Remote measurement technologies (RMTs) have the potential to revolutionize major depressive disorder (MDD) disease management by offering the ability to assess, monitor, and predict symptom changes. However, the promise of RMT data depends heavily on sustained user engagement over extended periods. In this paper, we report a longitudinal qualitative study of the subjective experience of people with MDD engaging with RMTs to provide insight into system usability and user experience and to provide the basis for future promotion of RMT use in research and clinical practice.We aimed to understand the subjective experience of long-term engagement with RMTs using qualitative data collected in a longitudinal study of RMTs for monitoring MDD. The objectives were to explore the key themes associated with long-term RMT use and to identify recommendations for future system engagement.In this multisite, longitudinal qualitative research study, 124 semistructured interviews were conducted with 99 participants across the United Kingdom, Spain, and the Netherlands at 3-month, 12-month, and 24-month time points during a study exploring RMT use (the Remote Assessment of Disease and Relapse-Major Depressive Disorder study). Data were analyzed using thematic analysis, and interviews were audio recorded, transcribed, and coded in the native language, with the resulting quotes translated into English.There were 5 main themes regarding the subjective experience of long-term RMT use: research-related factors, the utility of RMTs for self-management, technology-related factors, clinical factors, and system amendments and additions.The subjective experience of long-term RMT use can be considered from 2 main perspectives: experiential factors (how participants construct their experience of engaging with RMTs) and system-related factors (direct engagement with the technologies). A set of recommendations based on these strands are proposed for both future research and the real-world implementation of RMTs into clinical practice. Future exploration of experiential engagement with RMTs will be key to the successful use of RMTs in clinical care. Depressive disorders, characterized by periods of persistent low mood and anhedonia, are the third leading cause of disability worldwide . Major d.Novel remote measurement technologies (RMTs) have the potential to become an asset for chronic disease management. Multiparametric RMT systems can provide real-time, longitudinal symptom tracking by combining active symptom reporting via smartphone apps (active RMT) with physiological and behavioral wearable sensor data (passive RMT) . ContinuThe promise of remote tracking in MDD depends almost entirely on user engagement. Engagement with mobile health  technologies comprises the initial and sustained active use of a device . High enwhat it feels like ).The interviews were semistructured using open-ended questions, designed to elicit discussions around using the study technology in daily life . The conThe topic guides were translated from English into Spanish and Dutch, and interviews were conducted by native speakers at each site. The interviews lasted between 30 and 60 minutes and were conducted between February 2018 and April 2021.The semistructured interviews were approved by the ethics committee of RADAR-MDD . EthicalThe interviews were audio recorded and transcribed verbatim. A preliminary coding framework was developed in English based on previous findings of barriers to and facilitators of RMT use in hypothetical scenarios . All sitMultisite data were merged into one data set and thematic maps for 3-month, 12-month, and 24-month time points were developed by 3 researchers , identifying key themes and subthemes. To align with previous longitudinal qualitative research work , data arA total of 124 interviews with 99 participants were conducted across 3 sites. Of these 124 interviews, 40 (32.2%) interviews were conducted at the 3-month time point , 42 (33.9%) at the 12-month time point , and 42 (33.9%) at the 24-month time point . A total of 17 participants took part in an interview at 2 time points; 4 participants were interviewed across all 3 time points. Participant characteristics according to time points are shown in This study aimed to explore the subjective experience of long-term engagement with RMTs over a 2-year follow-up period. We present our results under five themes: (1) research-related factors, (2) the utility of RMTs for self-management, (3) technology-related factors, (4) clinical factors, and (5) system amendments and additions.When considering initial motivations for engaging with an RMT study, contributing toward novel research findings was the most prevalent reason for taking part. Across all time points, research team support was also a key facilitator of sustained engagement in the study.Taking part in the study was an opportunity to use personal experiences of depression to help others, to advance scientific understanding, and to “give back” to the system:I’ve suffered with depression the whole of my adult life, I’ve obviously had a lot out of the system. If I can do anything to put back, do you see what I mean—I will.P30, 24 months, United KingdomTaking part for “the future, for the people who come after me”  was a strong theme that arose in all sites when discussing reasons for enrolling in the research study. Altruistic motivations continued across later time points regardless of whether participants felt they had experienced any direct benefits:I am actually quite proud to say that I am doing this as part of research. Some people will ask me what it is [the wearable], and I say well it is good if more people get to know about it. And for the long-term benefits, might not be for me but for other people, because it might show.P18, 12 months, United Kingdom“I was very intrigued by a study that kind of has consistent monitoring” . However, many participants signed up with limited knowledge of the study procedure, or of the use of RMTs for health care monitoring. Thus, a lack of prior understanding of RMTs is not a barrier to initial engagement.With regard to the RMT aspect of the study, some mentioned that it “piqued my interest”  and Privacy was not a barrier to participants upon entering the study or throughout their participation. A key reason for this was that the research was conducted in a clinical and academic setting. In the Spanish cohort, one participant viewed the study as parallel to their clinical care:It’s not data about, about privacy, things about you, no, it’s related to a medical condition, isn’t it? A case of depression, that’s what it’s about. So if they ask you for medical data, well, it’s normal.P25, 24 months, SpainAny initial privacy or data security concerns were largely alleviated by the 3-month point through conversations with the research team. At later time points, privacy was not discussed frequently.Support from the research team was a facilitator to continued engagement with the RMTs. This was primarily practical; at 3 months, the research team provided support on how to use the devices and study apps, which was often imperative to successful enrollment into the study:I tried it once [the wearable] and wasn’t able to...to...put it on the phone. If it hadn’t been for [researcher name]’s help I wouldn’t have made it.P1, 3 months, SpainThe need for practical support remained a key theme at 12 months, this time concerning technological malfunctions. Ability to contact the research team through various methods and receiving a timely reply was important. Some felt comfortable with initiating support themselves: “I didn’t need that much contact personally, I could get in contact easily, if it were necessary” . Others wanted more contact, for example, more points of researcher-initiated contact, or specific contact from specialists. At-hand support was essential for continued participation:I think it is really important to have the practical support ‘cause you don’t want to be offline or not working for long than is necessary. Otherwise it goes against the purpose of the study really.P18, 12 months, United KingdomThere was a consensus at all time points that the research team was approachable, patient, and reassuring, helping to alleviate technological concerns.The research team also provided emotional support to the participants. Some participants sought comfort in the knowledge that they were being monitored as part of a study: “I liked it a lot because, jeez knowing, I felt safe, you know? Because knowing that you were there...” . Others had specific examples of receiving mental health support from the research team. One participant in the British cohort received direct signposting, which was noted in both their 12-month and 24-month interview as a crucial part of their study experience:because of the letter from [researcher] to the GP clinic I was able to get an immediate referral, and the problem is if you’re the system it’s great, if you’re not in the system it’s difficult to get in. I couldn’t have done it on my own.P27, 12 months, United KingdomDespite primarily engaging with the study for altruistic reasons, many participants experienced unexpected benefits of using RMTs for symptom monitoring during their time in the study. These comprised symptom awareness and communication, both of which were integrated into self-management of depression.Across all 3 time points, the most frequently reported benefit was an increase in symptom awareness. Monitoring various factors related to depression, for example, mood, sleep, and exercise, increased self-reflection, and the ability to identify patterns. For example, having access to objective sleep data provided clarification and reassurance:I loved that [the wearable data], I found that so reassuring to just relax, of course you’ve slept and then you go ok, the next time you’re lying in bed you go I’m not ever gonna sleep again but actually you have, you’ve seen that you do I think that’s brilliant, really reassuring.P14, 3 months, United KingdomAlthough the app did not provide feedback on symptom scores, many felt that the act of answering the questionnaires prompted them to analyze how they had been feeling:I’m more aware of it, the questions on the questionnaire, especially those that ask how I’m feeling right now raise my awareness, I feel quite average or, I’m feeling not great, sometimes you ignore these things. And if you can take more time to think about these things...maybe I need to meditate more, I really feel self-conscious...P10, 3 months, the NetherlandsFor some, answering the questionnaires and viewing the Fitbit data simply provided an understanding of their experience of depression: “I have noticed that my answers have gotten more