2019 Research Grant, Individual Project Outcome Reports

Mixed Reality and Holographic technologies (iHealth) to deliver cognitive and behavioural therapy for treatment of anxiety among teenagers with asthma

Chief Investigator: Associate Professor Kristin Carson-Chahhoud

Funding Amount: $75,000

Recipient: University of South Australia

Overview:

This study will establish the evidence-base for novel iHealth technologies (namely augmented reality, virtual reality and holographic technology) for delivery of cognitive and behavioural therapy (CBT) to manage anxiety among young people with asthma. Asthma and mental health disorders are two of the biggest health threats facing Australian youth today. Half of young people with asthma have co-morbid anxiety/depression primarily due to fear of exacerbations, double the rate in the wider community, contributing to functional impairment and preventable hospitalisation and mortality. iHealth tools can address issues of poor health literacy and can be personalised based on age and gender.

Research Outcomes:

Researchers: Associate Professor Kristin Carson-Chahhoud, Dr Andrew Tai, Professor Nicola Spurrier, Associate Professor Ross Smith, Professor Adrian Esterman, Professor Ian Gwilt, Dr Debra Sandford

Research Completed: 2022

Research Findings: Half of young asthmatics have mental health issues associated with their disease, which is two-times higher than non-asthmatics. We worked with health professionals, young asthmatics, and their parents, to co-create an 80-page self-help workbook, plus a smartphone application that brings book pages to life with augmented reality technology. Digital delivery of interactive self-management education, skill development and psychological support was found to be acceptable, user friendly and a practical way to bridge current service gaps.

Key Outcomes:

QUALITATIVE RESEARCH: The mixed reality tools we used for the qualitative study were pre-existing resources, including one bespoke augmented reality (AR) resource – an asthma education tool – developed by the research team, one virtual reality (VR) resource utilising a cardboard headset (goggles) and a meditative soundtrack over visual landscape content, and one holographic resource using a small plastic projector. The holographic resources would more accurately be described as an illusion using the principles of Pepper’s Ghost but gives the impression of a holographic image that sits over the top of a user’s smartphone or tablet device. Three different technologies were chosen for hypothesis generating purposes to identify if one mechanism was more acceptable compared to the others. To evaluate perceptions of usability and acceptability, 13 one-on-one interviews were carried out with the target audience: three young people with asthma, four parents of young people with asthma, and six health professionals, including two psychologists, one psychiatrist, one medical consultant, one respiratory nurse consultant, and one respiratory sleep nurse consultant. During the interviews, participants were allocated time to interact with the mixed reality resources. Interviews ran for approximately one hour; and took place in meeting spaces in the respiratory department at two large teaching hospitals in metropolitan Adelaide, South Australia, or online via Zoom software. Sessions were audio-recorded, and verbatim transcripts were sent back to the participant for validation post interview. All transcripts were coded by two independent researchers, with discrepancies resolved through discussion and consensus, or discussion with a third party. Qualitative data was coded using three pre-specified lenses to enable insight into different aspects of the mixed reality interventions – the Theoretical Domains Framework (TDF), the Theoretical Framework of Acceptability (TFA), and the Enlight protocol. Data obtained through the TFA has already been submitted for publication, while the TDF and Enlight frameworks to be featured in separate manuscripts. Feedback gained through this qualitative process determined that AR technology was the preferred method of intervention delivery for the target audience, and therefore the feasibility portion utilises only AR technology.

FEASIBILITY RESEARCH: A self-help smartphone application (YOLO_de.stress) was co-designed by research investigators with consideration given to participant feedback, with physical development by Portal Australia. It has been designed to facilitate navigation to credible online self-help websites and track self-monitoring of psychological symptoms. It will also be the access platform for AR tools. Daily symptom recordings will be displayed in visual charts for real-time feedback for participant self-management. Data from the application will be forwarded electronically to investigators and used to track application usage. An 80-page workbook has been developed based on best-practice asthma guidelines and through consultation with field experts in Clinical Psychology and Paediatric Respiratory Medicine. Written content includes educational information about asthma, mental health, psychological distress and includes psychological strategies such as mindfulness activities and distractions to alleviate symptoms of psychological distress. The YOLO_de.stress smartphone application then provides a completely new digital layer of information for the end user, by connecting with the phone’s camera. When using the phone’s camera via the smartphone application, the workbook seemingly comes to life to deliver asthma education including symptoms, triggers, and action plans, directly from Dr Andrew Tai, the Director of Respiratory Medicine from the Women’s and Children’s Hospital. Importantly, we have taken digital delivery of information one step further, by creating an augmented reality version of acceptance and commitment therapy (a component of cognitive and behavioural therapy), delivered by Clinical Psychologist Debra Sandford, who also specialises in respiratory-based diseases as a consultant in the Central Adelaide Local Health Network. Featured in our resources are concepts such as ‘normal, natural and to be expected’ with techniques on how to self-manage these experiences, how to cope with the uncontrollable, guided meditation and worst vs best case thinking. There are additional technology features including a games portal for distraction, geometric shape breathing exercises, a waterfall that comes to life and we include QR code features to blend familiar technology with the new AR technology. AR tools were developed through a detailed systematic needs assessment to create a biopsychosocial model for adolescents with asthma who are experiencing symptoms of psychological distress. This lengthy process was not premeditated in the funded grant proposal. However, it was deemed essential by Prof Helen Stallman, the clinical psychologist who collaborated on resource development, to ensure planned content was mapped to guidelines, proven theories, and the latest research and therefore at a high clinical standard of care. A necessary process given we proposed to deliver a virtual clinical intervention using AR technology, without direct face-to-face follow-up and interaction. Data collection and analysis for the feasibility study will continue throughout 2022, alongside A/Prof Carson-Chahhoud’s new appointment as Research Director at the Women’s and Children’s Hospital, scheduled to commence in late April.

