in twelve schools in Salvador, Bahia, Brazil. The schools' students were randomly distributed into the intervention and control groups. The intervention group participated in StayingFit, an online program designed to encourage and guide healthy eating habits and control body weight. Data on food consumption, anthropometry, physical activity level, and sedentary behavior were collected from all of the students at the beginning of and after the 12-month study. Demographic and socioeconomic data were collected at baseline. The baseline data indicated high rates of overweight (14.4% overweight and 8.5% obese), insufficiently active (87.6%), and sedentary (63.7%). Furthermore, few adolescents regularly consumed fruits (18.8%) and vegetables/legumes (16.4%). Generalized estimating equations (GEEs) were used to evaluate the effect of the intervention. At the end of the follow-up period, students in the intervention group had a 43% increased chance of regularly consuming beans (OR = 1.43, 95% CIs = 1.10-1.86) and a 35% decreased chance of regularly consuming soft drinks (OR = 0.65, 95% CIs = 0.50-0.84). No differences were found between the groups studied with regard to the anthropometric parameters. Despite these modest results, the implementation of a web intervention can be beneficial and help promote positive changes in adolescent eating habits.
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May 2019

Healthy Teens @ School: Evaluating and disseminating transdiagnostic preventive interventions for eating disorders and obesity for adolescents in school settings.

Internet Interv 2019 Apr 27;16:65-75. Epub 2018 Feb 27.

FernFH Distance Learning University of Applied Sciences, Wiener Neustadt, Austria.

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 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.
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April 2019

Efficacy of a Parent-Based, Indicated Prevention for Anorexia Nervosa: Randomized Controlled Trial.

J Med Internet Res 2018 12 14;20(12):e296. Epub 2018 Dec 14.

Department of Psychiatry, Stanford University School of Medicine, Stanford, CA, United States.

Background: Web-based preventive interventions can reduce risk and incidence of bulimia and binge eating disorders among young high-risk women. However, their specific effects on core symptoms of anorexia nervosa (AN) are rather weak.

Objective: The primary objective of this study was to evaluate the efficacy of an indicated, parent-based, Web-based preventive program Eltern als Therapeuten ([email protected]) in reducing risk factors and symptoms of AN.

Methods: Girls aged between 11 and 17 years were screened by selected risk factors and early symptoms of AN. At-risk families were then randomized to [email protected] or an assessment-only control condition. Assessments took place at pre- and postintervention (6 weeks later) and at 6- and 12-month follow-up (FU).

Results: A total of 12,377 screening questionnaires were handed out in 86 German schools, and 3941 including consent returned. Overall, 477 (447/3941, 12.10%) girls were identified as at risk for AN and 256 of those could be contacted. In all, 66 families (66/256, 25.8% of those contacted) were randomized to the [email protected] or a wait-list control condition, 43 (43/66, 65%) participated in postassessments, and 27 (27/66, 41%) in 12-month FUs. Due to low participation and high dropout rates of parents, recruitment was terminated prematurely. At 12-month FU, girls' expected body weight (EBW) percentage was significantly greater for intervention participants compared with control participants (group by time interaction beta=21.0 [CI 5.81 to 36.13], P=.007; group by time squared interaction beta=-15.5 [CI -26.6 to -4.49], P=.007; estimated Cohen d=0.42]. No other significant effects were found on risk factors and attitudes of disturbed eating.

Conclusions: Despite a significant increase in girls' EBW percentage, parental participation and adherence to the intervention were low. Overall, parent-based, indicated prevention for children at risk for AN does not seem very promising, although it might be useful for parents who engage in the intervention.

Trial Registration: International Standard Randomized Controlled Trial Number (ISRCTN): 18614564; (Archived by WebCite at
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December 2018

A study protocol for a non-randomised comparison trial evaluating the feasibility and effectiveness of a mobile cognitive-behavioural programme with integrated coaching for anxious adults in primary care.

BMJ Open 2018 01 13;8(1):e019108. Epub 2018 Jan 13.

Lantern, San Francisco, California, USA.