positive throughout the year” . For others, these data directly motivated behavior changes. At 3 months, the discussion focused on the motivational effects of the Fitbit data; participants felt encouraged to complete their daily step count or achieve target physical activity “badges.” Toward the later time points, these data came to act as prompts for self-care, for example, increased exercise or relaxation:Wearing a watch and knowing that my activity matters, you know? I mean, like the steps I take have a direct effect on my health, both physical and mental, all my activity makes me more aware of it, more conscious of it and it has also been like a driving force for me to put my batteries in sport or stress management...a habit forever, so I do not want to do without it.P26, 24 months, SpainThis became especially apparent during the 24-month interviews, when the Fitbit data were used to monitor sleep and mood symptom changes during the COVID-19 pandemic. Disruption to usual routines during this time allowed some to reflect more than ever on the benefit of monitoring exercise:I knew in theory, exercising and getting out and so on was good for your mental health, but over Covid, the monitor helped, and the benefit would have been even better. I think I might have been worse during Covid without it.P36, 24 months, United KingdomAt each time point, the RMT data were also used for communicating personal experiences to others. Participants used their increased understanding of their depression to inform others: “For the first time it kind of occurred to me to let me partner know when I could feel it was starting...so if you see my behaviour change or I’m unresponsive this is why” .Access to the Fitbit data also facilitated joint decision-making, both for immediate symptom management and long-term strategies:There are also days that I don’t reach 5000 steps, which will make me think oh I haven’t done that many today...my spouse will say that too, go for another walk.P2, 3 months, the NetherlandsThere was a consensus throughout that the benefits of participating in the study outweighed the costs, of which there were relatively few. Many had not envisioned any personal benefits when enrolling as they were aware that they would not receive personalized outcomes; however, had been pleasantly surprised by the integration of RMT data into their depression self-management, as early as the 3-month time point:I think its empowering to know more about myself to understand more so I think once I can see more what the data is from collecting from data when the other apps are working and being able to see what the data is and notice any correlations then I think that will be really valuable.P12, 3 months, United KingdomExperience of the technology used in the study (smartphone apps and Fitbit) was the most widely cited theme across all sites. This covered the convenience of integrating the RMTs into daily life, the usability of the technology, technological malfunctions that occurred, and the extent to which participants found the technologies intrusive.Using a mobile phone and wearing a watch were already an integral part of many participants’ daily routine. The Fitbit device, “it’s basically wearing a watch” , collected data passively without the need to input information, and continual wear, syncing, and charging were integrated into the routine as early as the 3-month time point. Reminder messages across the system were useful in the process of long-term integration.One aspect that participants found more difficult to integrate into their routine was the app questionnaires. Timing of the questionnaires was often inconvenient, for example when at work, driving, or in social situations: “Obviously I’m less likely to stop my conversation to be like oh this questionnaire, because that’s a bit rude” . Frequency of the ESM questionnaires was also too high from some: “it’s impossible to have a routine with that. If you have a full-time job, it’s always a bother” . The participants were rarely able to change their routine to accommodate answering the questionnaires, which sometimes caused guilt. One participant in the Spanish cohort reflected on how work affected their ability to respond to app notifications during their 2-year participation:At the beginning it was a bit difficult because I was working, then as I was on sick leave for two years, the truth is that I’ve been able to adapt quite well. And in the end, when I went back to work again, it was a bit difficult...P1, 24 months, SpainFor those who received a smartphone upon enrollment, a large technological barrier was the process of “relearning” a new operating system. This was described by some as “more difficult than anticipated” , particularly during the 3-month interviews, owing to adapting to a new user interface and decreased connectivity with other devices. At 24 months, some participants had adjusted to using the new device, whereas others planned to swap back upon study completion:No, my only peeve was that I’m an Apple user and having this bloody awful Android phone, the first thing I shall do on April 1st is take my SIM card out of the Motorola thingy.P35, 24 months, United KingdomThe participants reported a range of technological malfunctions that affected their participation in the study. Issues with the study apps were particularly prevalent during the 3-month interviews owing to ongoing technological challenges during the early phases of the study. These included not receiving notifications, apps crashing, apps logging out, and difficulties with rescanning QR codes. Participants sometimes had limited time or motivation to report issues to the team:I tried opening a questionnaire I wouldn’t be able to see it, I wouldn’t be able to do it and there was no way of saying this is happening or why this is happening so maybe I should have contacted you about it but I just kind of ignored it.P4, 3 months, United KingdomIssues with missing data persisted throughout the 3 time points. Participants were aware of the times when the active app had been unable to submit the completed data, or the passive app had ceased monitoring. Such malfunctions often led to anxiety or guilt that they were not “correctly” participating: “Well, yes, when it didn’t work, I became a bit nervous...” .Participants also reported frequent missing data with the Fitbit, caused either by a syncing error or inaccurate recording. These issues caused some to question the integrity of the study: “It just didn’t work and that’s not what you expect from a research study” .A participant in the Spanish cohort reflected on how these technological malfunctions affected not only their ability to participate in the study but also their experience of being able to use the resulting data:There is data that I have missed here, and of course I was analyzing it with me in important situations of how I was, and that I have missed them, for more than a month.P32, 24 months, SpainGenerally, the concept of remote monitoring, or the use of the technologies, was not regarded as intrusive. Rather, passive data collection was noted as a preferable method because “at some point you don’t notice it. You don’t notice that you’re wearing it anymore” .However, one area that caused disruption was the wearability of the Fitbit device. Several issues associated with the Fitbit strap were reported, including skin irritation, increased sweating, and allergic reactions. Some had briefly chosen to remove the device while experiencing discomfort, whereas others had purchased straps with alternative materials. At 12 months, many reported that their strap had broken, and by 24 months, some had to apply for a full device replacement. One participant felt guilty when asking the research team for their device to be repaired:I know that the money allocated to research programs or projects is minimal, and of course, when the strap broke or the Fitbit wouldn’t charge me and then I felt really bad because I thought “oh my God, now they have to change my Fitbit.”P26, 24 months, SpainWaiting for a replacement strap or device meant that participants were unable to continue to use the Fitbit for self-management:if I was going to continue and for the others who will be continuing, it will probably begin to happen more and more depending on how much people are actually exercising with them on. It only grows, that’s the problem, in my experience with the other Fitbit, that definitely happens.P3, 12 months, United KingdomThe participants were asked to reflect on whether and how they could see the RMT data being used in a clinical setting. Discussions included the extent to which participants felt comfortable sharing the data, how they envisioned clinicians using the data, and how feasible this was in the current climate.At the 12- and 24-month time points, the participants were specifically asked to comment on data sharing with medical professionals. In general, allowing trusted clinicians to view RMT data alongside medical records was acceptable, or even essential: “let’s say my whole history, my doctor already has it, if she has it more extensive, then all the better for me.” . There was some discrepancy over whether these data should automatically be available to clinicians or mediated by the patient. Some thought that medical professionals “would be in a better position to evaluate what they needed from it than me to decide that” . Others worried about interpretation of the data without context:I suppose, [I would like to] understand what it is that is proposed to be shared, and if there’s something there that would not be appropriate at that time, because I don’t know what it is until I see it, then yes, I would like to have a choice...I would want to make sure that my health record reflects actuality rather than something that can be interpreted by people incorrectly.P31, 24 months, United KingdomThe participants suggested several ways in which they might expect RMT data to be beneficial in clinical care. These included (1) allowing the clinician to view the “whole picture” of individual experience, (2) allowing the clinician insight into new symptoms, (3) as a way for patients to report specific areas of concern, and finally (4) as a basis for making decisions about suitable treatment or care. Importantly, treatment decisions should be reached as a joint decision involving the clinician, the patient, and the data:I think they could actually look at the data that’s being produced, and that could assist them in helping me to come to another decision. Like, if I was deciding that I would like to move my medication down, but they’ve got the data that says, no you’re not...but if it backs it up as well, so it can work both ways, so I think it does