Pilot Testing the Feasibility of a Game Intervention Aimed at Improving Help Seeking and Coping Among Sexual and Gender Minority Youth: Protocol for a Randomized Controlled Trial

Mental Health Needs, Barriers, and Receipt of Care Among Transgender and Nonbinary Adolescents

PURPOSE

Transgender and nonbinary youth disproportionately experience adverse mental health outcomes compared to cisgender youth. This study examined differences in their mental health needs and supports, barriers to care, and receipt of mental health care.

METHODS

This study examined cross-sectional data from 43,339 adolescents who completed the California Healthy Kids Survey, 4% (n = 1,876) of whom identified as transgender and/or nonbinary. Chi-square test and t-test were used to compare mental health needs and supports, resilience, and barriers to and receipt of care experienced by transgender and nonbinary youth compared to cisgender youth.

RESULTS

Transgender and nonbinary youth were significantly more likely to experience chronic sadness/hopelessness (74% vs. 35%) and consider suicide (53% vs. 14%) and less likely to report resilience factors (school connectedness: mean score 3.12 vs. 3.52). Transgender and nonbinary youth were significantly less likely to be willing to talk to teachers/adults from school (12% vs. 18%) or parents/family members (21% vs. 43%), but more willing to talk to counselors (25% vs. 19%) regarding mental health concerns. Transgender and nonbinary youth were significantly more likely to select being afraid (48% vs. 20%), not knowing how to get help (44% vs. 30%), or concern their parents would find out (61% vs. 36%) as barriers to seeking mental health care, yet reported slightly higher odds of receiving care when needed (odds ratio: 1.2).

DISCUSSION

Transgender and nonbinary youth are more likely to report mental health concerns and barriers to seeking care than cisgender youth. Increasing access to care is critical for this population.

Moderating role of coping in the association between minority stress and suicidal ideation and suicide attempts among sexual and gender minority young adults

OBJECTIVE

This study examined associations of minority stressors (i.e., victimization, internalized homonegativity, and stigma consciousness), and coping styles (i.e., active, avoidant, and passive) with suicidal ideation and suicide attempts (suicidality) among sexual and gender minority (SGM) young adults, and whether coping style moderated these associations.

METHODS

Logistic regression analyses examined these associations among 1432 SGM young adults (ages 18-29).

RESULTS

Minority stressors and passive coping were associated with a higher likelihood of suicidality. Avoidant coping was associated with a lower likelihood of lifetime suicidal ideation and attempts among sexual minority participants, and active coping with a lower likelihood of past-year suicidal ideation among sexual minority participants. Moderation analyses among sexual minority participants showed that when avoidant coping was high, associations between low victimization (compared with no victimization) and lifetime suicide attempts, and stigma consciousness and lifetime suicide attempts became non-significant, and the association between internalized homonegativity and lifetime suicide attempts became significant. Among gender minority participants, when passive coping was high the association between low victimization and lifetime suicidal ideation became significant.

CONCLUSION

This study underlines the importance of minority stress and coping for suicidality among SGM young adults and the need for more research regarding the role of coping.

The Male Domain-Digital Game-Based Learning for Human Papillomavirus Vaccination Among Young Males

Background: Human papillomavirus (HPV) is the most common sexually transmitted disease, with the highest infection rates among those sexually active under 25. Although vaccination can reduce HPV cancers among men, public health interventions have primarily targeted females. Increased gaming rates among men provide innovative opportunities to motivate behavior change. This study sought to explore which game development and design strategies are most effective in a game for sexual health, specifically focused on HPV. We also sought to capture information relevant to preferred gaming platforms and game mechanics (health messages, avatars, and visual imagery). Materials and Methods: Twenty-two (n = 22) qualitative interviews were conducted with experts. Using grounded theory, interview data was coded, and emergent themes were identified. Results: Game mechanics most mentioned included simulation/role-playing, social interaction, narrative, and rewards. Experts felt it was important to keep the game in the context of the target audience and integrate the game into an existing game/game scenario or application. Experts also felt the game should link to external resources and enlist partnerships or collaborations with external health agencies. Moreover, while there are benefits to each gaming platform, games on mobile phones and tablets are most appropriate. Conclusion: Digital games are a nonconfrontational approach to discussing HPV and can increase knowledge/awareness and positively influence behavior change toward vaccine uptake. Digital games present a safe environment for role-playing through simulated activities without real-world consequences.