Introduction: Generalised anxiety disorder (GAD) and subclinical GAD are highly prevalent in primary care. Unmanaged anxiety worsens quality of life in patients seen in primary care practices and leads to increased medical utilisation and costs. Programmes that teach patients cognitive-behavioural therapy (CBT) techniques have been shown to improve anxiety and to prevent the evolution of anxiety symptoms to disorders, but access and engagement have hampered integration of CBT into medical settings.

Methods And Analysis: This pragmatic study takes place in University of Pittsburgh Medical Center primary care practices to evaluate a coach-supported mobile cognitive- behavioural programme (Lantern) on anxiety symptoms and quality of life. Clinics were non-randomly assigned to either enhanced treatment as usual or Lantern. All clinics provide electronic screening for anxiety and, within clinics assigned to Lantern, patients meeting a threshold level of mild anxiety (ie, >5 on Generalised Anxiety Disorder 7-Item Questionnaire (GAD-7)) are referred to Lantern. The first study phase is aimed at establishing feasibility, acceptability and effectiveness. The second phase focuses on long-term impact on psychosocial outcomes, healthcare utilisation and clinic/provider adoption/sustainable implementation using a propensity score matched parallel group study design. Primary outcomes are changes in anxiety symptoms (GAD-7) and quality of life (Short-Form Health Survey) between baseline and 6-month follow-ups, comparing control and intervention. Secondary outcomes include provider and patient satisfaction, patient engagement, durability of changes in anxiety symptoms and quality of life over 12 months and the impact of Lantern on healthcare utilisation over 12 months. Patients from control sites will be matched to the patients who use the mobile app.

Ethics And Dissemination: Ethics and human subject research approval were obtained. A data safety monitoring board is overseeing trial data and ethics. Results will be communicated to participating primary care practices, published and presented at clinical and scientific conferences.

Trial Registration Number: NCT03035019.
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January 2018

Mobile and traditional cognitive behavioral therapy programs for generalized anxiety disorder: A cost-effectiveness analysis.

PLoS One 2018 4;13(1):e0190554. Epub 2018 Jan 4.

Evidation Health, San Mateo, California, United States of America.

Background: Generalized anxiety disorder (GAD) is a debilitating mental health illness that affects approximately 3.1% of U.S. adults and can be treated with cognitive behavioral therapy (CBT). With the emergence of digital health technologies, mobile CBT may be a cost-effective way to deliver care. We developed an analysis framework to quantify the cost-effectiveness of internet-based CBT for individuals with GAD. As a case study, we examined the potential value of a new mobile-delivered CBT program for GAD.

Methods: We developed a Markov model of GAD health states combined with a detailed economic analysis for a cohort of adults with GAD in the U.S. In our case study, we used pilot program efficacy data to evaluate a mobile CBT program as either prevention or treatment only and compared the strategies to traditional CBT and no CBT. Traditional CBT efficacy was estimated from clinical trial results. We calculated discounted incremental costs and quality-adjusted life-years (QALYs) over the cohort lifetime.

Case Study Results: In the base case, for a cohort of 100,000 persons with GAD, we found that mobile CBT is cost-saving. It leads to a gain of 34,108 QALYs and 81,492 QALYs and a cost reduction of $2.23 billion and $4.54 billion when compared to traditional CBT and no CBT respectively. Results were insensitive to most model inputs and mobile CBT remained cost-saving in almost all scenarios.

Limitations: The case study was conducted for illustrative purposes and used mobile CBT efficacy data from a small pilot program; the analysis should be re-conducted once robust efficacy data is available. The model was limited in its ability to measure the effectiveness of CBT in combination with pharmacotherapy.

Conclusions: Mobile CBT may lead to improved health outcomes at lower costs than traditional CBT or no intervention and may be effective as either prevention or treatment.
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February 2018

Towards successful evidence-based universal eating disorders prevention: The importance of zooming out.

Eat Behav 2017 04 29;25:89-92. Epub 2016 Oct 29.

School of Psychology and Public Health, La Trobe University, Melbourne, Australia.

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April 2017