have those benefits.P33, 24 months, United Kingdom. One participant in the British cohort also discussed their experience of integrating the sleep data into their sleep clinic appointments:Sleep data were repeatedly cited as a data stream that would cause change in treatment. Participants from all sites provided examples of conversations with their mental health cliniciansIt’s too expensive for the NHS to keep on doing [sleep tests]...I said, well, actually, I can show you any time in the last six months or so...an indication of when I’m sleeping...It helped them choose what exercises I needed to do and what therapy was required, so, yes, it was extremely helpful.P22, 12 months, United KingdomPresentation of objective sleep data was seen as helpful “proof” of the participant’s recent experiences:You can tell your GP that you sleep terribly, but of course your GP can also think that you’re just worried, but with the data it’s a fact that you can prove, so that’s nice, that you have concrete info...whether you worry or complain about it or not doesn’t matter, the facts are there.P10, 12 months, the NetherlandsAlthough the potential for RMTs in clinical care was recognized, 2 key barriers to their implementation were envisioned. First, the level of technological acceptance of medical professionals influenced participant views on the long-term utility of the data. Participants in the Spanish cohort, who were recruited through their clinical care, generally reported acceptance of the study from their clinicians: “even my psychiatrist here and in Barcelona had the same way of thinking and saw that this was very useful for me and encouraged me” .Others described more negative experiences, often causing them to question the use of the data:I thought it would be more relevant for my neurologist, but my neurologist wasn’t particularly interested when I told him about what I was doing in the study.P17, 12 months, United KingdomSecond, lack of funding, resources, and time was perceived as a major roadblock to using RMT data in appointments. This was particularly apparent in the British cohort with regard to the National Health Service. For the data to be monitored and reflected on, new procedures would need to be put in place:I would be amazed if there was sufficient funding for that...I don’t believe that the NHS have got the resources to have people monitoring this sort of stuff.P22, 12 months, United KingdomGiven the perceived lack of resources to effectively use RMT data in the National Health Service, some have considered how best to come to a compromise:I think realistically, if they had that [data] and I went to them with a problem, then I would like them to be able to use it at that point. But I don’t see it as something that they would be—so, for example, if I went to them with something and if somehow, it was a part of my NHS records, if they could access that, that might be helpful to them. But I don’t see them using it other than that really.P32, 24 months, United KingdomParticipants discussed various changes or additions to the RMT system used in this study to further encourage long-term engagement. These included suggestions for questionnaire data collection and feedback.Across all sites and time points, the most prevalent suggestions for changes to the study design were the content of active RMT questionnaires. Participants felt that they were frequently being asked to complete the same questions, particularly within the ESM schedule, which often prompted them to provide the same answers, for example, with regard to mood changes. This affected motivation:At first, I was more excited about it, but as time has passed, sometimes I don’t feel much like answering since the same questions get repeated.P19, 12 months, SpainSome also suggested the ability to postpone questionnaires if feeling too low to complete them and the ability to provide contextual information. As early as the 3-month time point, some noted that external factors affecting their mood were not being monitored within the validated mood and self-esteem questionnaires: “I notice that when my home situation isn’t great, I also fill in the questionnaires less positively” . On reflection, some would have liked to have given more information at certain points:The answers are very closed, so you can’t really answer what you feel. You know? It’s very...it’s very up in the air.P1, 24 months, SpainWhen asked how they might wish to view their symptom data in future use, the majority felt that this was best displayed visually through in-app graphs. Many also expressed that this would need to be accompanied by a “human explanation for what those things mean” . There was a discrepancy between when these data would be best received; some only expected to receive it at the end of the study, some felt that it would be more useful in real time, whereas others were cautious that receiving data during periods of low mood would be detrimental:If I’m well I want to see it, if I’m unwell, no. If I was reporting that I was feeling suicidal I don’t think I’d want to revisit it.P27, 24 months, United KingdomFurthermore, some participants considered the potential for RMT data to provide feedback on symptom patterns and changes over time, correlations with other factors, and depressive relapse prediction. Specific examples included relationships between exercise and mood, sleep and mood, and mood and concentration: “At some point I had a burn out. I’m very curious as to how my ability to concentrate changed, and if that maybe shows on the THINC-it app” .It was generally accepted that having access to data of this nature would be useful for both self-management and integration into clinical care. Looking forward at the 24-month time point, one participant at the British site explained their hopes for the future of this field:I think trends are really quite important for me in managing what is going on...I think one of the things I am thinking would be good to come out of this is an ability to see patterns over time and then maybe being able to use that as a predictor or, I need to do some intervention here so that I don’t end up there again if that makes sense.P30, 24 months, United KingdomAn exploration of the subjective experience of long-term engagement with RMTs for depression symptom management could prove a necessary complement to objective engagement statistics, providing insights into technology usability, user experience, and facilitators of sustained use. This study aimed to (1) explore the key themes associated with long-term RMT use and (2) identify recommendations for future engagement through longitudinal qualitative analysis at 3-month, 12-month, and 24-month time points of the RADAR-MDD study.The themes uncovered suggest that long-term engagement with RMTs can be understood from two main perspectives: (1) experiential factors and (2) system-related factors . ExperieOn the basis of these perspectives, we present a set of considerations for the promotion of engagement with RMTs for depression. Given the breadth of use cases proposed for RMTs in MDD, we focused on two areas: (1) engagement with research and (2) engagement with real-world implementation. Recommendations for engagement with future RMT research are outlined in Although our data were derived from research participants, we believe that our findings can also be useful when considering implementation into clinical practice. Participants identified the following opportunities for RMTs in clinical care: (1) provision of feedback-informed care, (2) strengthening the therapeutic relationship, and (3) the specific clinical value of sleep monitoring. However, this potential was acknowledged with the caveat of a perceived lack of time and resources in clinical care across all 3 countries. Our findings indicate that a large difference between engagement with RMTs for research and long-term clinical engagement could be research altruism. In this study, an important facilitator of both initial and sustained engagement was the experiential factor of taking part in a novel, academic study to advance understanding and help others. To this end, participants forewent privacy concerns and initial receipt of personal benefit. They were also willing to engage despite the implementation concerns. In the absence of research altruism, This study builds on previous qualitative analyses of the barriers to and facilitators of intended RMT use for depression management. The functional and nonfunctional requirements set out by Simblett et al  roughly When comparing our findings with those from the wider mHealth literature, technological and system-related factors remained a common theme. Borghouts et al  and PateTo the best of our knowledge, this is the largest study to qualitatively explore long-term RMT use for depression across multiple countries. Data collection and analyses were conducted in the native language of each country and only quotes were translated into English, aiding the transfer of meaning process . HoweverFuture work should continue to explore subjective engagement with RMTs, conceptualized in terms of both experiential and system-related factors. Where system-related factors often represent clear recommendations for technological improvements, understanding the experiential effects of engaging with RMTs is a novel finding that could prove fundamental in promoting future engagement. A recent systematic review  found thOur findings explore the initial and sustained engagement with RMTs for depression symptom monitoring in a research setting. The next step would be to replicate this work in a clinical setting. Recent qualitative analyses have reported positive views from patients and clinicians on the potential for implementation of RMT into psychological services . This paThis study aimed to understand the subjective experience of long-term engagement with RMTs for depression symptom monitoring as a complement to the high rates of objective engagement observed in the RADAR-MDD study. Key experiential and system-related themes associated with long-term RMT use were identified along with a set of recommendations and considerations for promoting future system use in both research and clinical settings. Further understanding of the construction of the “experience” of using RMTs will be key to promoting long-term engagement in clinical care and depression management in comparison with general mHealth interventions that offer immediate or tangible rewards. In the wake of the rapid expansion of this field, we urge professionals to continue monitoring the subjective experience of RMT engagement to maximize the potential of remote monitoring as both a method for data collection and a tool for symptom management.