Coping Strategies to Enhance the Mental Wellbeing of Sexual and Gender Minority Youths: A Scoping Review

Robust population-based research has established that sexual and gender minority youths (SGMYs) are at an increased risk of mental ill-health, but there is a dearth of literature that seeks to explore how to best support SGMY mental wellbeing. This scoping review aims to identify findings related to coping strategies and/or interventions for building resilience and/or enhancing the mental wellbeing of SGMYs. PRISMA extension for scoping review (PRISMA-ScR) guidelines was utilized for this review. Studies were included if they were peer-reviewed papers containing primary data; reported psycho-social coping strategies for SGMY; were conducted with SGMYs in the adolescent age range; and were published in English. MEDLINE, Embase, and PsycINFO databases were searched. Of the 3692 papers initially identified, 68 papers were included with 24 intervention-focused studies of 17 unique interventions found. The most commonly cited therapeutic modality was cognitive behavioral therapy (CBT) (n = 11 studies). Despite the need to support the mental wellbeing of SGMYs, few interventions focused on this area and unique populations have been reported upon in the peer-reviewed literature. As a result, there is considerable potential to develop supports for SGMYs.

E-health interventions targeting STIs, sexual risk, substance use and mental health among men who have sex with men: four systematic reviews

Background

Human immunodeficiency virus/sexually transmitted infections, sexual risk, substance (alcohol and other legal and illegal drugs) use and mental ill health constitute a ‘syndemic’ of mutually reinforcing epidemics among men who have sex with men. Electronic health (e-health) interventions addressing these epidemics among men who have sex with men might have multiplicative effects. To our knowledge, no systematic review has examined the effectiveness of such interventions on these epidemics among men who have sex with men.

Objective

The objective was to synthesise evidence addressing the following: (1) What approaches and theories of change do existing e-health interventions employ to prevent human immunodeficiency virus/sexually transmitted infections, sexual risk, alcohol/drug use or mental ill health among men who have sex with men? (2) What factors influence implementation? (3) What are the effects of such interventions on the aforementioned epidemics? (4) Are such interventions cost-effective?

Data sources

A total of 24 information sources were searched initially (October–November 2018) [the following sources were searched: ProQuest Applied Social Sciences Index and Abstracts; Campbell Library; EBSCO Cumulative Index to Nursing and Allied Health Literature Plus, Wiley Online Library The Cochrane Library; Centre for Reviews and Dissemination databases (the Database of Abstracts of Reviews of Effects and the NHS Economic Evaluation Database); the Health Technology Assessment database; Evidence for Policy and Practice Information and Co-ordinating Centre (EPPI-Centre) database of health promotion research (Bibliomap); ProQuest Dissertations & Theses Global; OvidSP EconLit; OvidSP EMBASE; OvidSP Global Health; OvidSP Health Management Information Consortium; ProQuest International Bibliography of the Social Sciences; Ovid MEDLINE ALL; OvidSP PsycINFO; Web of Science Science Citation Index Expanded; Elsevier Scopus; OvidSP Social Policy & Practice; Web of Science Social Sciences Citation Index Expanded; ProQuest Sociological Abstracts; ClinicalTrials.gov; World Health Organization International Clinical Trials Registry Platform; EPPI-Centre Trials Register of Promoting Health Interventions; and the OpenGrey database], and an updated search of 19 of these was conducted in April 2020. Reference lists of included reports were searched and experts were contacted.

Review methods

Eligible reports presented theories of change and/or process, outcome and/or economic evaluations of e-health interventions offering ongoing support to men who have sex with men to prevent human immunodeficiency virus/sexually transmitted infections, sexual risk behaviour, alcohol/drug use and/or common mental illnesses. References were screened by title/abstract, then by full text. Data extraction and quality assessments used existing tools. Theory and process reports were synthesised using qualitative methods. Outcome and economic data were synthesised narratively; outcome data were meta-analysed.

Results

Original searches retrieved 27 eligible reports. Updated searches retrieved 10 eligible reports. Thirty-seven reports on 28 studies of 23 interventions were included: 33 on theories of change, 12 on process evaluations, 16 on outcome evaluations and one on an economic evaluation. Research question 1: five intervention types were identified – ‘online modular’, ‘computer games’ and ‘non-interactive’ time-limited/modular interventions, and open-ended interventions with ‘content organised by assessment’ and ‘general content’. Three broad types of intervention theories of change were identified, focusing on ‘cognitive/skills’, ‘self-monitoring’ and ‘cognitive therapy’. Research question 2: individual tailoring based on participant characteristics was particularly acceptable, and participants valued intervention content reflecting their experiences. Research question 3: little evidence was available of effects on human immunodeficiency virus or sexually transmitted infections. The analysis did not suggest that interventions were effective in reducing instances of human immunodeficiency virus or sexually transmitted infections. The overall meta-analysis for sexually transmitted infections reported a small non-significant increase in sexually transmitted infections in the intervention group, compared with the control group. Meta-analyses found a significant impact on sexual risk behaviour. The findings for drug use could not be meta-analysed because of study heterogeneity. Studies addressing this outcome did not present consistent evidence of effectiveness. Trials did not report effects on alcohol use or mental health. Research question 4: evidence on cost-effectiveness was limited.