Research Papers:

Published

  1. Sharrad KJ, Kopsaftis Z, Carson-Chahhoud KV, Stallman H. The modifiable biopsychosocial drivers of psychological distress for adolescents with asthma: implications for clinical care. Paediatric Respiratory Reviews 2021, Aug. DOI: https://doi.org/10.1016/j.prrv.2021.07.005
  2. Sharrad, K., Kopsaftis, Z., Tai, A., Spurrier, N., Smith, R., Esterman, A., Gwilt, I., Stallman, H., & Carson-Chahhoud, K. (2021). Mixed Reality Technology as a Delivery Mechanism for Psychological Intervention in Adolescents with Asthma: A Qualitative Protocol. International Journal of Qualitative Methods. https://doi.org/10.1177/16094069211008333

Submitted for publication

  • Sharrad, KJ., Kopsaftis, Z., Tai, A., Spurrier, N., Smith, R., Esterman, A., Gwilt, I., Sandford, D., & Carson-Chahhoud, K. Acceptability of mixed reality technology as a delivery mechanism for psychological intervention in adolescents with asthma: a qualitative study using the Theoretical Framework of Acceptability. JMIR mHealth and uHealth (Submitted for editorial and peer review, Nov 2021)
  • Sharrad KJ, Martini C, Kopsaftis ZK, Tai A, Spurrier N, Smith R, Esterman A, Gwilt I, Sandford D, Carson-Chahhoud KV. Augmented reality technology as a delivery mechanism for psychological intervention in adolescents with asthma: a randomised controlled feasibility trial protocol. BMC Pilot & Feasibility Studies. (Submitted for editorial and peer review, Nov 2021)

Conference abstracts accepted

  1. Kelsey Sharrad, Caitlin Martini, Dr Zoe Kopsaftis, Dr Andrew Tai, Assoc. Prof Nicola Spurrier, Assoc. Prof Ross Smith, Prof. Adrian Esterman, Prof Ian Gwilt, Dr Debra Sandford, Assoc. Prof Kristin Carson-Chahhoud. AR as a delivery mechanism for psychological intervention. Thoracic Society of Australia and New Zealand, Annual Scientific Meeting, Virtual attendance 31st of March to 2nd of April 2022

Copies of the two publications, two submitted manuscripts and the conference abstract are included as attachments.

The 80-page workbook is only accessible electronically via three separate documents, all available for review via Dropbox. Multiple printed copies can be sent out for your reference if a postal address is provided.

As the March/April 2022 Thoracic Society of Australia and New Zealand conference was a virtual attendance only, the presentation was recorded and available to be viewed via this Dropbox link, delivered by Carson-Chahhoud:  https://www.dropbox.com/s/onop5632ycru0qx/Carson-Chahhoud_TP_137_AugmentedReality%28AR%29asa.mp4?dl=0

Instructions on how to download the two smartphone applications are provided on page three of the workbook. Note: two smartphone applications are currently needed to activate the AR technology. Once both applications are downloaded on a smartphone, open the YOLO_de.stress application, and enter username ‘YP1Q’ and password ‘CBT1’ (caps sensitive) to access the features. The reason it is currently password protected is to protect data entered by participants during the feasibility study at the Women’s and Children’s Hospital. To view AR content in the workbook, click on the ‘Augmented Reality’ button on the bottom panel, then click ‘start camera’. AR content is then enabled from page four onwards. Although AR video content on that image is slightly glitchy, we are aware of the problem and are sourcing a more powerful computer to ‘render’ the videos to enable smooth play.