While the negative and positive outcomes of pro-eating disorder groups have been well-documented, more research is needed on the effects of pro-recovery communities. In particular, a gap in knowledge remains surrounding users’ feelings about their experiences in such communities. Using open-ended questions, we surveyed those involved in the recovery community on the social media site Tumblr, to determine how the community helped/did not help with recovery, and how it made them feel about recovery.n = 29) answered a series of Likert and open-ended questions. The open-ended questions were examined using thematic analysis to learn about users’ lived experiences.Participants  to be motivating for their recovery. Feelings of competition and comparison were mixed; some felt that comparing to others made them feel less than, while others used such comparisons as reminders to stay strong in recovery. Participants indicated that the content within the community varies; sometimes there is a large presence of pro eating disorder posts, while at other times, posts are more positive, motivational, and encouraging.Participants overall indicated that the community had many helpful aspects and made them feel better about recovery. However, the presence of triggering content and competition in particular were notable drawbacks of the community. Overall, recovery communities on unmoderated sites or social media applications may be useful tools during the recovery process, despite some important limitations. Recovery communities on Tumblr and other social media sites are not moderated by a trained eating disorder professional, but are often an important source of connection for those going through treatment, or those unable to currently access professional treatment. This study asked Tumblr users who participated in the eating disorder recovery community about their experiences, and specifically what they thought about how the community might help or harm their recovery. Users felt the community was overall beneficial, and that the community helped users feel connected, motivated, and encouraged. However, they felt the community could also be triggering and competitive, and comparisons to others in recovery could be helpful or harmful, depending on the context. This information is important for understanding how unmoderated social media sites might support those as they continue on their eating disorder recovery journeys. There is a plethora of research on the negative impacts of pro-eating disorder (ED) communities on the internet, such as increased restriction and increased identification with one’s ED . Yet, tunmoderated social media communities, where professionals are not present? Such communities remain understudied, even though a substantial minority of ED-related posts are pro-recovery [However, what about recovery . One sturecovery . Similarrecovery , 13. TheWhile such research has added to the field’s knowledge regarding unmoderated pro-recovery communities, it is also essential to understand lived experiences within such groups. Indeed, Branley and Covey  noted a Two theoretical frameworks guided the present study. Egosyntonic refers to the harmony or alignment of one’s thoughts, feelings, and behaviors, to their ego; egosyntonic theory applies to EDs, Anorexia Nervosa (AN) in particular. According to this theory, identity is intertwined with EDs, and individuals with AN value their disorder and it provides a source of identity , 21. SymThe transtheoretical model of change (TTM) is another theoretical framework which relates to motivations in treatment. The TTM is a stage theory proposing that individuals progress through six stages of readiness to change: precontemplation, contemplation, preparation, action, and maintenance . In termUnmoderated communities will continue to proliferate as social media use becomes a seemingly integral part of everyday life . Those According to the about section of Tumblr.com at the time of study creation, Tumblr users can, “post texts, photos, quotes, links, music, and videos from your browser, phone, desktop, email or wherever you happen to be.” Users also have a “dashboard” where posts from other blogs appear; users can comment, reblog, and add hashtags. Tumblr has an “ask” feature, where users can send messages, both as themselves and anonymously. There is also a direct messaging feature.Tumblr was chosen because the setup of the site mimics more traditional “blog” sites, while combining the features of newer social media sites , giving users a variety of ways to engage. We also believed this site allowed us to be authentic about our identities as researchers with a science-based background who believe recovery is possible, without encouraging users to see us as a recovery resource.An account was created for our lab after IRB approval. With the exception of the survey post, we did not create any content, only reblogging informational posts or motivational posts already on Tumblr. Informational posts were chosen based on our positionality as scientific researchers who believe it is important to combat misinformation and stereotypes. We did not interact with any users; the messaging feature was disabled. A secure Qualtrics link was shared in a post, using recovery-related hashtags such as #EDrecovery, #eatingdisorderrecovery, and #EDtreatment. International recovery resources were listed at the top of each survey page, as was a reminder that participants could skip questions. A combination of 18 Likert-style and open response questions were included in the survey , female (n = 26), and indicated having an ED diagnosis from a doctor (n = 25). Of those that had an official diagnosis, seventeen listed Anorexia Nervosa (AN), three Eating Disorder Not Otherwise Specified/Other Specified Feeding or Eating Disorder (EDNOS/OSFED), three Bulimia Nervosa (BN), one Binge Eating Disorder (BED), and one did not answer. Of those that stated they had not been officially diagnosed, one indicated they had BN, while another believed they had EDNOS. Of the 27 participants that responded to a question about professional help-seeking, 21 (77.8%) indicated they were receiving professional aid, while 6 (22.2%) indicated they were not.Participants who answered at least half of the questions (29 out of 31) were included in the analyses. Participants ranged in age from 15 to 43, , were majority White ,” while another user said, “The community helps break down the isolation that comes with having an ED (P25).” For some, humor made them feel connected: “i look at ironic/sarcastic posts about ed and feel understood (P6).”In particular, the community helped some get support that they felt was missing in their daily lives. For example, one participant noted, “the fact that I can connect with other people going through recovery helps me feel less isolated. I can share how I'm feeling , which really helps me to understand my thinking and allows me to let off some steam (P24).”One participant did note a negative outcome of the connection to the community, “i often feel obligated to offer help when i have barely enough love for myself, hindering my own progress (P4).” Similarly, another participant noticed that the acceptance could sometimes lead them to feel their disordered habits were not as concerning, “I think that as much as this community makes me feel validated, it also makes me feel like my eating disorder is somewhat of a normal thing… and I tend to see it as less serious than it is. Like 'Oh well I have bulimia, it's normal for me to binge and purge, nothing I can do about it (P6).'" Further, another participant noted, “I had a popular blog and got a lot of attention from that—which fed into my ed. otherwise nothing else (P26).” While the majority of participants found connection to be a positive part of the community, these participants indicated that that connection can have more negative outcomes as well. It is possible that how they experienced connection within the community may depend on which stage of the TTM participants were engaged in, as well as how enmeshed their overall identity still was with their eating disorder identity. In other words, connection to and acceptance from the community may have more positive outcomes for those engaged in the contemplation stage or more advanced stages of the model.Participants also felt that the community motivated them in their recovery, both generally from posts, and from seeing others succeed. For instance, one user noted that it helped, “Seeing so many people going on the right path (P28),” while another stated, “… one day, I could have the mindset of most of these people, who know that food and weight isn't everything (P10).” Finally, another participant stated that they could, “… do the right thing for myself because others are affirming that it IS the right thing (P11).”Sometimes the encouragement involved direct advice: “… the advice that people who are recovered or who are further down the road than you are give help motivate you and help you through some of your struggles… (P14).” For others, reading about or listening to success stories was important, “The motivating speeches and pictures of people,who talk about for example spending their whole life fitting into a piece of fabric and then burning these clothes (P10).”Finally, some participants found that seeing others struggle motivated them to focus more on their own recovery, as they wanted to avoid the difficulties they saw others experience; “It makes me see what a waste of a life starving/counting calories/obsessing is and how much more of a satisfying life people have without that. It shows me the real dangers of eating disorders such as serious/life threatening conditions. It shows that EDs are not a game, one must either recover or die of it (P12).”It may be that such motivation and encouragement from others in the community assists users in battling the egosyntotic nature of their eating disorders, as it confirms and reinforces the idea that illness is not an achievement, and identity outside of their ED is possible. Motivation and encouragement may also help users transition through the TTM stages, particularly from contemplation through to action and maintenance.Participants expressed mixed feelings about the content itself within the community. Some noted that whether or not they felt positive or distressed about their recovery, depended on the content posted at any given time. One participant said, “If I am having a bad day I will be less likely to fight my urges to engage in behaviors if I am triggered by something (P17),” while another said, “most people in the recovery tags on tumblr do not want to recover properly (P8).” Another participant described this theme well, nothing that it, “Depends on the content seem sometimes it's uplifting and other times it can make me upset (P18).”Indeed, several participants noted feeling triggered by the presence of pro-ED content. One participant noted, “Some people post triggering posts, such as very low weights, or even things tagged in both pro recovery and pro ana… (P14),” while another commented on, “People in the #edrecovery tag who say about the calories they've eaten/are planning to eat… (P10).” One participant believed that the majority of the community is not actually interested in recovery, “… Most of the recovery community engages in and encourages extremely disordered behaviors like posting low weight photos, under eating, over exercising, etc. (P5),” while another noted, “There are alot of things out there to do with thinsporation that I haven't necessarily gone out of my way to find but have ended up on my news feed, which can cause me to begin a cycle of feeling bad about myself, and ultimately going to look for more thinspo (P13).” In these ways, content may feed into the egosyntonic nature of EDs, such that triggering posts and photos may reinforce the role of the illness in users’ identities.However, others found the content encouraging, as it may be helpful to see, “… so many people going on the right path… seeing important reminders and affirmations (P26).” “It just provides inspirational quotes and pictures (P2),” and, “seeing important reminders and affirmations. Analysis of the behaviors in ways that help me realize where my anorexic behaviors stem from . It helps being able to understand where my problems stem from (P21).” It is possible that users’ experiences of content may depend on which stage of the TTM they would fall within; those that are further along in their recovery may seek out more recovery-specific content, and/or be better able to resist engaging with triggering content.Some participants also discussed a tendency among users to compare and/or compete with others in recovery; one participant noted, “The sense of competition has always been difficult for me in recovery settings… If one person says they engaged in a behavior, the voice in my head will scream ‘see, you are not strong like them’ (P17).” Others noted, “because its been hard for me to recover and I feel weak (P3),” and, “It makes me feel worse because I dislike not ‘winning’ at things… Also, when there seems to be kind of a severity ranking system… Some people seem to have, and they may be unaware of this or disagree with it on a factual level, kind of an idea that once you become weight restored or eat healthy that you're better and done, and therefore less sick than people who actively engage in behaviors (P19).”However, some felt that seeing others’ struggles and successes made them feel more positively about recovery. For example, one participant noted, “I compare myself a lot but then I love seeing people do well, it inspires me (P14),” while another explained they felt positively because of the “… realization that (a) I don't want to be as sick as some others there (b) I can do the right thing for myself (P11).” The potential positive or negative effect of comparison and competition may be a particular result of the confluence between identification with EDs versus recovery, and the TTM. Specifically, those further along in the stages of the TTM may have experienced shifts in identity identification, such that those further in recovery identify more with symptom alleviation and overall health, rather than illness severity. Competition and comparison may in turn strengthen recovery identity, versus those earlier in the transitional stages who may find competition and comparison still invokes their identification with their ED.This study qualitatively examined individuals’ perceptions of the ED recovery community on Tumblr, noting both positive and negative effects on recovery. Themes related to connection and acceptance, motivation and encouragement, content, and comparison and competition were identified by the authors. While participants expressed gratitude for the opportunities for social connection and recovery specific support, many struggled with triggering content, and more were ambivalent about the presence of comparison and competition within the community.The theme of connection and acceptance was overall highly positive; participants expressed that they were able to feel validation and appreciation for their struggles. The community seemed to provide a sense of belonging and even relief for many who did not feel that they had that type of support outside of the community. Three participants did note that the connection could sometimes lead to pressure to give support, normalization of disordered habits, and that attention via connection to others could sometimes feed unhealthy habits. However, these findings overall support previous works on pro-recovery communities, such that feelings of connection and support were prevalent, even with the presence of triggering content e.g., , 14, 22), 2214, 2Indeed, participants frequently noted that content may be triggering; there was a sense by several that some people within the community purposefully posted triggering content under the guise of recovery. Others noted that the recovery hashtags often had content they perceived as pro-ED. These findings may be explained by the egosyntonic nature of EDs in that perhaps user posting such triggering content are not truly seeking recovery and do not see a problem with their disorder. The presence of pro-ED content may affect some participants more depending on their own internal states at the time of exposure, as some noted that the content many only affect them depending on their own current feelings about their recovery.Such feelings about the content are related to the themes of comparison and competition, as well as motivation and encouragement. Many participants noted that the recovery community felt competitive; some commented on the desire to be the “best” at recovery, while others felt there was an unhealthy focus on severity of ED symptoms. However, some felt that seeing others struggle made them compare themselves positively, such that they wanted to make sure they did not experience those symptoms themselves. Broadly speaking, receiving positive advice and encouraging feedback, as well as viewing inspirational posts, was also very motivating for participants. These themes align with the more general findings of Saunders and Eaton , who fouThis study extends these works by connecting with users to better understand their specific experiences, and how those may affect their internal states and recovery . ParticiBeyond the overall examination of an unmoderated, online recovery community, a key strength of this study is the inclusion of open-ended questions, as participants could write about their lived experiences. The anonymity of the survey may have also allowed participants to feel comfortable expressing their genuine views. Further, these results add to the nuance of users’ experiences, providing a more in-depth picture of how individuals may benefit from unmoderated communities.(n = 29), though we believe that the number of responses allowed us to gain a meaningful understanding of participants’ perspectives regarding the community [The findings from this study should be considered in light of the following limitations. First, our sample size may be considered small ommunity . In addiommunity ). Futureommunity ).As social media is ever-evolving, it is imperative to understand users’ experiences of online, unmoderated ED recovery communities. Given the barriers to ED treatment , free o


Mental health challenges are highly significant among older individuals. However, the non-utilization of mental health services increases with age. Although universal health coverage (UHC) was reported to reduce unmet health care needs, it might not be sufficient to reduce unmet mental health care needs from a clinical perspective. Despite the existence of UHC in Japan, this study aimed to explore the factors related to the non-utilization of formal mental health care systems among middle-aged and older people with urgent, unaware, and unmet mental health care needs.Purposeful sampling was used as the sampling method in this study by combining snowball sampling and a specific criterion. The interviewees were nine practitioners from four sectors outside the mental health care system, including long-term care, the public and private sector, as well as general hospitals in one area of Tokyo, where we had conducted community-based participatory research for five years.The interviews were conducted by an interdisciplinary team, which comprised a psychiatrist, a public health nurse from a non-profit organization, and a Buddhist priest as well as a social researcher to cover the broader unmet health care needs, such as physical, psychosocial, and spiritual needs. The basic characteristics of the interviewees were enquired, followed by whether the interviewees had case of middle-aged or older individuals with urgent, unaware, and unmet mental health care needs. If the answer was yes, we asked the interviewees to describe the details. The interviews pertinent to this study were conducted between October 2021 and November 2021.In this study, we adopted a qualitative descriptive approach. First, we created a summary of each case. Next, we explored the factors related to the non-utilization of formal mental health care systems by conducting a thematic analysis to identify the themes in the data collected.The over-arching category involving “the factors related to an individual person” included two categories, as follows: 1) “Individual intrinsic factors,” which comprised two sub-categories, including “difficulty in seeking help” and “delusional disorders,” and 2) “family factors,” which comprised “discord between family members,” “denial of service engagement,” “multiple cases in one family,” and “families’ difficulty in seeking help.”The over-arching category “the factors related to the systems” included four categories, as follows: 1) “Physical health system-related factors,” which comprised “the indifference of physical healthcare providers regarding mental health” and “the discontinuation of physical health conditions,” 2) “mental health system-related factors,” which comprised “irresponsive mental health care systems” and “uncomfortable experiences in previous visits to clinics,” and 3) “social service system-related factors,” which comprised “the lack of time to provide care,” “social service not allowed without diagnosis,” and “no appropriate service in the community,” as well as 4) “ the lack of integration between the systems.”Apart from the aforementioned factors, “the community people-related factor” and “factors related to inter-regional movements” also emerged in this study.The results of this study suggest a specific intervention target, and they provide further directions for research and policy implementation. The suggested solutions to the issues pertinent to this study are as follows: the recognition of the ways in which older people may inadequately understand their health or be unaware of available services, the building of a therapeutic alliance for “the individual intrinsic factors.” Regarding the “family factors,” the solutions include the provision of particularly intensive care for families with family discords, families with multiple cases, and families who find it difficult to seek help, as well as making intensive efforts for ensuring early involvement after contact with health care services. Regarding the “the factors related to the systems,” the solutions include the implementation of mental health education campaigns aimed at enhancing mental health knowledge among non-mental health professionals, as well as formulating and implementing reforms ensuring that such professionals are increasingly responsible especially with regard to emergency inpatient care. It also include listening without ageism in clinical practice, the expansion of social services regarding human resources and the flexibility of use which increases the breadth of the types of care, as well as facilitating the integration between the associated health care systems. Further suggestions include encouraging community residents to join social security systems as well as the provision of particularly intensive care for people who have just moved in. The Japanese society continues to age rapidly. In 2022, the proportion of people aged 65 years and above was 29.1%, which is the highest worldwide. By the year 2050, this number is estimated to increase to approximately 40% , differeMental health challenges are significant among older individuals. In 1999, Jeste et al. presented a consensus statement  in whichSpecific models of care have been proposed and implemented throughout the society to address mental health challenges among older people . For affGenerally, broad or universal health coverage is an effective strategy for reducing unmet medical needs. According to an analysis conducted by the National Health Service in China, universal health coverage (UHC) reduced the levels of unmet healthcare needs . As repoDespite the societal implementations mentioned above, the non-utilization of health care among older people has been reported. The non-utilization of psychotherapy was reported to increase with age in the USA . In JapaJapan’s healthcare system has been changing in response to rapid societal aging. In 1973, UHC, which was established in 1961, became completely free of charge for older people. However, the financial burden was significant, and in 2006, a flat rate of 10% co-payment was introduced for individuals aged 75 years and above . CurrentIn 2000, the implementation of the Long-Term Care Insurance Act enabled people aged 65 years and above to use long-term care insurance, with a 10% co-payment. In 2005, owing to the increased number of people living alone and individuals suffering from dementia, community general support centers (CGSC) were set up, where older people could go for advice .Cases involving “delusions” were expressed as significantly difficult cases by several interviewees, as follows:The client’s family who live together and the client’s parents who live in a different household were not aligned at all .