To see an example of the AR features without going through the process of downloading the smartphone application, loose AR-enabled pages from the book have been compiled into a video accessible via this Dropbox link: https://www.dropbox.com/s/vpgb34nuqtmmh2q/YOLO_example.mp4?dl=0

Following a media release by UniSA in collaboration with Channel 7, a television interview reaching over 130,000 viewers was run in May 2020, along with four written articles, and one radio interview with National Radio News, as below:

Channel 7 news story about the research being undertaken, 25th of May 2020 (screenshot, link and subsequent media references as a result of the May 2020 press release are listed below).

CRF supports study using Pokemon Go-style app to reduce asthma and anxiety

Television:

  1. Channel 7 News Tasmania, Hobart 2 min 0 sec, by Kim Millar, 62,000 viewers; ‘SA researchers want to know if another app reduces symptoms of anxiety and controls asthma’ (22/05/20)
  2. Channel 7 News Adelaide, Melbourne 1min 44 seconds, by Mike Amor 39,965 viewers; Sydney (weekend) 1min 48 sec By Michael Usher 68,545 viewers (23/05/20); (work of PhD student Kelsey Sharrad who was interviewed for this piece) ‘Researchers found that teenagers with asthma are twice as likely to experience anxiety; Also broadcast on Prime7 Albury (Albury), Prime7 Ballarat (Ballarat), Prime7 Bendigo (Bendigo), Prime7 Gippsland (Sale), Prime7 Mildura (Mildura), Prime7 Shepparton (Shepparton), Prime7 Swan Hill (Swan Hill), Prime7 Warrnambool (Warrnambool), Prime7 ACT (Canberra), Prime7 Armidale (Armidale), Prime7 Coffs Harbour (Coffs Harbour), Prime7 Cooma (Cooma), Prime7 Dubbo (Dubbo), Prime7 Griffith (Griffith), Prime7 Moree (Moree), Prime7 Newcastle (Newcastle), Prime7 North Coast (Lismore), Prime7 Orange (Orange), Prime7 Tamworth (Tamworth), Prime7 Taree (Manning River), Prime7 Wagga Wagga (Wagga Wagga), Prime7 Wollongong (Wollongong); (https://www.facebook.com/7NEWSMelbourne/videos/teenswith-asthma-twice-as-likely-to-experience-anxiety-and-depression/242557463671778/)

Online articles:

7News (25/05/20) By Emily Olle ‘University of SA study using Pokémon Go-style app to reduce asthma and anxiety’ (https://7news.com.au/lifestyle/health-wellbeing/university-of-sa-study-using-pokemon-go-style-app-to-reduce-asthma-and-anxiety–c-1057284

Related Publications:

Future Outcomes:

Although we have not yet commercialised the research project outcomes, two plans have been developed.

Commercialisation potential will be explored by adapting the 80-page workbook and YOLO_de.stress smartphone application to empower confidence and agency among Aboriginal and Torres Strait Islander women. We will do this using the infrastructure developed in this Channel 7 Children’s Research Foundation grant, to deliver self-management education and digital psychological support aiming to address disproportionate burdens linked to bi-directional lung and mental health disparities. A funding application is undergoing a second for submission to the Global Alliance for Chronic Disease (GACD) 7th call to reduce the burden of non-communicable diseases from cross-cultural teams.

Our application is being led by Australia’s first Aboriginal Obstetrician/Gynaecologist, Dr Marilyn Clarke, as CIA and I will join the team as CIC. By the end of this five-year program (approximately $2.25million) our aim is to have co-designed, implemented, and attempted up-scale/expansion of a blended digital health/print model of care that is capable of addressing language barriers and limited access to health services, while simultaneously providing opportunities to record and promote empowering local narratives through role-models, culture by sharing traditional medicines and healing, and confidence by putting these skill-developing accessible tools directly into the hands of end users who need them the most. Another piece of work plans to expand these resources specifically in youth asthma, with expansion and up-scale proposed via a new Channel 7 Children’s Research Foundation grant application led by Carson-Chahhoud’s PhD candidate, Dr Antonia O’Connor. Toni is also a Paediatric Respiratory Specialist (finishing Advanced Trainee in June) at the Women’s and Children’s Hospital and will also be submitting her PhD thesis in June 2022, coinciding with completion of her Advanced Training. Importantly, the biopsychosocial publication, co-design qualitative research paper on resource acceptability (submitted), the developed 80-page workbook, and the smartphone application, are all being used as foundational research evidence sources and as the prototypes for up-scale and expansion to underpin both of these applications.

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