“Discord between family members” was reported to be a crucial factor.There is a family in the distant region. However, they said that they could not do anything in case the hospital staff tried to make contact .In cases where the family denied engagement, the case work sometimes stopped. This was named “denial to engage.”The mother has dementia, the older son has schizophrenia, and the younger son has undiagnosed intellectual disabilities. After the father died, everything went wrong .According to the interviewees, “multiple cases in one family” made the situation significantly complex.It is difficult to provide support if the husband is attempting to deal with the wife’s problem alone, and if the husband is older but still working, it is difficult for him to entrust his wife to someone else .In addition to the client’s difficulty in seeking help, as described above, the “family's difficulty in seeking help” was also discussed.In general hospitals, people suffering from mental illnesses are sometimes regarded as troublemakers and are talked about in the contexts of the ways in which to quickly discharge them .In the physical health setting, people providing professional care to individuals suffering from mental illnesses were not well-equipped. Staff members without enough skills or knowledge were regarded as those in the “indifference of the physical health care provider regarding mental health matters” category.The problem was that he had infections resulting from the human immunodeficiency virus and the hepatitis B virus. However, he stopped seeing doctors .Some people were out of the medical health care system, and they were placed in the category of “discontinuation of physical health conditions.”A person who was just discharged from a psychiatric hospital got worse again. When we asked the hospital about further inpatient care, they said that they cannot apply to the health insurance provider for the payment of additional acute care within three months after the previous discharge  ..Furthermore, the issue of “irresponsive mental health care systems” was also discussed.We once went to a psychiatric clinic together, but he did not get along with the doctor, and he fell into a state of medical mistrust, saying that he would never go back .Some clients had “uncomfortable experiences in their previous visits to clinics.”In our work settings, we cannot repeat interviews like psychologists. If we communicate intensively for a long time, the patients might start talking about previous traumatic experiences .Some of the staff members did not have enough time to support people suffering from mental health challenges, and this category was named as “lack of time to provide care.”In short, if one is not eligible for drug therapy, clinics will not readily accept them (Interviewee No 4).The limitations of social welfare systems were also discussed, especially as they pertained to cases without rigid diagnosis, and this category was named “social service was not allowed without diagnosis.”Concerning individuals with developmental disabilities, medical staff remained negative. Public health nurses said that they cannot deal with such individuals. The staff of the center for developmental disorders said that the services can commence only after the person comes to the center .Sometimes they found “no appropriate service in the community.”They say, “We can only help you so far.” With an increase in the number of various systems, the subject falls between the cracks .We should work based on the idea of the ways in which we can solve the problems in front of us, and we should not work within the job description given to us .There are many different parties involved, but each party is working on a single problem of the client. Therefore, information is not being shared between the parties involved .The lack of integration between the systems was repeatedly mentioned.Until then, people in the community had been helping them in various ways. However, with the introduction of long-term care insurance services, local people are becoming increasingly reserved or at ease, and as a result, they are no longer involved. Until then, people in the community helped such individuals, but currently, they find themselves in situations where the only people around them are professionals .In addition to the individual and system factors, community people played a significant role in ensuring social inclusion.As for those who have recently moved to the area, the names of their previous residences are personal information, and we do not have any knowledge of such information. We can only ask the patient. We are not allowed to collect information about such individuals unless they are a nuisance or otherwise, significantly serious. Therefore, we do not know anything about someone who has just moved into the area .As per clinical knowledge, it was reported that the moment of just having moved to another area was a crucial moment.This study explored the factors related to the non-utilization of formal mental health care systems among middle-aged and older people with urgent, unaware, and unmet mental health care needs, despite the existence of UHC. As per the results, two over-arching categories emerged, i.e., “factors related to an individual” and “factors related to systems,” which suggested certain targets for intervention, as discussed below. In addition to the factors under these categories, “inter-regional movement” and “community people-related factors” also emerged in this study.Individual intrinsic factors involved the “difficulty in seeking help” and “delusional disorders,” consistent with previous literature as well as our clinical experiences. Concerning the difficulty in seeking help, the low rates of professional mental health service usage among older people has been reported in previous studies . WhetherThe family factor, specifically, that involving “multiple cases in one family,” was a phenomenon sometimes faced by the clinicians. In biological psychiatry, a multiplex family has been a major concern because it is the key to establishing the crucial gene behind the disease. As an extension of this context, the burden of care was reported to be highly significant for families with more than one ill member (multiplex) compared to families with a single affected individual (simplex) . ContrarThis study suggests the improvement of both the physical and mental health systems. In this study, concerning physical health systems, the indifference of medical health staff regarding the provision of care to people with mental health care needs emerged. Wu et al.  conducteConcerning mental health care systems, the “irresponsive mental health care system” factor was merged in this study. Mental health care systems should ensure increased responsibility, especially regarding emergency inpatient care. Regarding the provision of social services, the lack of human resources, the excessive need for medical diagnoses, and the narrowness of the prepared services were discussed in this study. In this study, we advocated for the expansion of social services, as they pertain to human resources, the flexibility of use, and the breadth of the types of care provided. Additionally, “uncomfortable experiences in previous visits to clinicians” were noted in this study. Previous studies show that older people experience being treated differently as a result of ageism  or not bIn this study, we also suggested that social service systems are not responsive to older people with mental health care needs because 1) the staff do not have enough time, 2) the staff cannot respond freely without diagnoses, 3) and no appropriate service menus are prepared when the older people with urgent, unaware, and unmet mental health care needs contact social services. To the best of our knowledge, there are no studies investigating this issue. From the limited data obtained in this study, we suggest the expansion of social services, as they pertain to human resources, the flexibility of use, and the breadth of the types of care provided.Concerning the “lack of integration between the systems,” the Ministry of Health, Labor, and Welfare of Japan points out that vertically segmented administrative systems present a point of weakness in Japan’s social security system . This isNo overt spiritual needs were discussed in this study. However, this was because we only interviewed professionals and not individuals. Therefore, it is natural that the objectively assessed medical and social needs were discussed first. In our previous study, we reported the possibility that medical professionals disclosed their suffering only in the presence of a priest .In this study, the factors related to the non-utilization of formal mental health care systems among middle-aged and older people with urgent, unaware, and unmet mental health care needs, despite the existence of UHC, were categorized, and they suggested the requirement of a specific target for intervention. The interventions discussed in this study are listed in Table This study has several limitations. First, the interviewees were selected through snowball sampling, with inclusion criteria. As a result, the interviewees’ representativeness was not robust. Second, we suggested an interdisciplinary interviewer team’s function for unspoken views. However, we cannot compare this with control interviews, such as interviews conducted by psychiatrists alone among the same interviewees. Third, this study comprised interviews involving experts or care providers. The advantage of this study was that the facts were organized, and the viewpoints were fixed. However, there had to be facts and views from the care recipients’ side, which were not discussed in the supporters’ interviews. Interviews involving the latter are required to explore the inner need of individuals and understand the unbiased views of both the supporter and the individual. However, the access to such individuals was not possible after they became people with urgent, unaware, and unmet mental health care needs. In this study, we revealed that inter-regional movement was a critical point. Accordingly, people who moved were candidates of future studies. Therefore, it is feasible to broadly reach out to people in our catchment area who have just moved into the community, build relationships, and investigate the internal struggles of those with mental health needs.


Girls Active Project (GAP), was codesigned with adolescent females. This study aimed to assess the feasibility of implementing and evaluating the GAP programme.There is a critical need for interventions that can be feasibly implemented and are effective in successfully engaging adolescent females in physical activity (PA). A theory-based, peer-led, after-school PA intervention, the One single-sex, female-only, designated disadvantaged postprimary school (students aged 12–18) in Dublin, Ireland.Mixed methods were applied with multiple stakeholders over a 12-week trial (March to May 2021). A single-arm study design was used to examine intervention: reach, dose, fidelity, acceptability, compatibility and context. Feasibility of using proposed self-reported outcome measures  was also explored. Due to school closure resulting from the COVID-19 pandemic, the intervention was delivered both online and in person in the school setting.n = 6, students aged 15–17) to intervention recipients (students aged 13-14). Recruitment was low , yet retention was high . Attendance rates were satisfactory (68%), and the intervention was implemented with high fidelity (87%). Data completion rates suggested proposed self-reported outcome measures were deemed appropriate (≥ 95%), except for weight (50%) and height data (80%). Despite COVID-19 hindering intervention implementation, both quantitative and qualitative data suggested that stakeholders were satisfied and perceived the in-person delivered intervention to be compatible with the school setting. Recommended refinements included extending class duration, introducing different rewards, and boosting programme awareness.Eight exercise classes were peer delivered by project leaders The online version contains supplementary material available at 10.1186/s40814-022-01149-2. What uncertainties existed regarding the feasibility? It was unclear if the Girls Active Project programme to increase adolescent females PA levels could be successfully implemented and evaluated in a postprimary school setting.What are the key feasibility findings? Recruitment was low, yet retention was high. The intervention was implemented as intended, and most of the proposed self-reported outcome measures were deemed appropriate. Stakeholders indicated satisfaction with the in-person delivered intervention and perceived it to be compatible with the school setting.What are the implications of the feasibility findings for the design of the main study? The in-person delivered intervention shows promise; however, further work is required to revise and test recruitment strategies. Prior to the main study, refinements to the intervention should be made based on stakeholder recommendations, while further consideration needs to be given to retaining proposed self-reported outcome measures weight and height,  and introducing direct observation to assess fidelity.Despite evidence continuing to accumulate on the health benefits of regular physical activity (PA) for adolescents , 2, globThere is a critical need to strengthen the development and implementation of effective interventions to increase adolescent female PA levels , 13. TheAt postprimary school level in Ireland, traditional team-based and structured sports dominate extra-curricular PA, i.e., PA or sport played before, during or after school, but not part of the curriculum . Given tThere is a growing appreciation of the significant role that feasibility studies play in the development and evaluation of complex interventions, primarily its value of progressing to a larger-scale trial or effectiveness study –38. ThisCapture the recruitment and retention rates of intervention recipients and explore factors influencing participation (reach).Determine attendance rates and the extent to which intervention providers implemented the intervention as intended (dose and fidelity).Assess the feasibility of using proposed self-reported outcome measures (data completion rates).Explore stakeholders’ satisfaction with the intervention (acceptability).Examine the perceived fit and sustainability of the intervention in the school setting (compatibility).Understand context, i.e. the external factors that affected intervention implementation (context).The specific objectives of this feasibility study were as follows:A mixed-methods single-arm feasibility trial was conducted in a female-only, designated disadvantaged postprimary school in Dublin, Ireland. This school had previously participated in the codesign of the GAP programme  and was In January 2021, there was a nationwide lockdown that involved national school closures. Consequently, although the intervention was originally designed to be delivered in person on school grounds, it was divided into two phases. Both phases were delivered at the same time (4 pm) each week on the same day (Tuesday). Four classes were delivered via Zoom during phase 1 using the online school platform. When schools fully reopened in April 2021, four classes were delivered in person (phase 2) in the school sports hall or playing field. In response to COVID-19-related social restrictions, just 1 year group was invited to participate as ‘intervention recipients’. This was a protective measure to avoid integrating students from different year groups and to accommodate for social distancing (2 m). Furthermore, school guidelines permitted just one researcher (SMQ) to attend the school to collect data during intervention implementation.n = 6). In Ireland, transition year is a 1-year school programme that can be taken in the year after the junior cycle (students aged 12–15) and before the 2-year leaving certificate programme (students aged 15–18)  arrive so that we are prepared, and it doesn’t take up class time’ . Additional promotional activities from the school to encourage participation was also suggested, ‘the school didn’t really like promote it that much, like they could have posted it more and put it on the Instagram pages, I think that would have of like helped more people come’ .Recipients disliked that not many students enrolled and equally suggested that the school further promotes the GAP programme through weekly reminders, more posters and announcements via the school intercom and social media posts, ‘put up a few pictures or a link or if there was a little video put together of what one class is literally like’ . Recipients described how they enjoyed the exercise classes because they got to spend time with friends, relieve stress, did not feel judged and liked that the project leaders were close in age. They also expressed their satisfaction with the variety of activities offered as it introduced them to new activities, ‘they’re things that like I wouldn’t pick myself but then when I done it, it was good’  and kept it fun, ‘if it was the same every week, it would just get boring like’ . In the phone call interview, one parent/guardian described how it was the variety that attracted her daughter to participate, ‘it was because you were doing a bit of something different every week. That’s what made her, that’s what appealed to her’ . Both parents/guardians suggested additional encouragement from the school would increase participation and improve its acceptability, ‘I suppose if they could point out that it was more fun than anything, you know? It wasn’t like it was work’ .School staff members also liked that the programme provided students with an opportunity to try new activities, ‘I think when you give those opportunities then of doing a variety of things where they get the opportunity to try them out, it’s huge because then that could be their thing that they actually go on to do’ . They believed the students involved enjoyed it, ‘you can see them laughing and joking, and that’s what I liked about it, it’s simple and effective and they come away from it happy’  and particularly liked that, unlike many other extra-curricular PA programmes, the emphasis was not on competition or performance, ‘it was about getting involved and just enjoying physical activity, which I really enjoyed that aspect of it’ . Staff members expressed satisfaction with the intervention being peer-led ‘it’s great because I think we have students that have a great ability to lead and they obviously look up to each other, especially the younger years to the older years’  and cited many positive impacts the intervention had on the students involved, alongside being active, such as socialising, gaining a sense of belonging, and particularly for project leaders, to feel trusted and develop leadership skills.To enhance intervention acceptability, staff members recommended extending class duration from 45 min to 1 h, creating more reminders and introducing different rewards to maintain student involvement, such as a ‘Girls Active Project’ t-shirt. Staff members considered the intervention acceptable yet were open to modifications, ‘I think as it goes on in the future, we’ll see where it can be developed as well when it’s more established in the school. And then if there are tweaks and things that need changing, we could do it then’ .n = 6/6), most parents/guardians  and most recipients  wanted the programme to remain in the school. Project leaders perceived the programme as an appropriate fit, ‘I loved it and it would be a great thing to keep in the school’ , with six of them  reporting that they would recommend becoming a project leader to other students ‘I would definitely recommend it as it is an amazing, fun and rewarding experience and not only does it develop your fitness skills, but your leadership ones also’ . More recipients reported that they would continue to participate if it were delivered in person than online . During the post-intervention focus group, some of the recipients explained how they never participated in other after-school PA programmes because they perceived them to be competitive in nature. If given the chance, however, they would continue to participate in the GAP programme because it was significantly less competitive, ‘this was a lot more chill’ . Likewise, staff members acknowledged how the programme attracted students that were not usually involved in extra-curricular PA clubs, ‘it’s the same girls all the time doing the same sports, whereas the GAP actually opens up exercise to a bigger cohort because you’re not attracting the same people, which is good’ . They perceived this as important as it offered an opportunity for the ‘noncompetitive’ students to engage with PA, ‘the non-competitive people, they need to have something. I mean, those are the people you’re trying to keep involved and to get active, so yeah, absolutely, I think it [the GAP programme] needs to be as fundamental as the other sports, 100%’ . School staff members were optimistic about the intervention’s long-term potential in the school. One staff member believed it was less administratively demanding and required limited involvement in terms of class delivery when compared to other after-school PA programmes, ‘it’s easier. I think it gets better results for less time. So, why wouldn’t you do that?’ . The perceived sustainability of the intervention was also influenced by student enjoyment, ‘I think it’s also far more likely that they continue doing physical activity if it’s enjoyable in the first place. So, as a lifelong learning thing, I think it’s far more sustainable, even than playing on the school team, because lots of people do that for a year or two and then they drop off anyway even if they were sporty. So, from the point of view of enjoyment and doing it from a health promoting point of view, I think this was far more sustainable and I think they’re likely to go with it’ .All project leaders . Recruiting and engaging students online were identified as barriers, ‘initially it had to be online you know, and that doesn’t really work for a lot of our students, as we learned’ . Staff members stated that many students did not attend compulsory academic classes online; therefore, anything extra-curricular was considered increasingly challenging. Additionally, project leaders suggested that the intervention being online was a barrier to participation, ‘you’re tired from doing online school and then you just want to take a break after it, and then it’s hard to go back online to do it’ . Recipients reported homework and distinct to phase 1 (online), failing to remember ‘quarantine brain got the best of everyone’  as barriers to participation.n = 8/15, 53%) listed homework, other commitments such as music, a dislike for after-school activities and anxiety and fears surrounding the COVID-19 pandemic as barriers to enrolment, ‘she is finding it hard to settle back into school since lockdown, with her anxiety of school’ .The COVID-19 pandemic continued to affect intervention implementation during phase 2 (in person). Project leaders felt constrained, ‘even now in school we’re limited in what we can do because of Corona’ . The eight parents/guardians of second-year students whose daughter did not take part in the intervention . Project leaders could also recognise COVID-19 as a facilitator to enrolment, ‘loads of the places weren’t open at the time to go and do your exercises’ . Staff members identified the school reopening  as an external factor that positively affected intervention implementation as it allowed for the ‘word of mouth’ recruitment strategy to be implemented, ‘the numbers definitely increased over the weeks and when they’d be in class talking, they’d talk to each other and encourage each other to go, which is… that’s huge’ . Staff members believed that with time, enrolment into the in-person delivered PA programme would have increased. Other identified facilitators included the following: stakeholder buy-in via the schools’ steady support and commitment, including use of the online platforms and sport hall facilities; the positive working relationship and regular communication with the research team; and the project leaders, ‘they’re confident students, they’re enthusiastic. So, you know, that’s a huge strength in a way’ .This paper presents the reach, dose, fidelity, acceptability and compatibility of the peer-led, after-school GAP intervention programme, the data completion rates of proposed self-reported outcome measures and identifies the external factors to implementation. The peer-led, after-school PA programme was trialled for the first time over a 12-week period with disadvantaged adolescent females in a single-sex, female-only, designated disadvantaged postprimary school in Ireland during the COVID-19 pandemic. This study encountered significant contextual barriers and challenges with recruitment. The in-person delivered programme, however, shows promise as an intervention that can be feasibly implemented and evaluated. Results indicated the intervention was implemented as intended and was deemed acceptable and compatible with the school setting. The following paragraphs discuss the strengths and challenges of this trial and provide recommendations for future research.Retention rates were high, providing support for the feasibility of this trial. Peers, enjoyment, improving health and fitness and the wide variety of activities offered were regarded as essential for initiating and maintaining interest. The logbooks signified that the exercise classes were delivered with high fidelity (> 80%), suggesting that the intervention was delivered as intended. These results, however, must be interpreted with caution since, as often required , the fidPositive stakeholder responses were particularly welcome, given the unprecedented circumstances of the COVID-19 pandemic during intervention implementation. Consistent with previous school-based PA interventions for adolescent females , 75, theDespite recent findings to support the use of online interventions to encourage adolescents engagement with PA , given tDespite two rounds of recruitment, enrolment was low. Recruitment is crucial to the success of research programmes as high enrolment rates demonstrate that the programme reached the population for which it was designed. Adolescent females, particularly from disadvantaged groups , 83, howThis study encountered additional contextual barriers to recruitment attributable to the COVID-19 pandemic. Employing recruitment strategies during school closure (phase 1) was difficult given students were not present in school and the lack of engagement with ‘online school’. Another factor which may have proven to impact recruitment is that after-school PA programmes are often available to all students in the school or split into junior  and senior cycle . As previously discussed, just 1 year group was invited to take part in this study. This would be unusual school practice and could have made the recruitment process more difficult. It was observed that additional students attended the in-person programme (phase 2) yet failed to return the relevant documents to participate in data collection. The perceived burden of returning documents could be a reason for this. Student absenteeism was a barrier to data collection identified in this study. A future trial could encounter similar challenges given that evidence suggests lower socio-economic status is associated with higher levels of absenteeism at school among adolescent females . DespiteThe two proposed self-reported outcome measures least completed by recipients were weight and height data. This could indicate that despite the detailed written instructions provided, requesting recipients to record these measurements at home and complete the questionnaires at school was not feasible. Project leaders deemed completing weekly logbooks as unfeasible in the feedback questionnaires; however, they did not indicate any dissatisfaction with the task in the focus groups. The online programme (phase 1) was also deemed unacceptable by intervention recipients. Most stakeholders agreed that phase 1 (online) went better than anticipated but found phase 2 (in person on school grounds) more acceptable and sustainable. This unique aspect to the study was necessary due to school closure resulting from the COVID-19 pandemic. Ultimately, similar to O’Kane et al. , who repLow enrolment rates in this study could suggest current recruitment strategies were ineffective; thus, further work is required to develop and test recruitment methods. This could involve codesigning strategies with students, parents and school staff to ensure the revised strategies are relevant, acceptable and practical. The ‘word of mouth’ campaign used in phase 2 was considered valuable by stakeholders in this study; however, students recommended to further boost programme awareness via school announcements and additional posts on social media, including short videos. Similar to Jago et al. , stakehoThe motivating factors to participation identified in this study, such as being with others and a desire to improve health and fitness, could also prove useful when revising recruitment strategies for a future trial. Indeed, given that friend involvement can be an important factor affecting PA participation , 26, recAs per usual school practice for after-school PA programmes, a future trial, if permitted, should invite additional year groups to take part. Proposed strategies to improve research with socially disadvantaged groups, such as using flexible data collection methods , may neeGiven the low completion rate for self-reported weight, a future trial should reconsider using weight and height measures. Body image has been previously cited by adolescent females, especially those with low perceived competence and high weight status, as an internal barrier to PA participation . In contThere are strengths to this study. This paper contributes to the expanding literature on feasibility studies of school-based PA interventions. Although unintended, the two-phase delivery of the intervention during COVID-19 allowed us to compare feasibility between an online and in-person delivered after-school PA intervention. This feasibility study used a mixed-methods approach and included multiple stakeholders perspectives . This allowed us to collect rich meaningful data on feasibility and acceptability of the intervention. Another strength of this study are the learnings and practical recommendations provided for future research.There are a number of limitations to this study. Although it is acceptable given that this study’s primary aim was to evaluate feasibility, this study involved a small sample size, and therefore, caution in generalisation is warranted. This study did not include an economic evaluation. Assessing the feasibility of using an objective measure (e.g. accelerometers) to capture adolescent MVPA levels was not possible due to school closure and travel restrictions. This study used self-reported PA data, which is dependent on students’ recall ability , 90. FurThe in-person delivered intervention was well-received by stakeholders involved and shows promise as an intervention that can be feasibly implemented and evaluated. Despite the COVID-19 pandemic hindering intervention implementation, classes were delivered as intended, and retention was high. Enrolment, however, was low, amplifying the need for further work on revising and testing recruitment strategies. There were important lessons to be learned from this study, both with and without the lens of the COVID-19 pandemic. This paper contributes to the growing body of knowledge on feasibility studies of after-school PA interventions, where the sharing of this detailed feasibility work may benefit other researchers in reusing techniques that have proved successful or in avoiding similar challenges. The novel GAP intervention programme should be revised using the recommendations from this study, before continuing to a more robust evaluation.Additional file 1: Supplementary file 1. GAP Feasibility Trial_CONSORT checklistAdditional file 2: Supplementary file 2. GAP TIDieR checklistAdditional file 3: Supplementary file 3. Data Collection ToolsAdditional file 4: Supplementary file 4. GAP Materials


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