Limitations

The quality of the eligible reports was variable and the economic synthesis was limited to one eligible study.

Conclusions

There is commonality in intervention theories of change and factors affecting receipt of e-health interventions. Evidence on effectiveness is limited.

Future work

Future trials should assess the impact of interventions on multiple syndemic factors, among them sexual risk, substance use and mental health; incorporate sufficient follow-up and sample sizes to detect the impact on human immunodeficiency virus/sexually transmitted infections; and incorporate rigorous process and economic evaluations.

Study registration

This study is registered as PROSPERO CRD42018110317.

Funding

This project was funded by the National Institute for Health Research (NIHR) Public Health Research programme and will be published in full in Public Health Research; Vol. 10, No. 4. See the NIHR Journals Library website for further project information.

Effect of a Brief Social Contact Video on Transphobia and Depression-Related Stigma Among Adolescents: A Randomized Clinical Trial

IMPORTANCE

Transphobia and stigma remain barriers to seeking mental health care for gender-diverse adolescents.

OBJECTIVE

To examine the utility of brief social contact-based video interventions of transgender protagonists with depression to reduce transphobia and depression-related stigma and increase treatment-seeking intentions among adolescents in the general population.

DESIGN, SETTING, AND PARTICIPANTS

During August 2021, a total of 1437 participants were recruited and randomly assigned to 1 of 4 video-based conditions in a 2:2:1:1 ratio: (1) transgender adolescent girls, (2) transgender adolescent boys, (3) cisgender adolescent girls, or (4) cisgender adolescent boys.

INTERVENTIONS

In each of the approximately 110-second videos, an empowered presenter shared their personal story about coping with depression and reaching out for help.

MAIN OUTCOMES AND MEASURES

The primary outcome was the score on the Attitudes Toward Transgender Men and Women (ATTMW) scale. Secondary outcomes were (1) a "gender thermometer" rating for warmth in transgender perception, (2) the Depression Stigma Scale (DSS) score, and (3) the General Health-Seeking Questionnaire (GHSQ) score.

RESULTS

Of the 1437 randomized participants, 1098 (76%) completed the postintervention assessment and passed all the validity tests (mean [SD] age, 16.9 [1.2] years; 481 [44%] male; 640 [58%] White). A significant change in attitudes toward transgender youth was found within the intervention group only (mean [SD] ATTMW scores: intervention group, 34.6 [23.1] at baseline to 32.8 [24.2] after intervention; P < .001; control group, 33.5 [23.4] at baseline to 32.4 [24.1] after intervention; P = .01). The mean (SD) total DSS scores decreased significantly across study groups (intervention: 1.3 [3.3]; control: 1.7 [3.3]; P < .001). A significant increase in intention to seek help from a parent was found in the intervention (mean [SD] GHSQ score, 0.2 [1.1]) and control (mean [SD] GHSQ score, 0.3 [1.2]) groups (P < .001), as was a decrease in those not wanting to seek help from anyone (mean [SD] GHSQ score: intervention, 0.2 [1.6], P = .009; control, 0.3 [1.2], P < .001) Secondary analyses revealed significant differences in baseline ATTMW scores and intervention effects between transgender and gender-diverse and cisgender participants and between lesbian, gay, bisexual, or queer (LGBQ) and straight participants (F = 36.7, P < .001) and heterosexual participants (F = 37.0, P < .001). A significant difference was also found in mean (SD) transgender warmth scores from baseline to after intervention between groups (2.6° [13.1°] in the intervention group vs 0.4° [8.3°] in the control group; P < .001).

CONCLUSIONS AND RELEVANCE

In this randomized clinical trial, brief social contact-based videos proved efficacious in reducing transphobia and depression-related stigma and in increasing treatment-seeking intentions among adolescents in the general population. By personifying, individualizing, and providing face and voice to the experience of transgender youth, other adolescents, especially those who are cisgender and/or of a heterosexual orientation, can gain empathetic insights into the lives of their often marginalized and stigmatized fellow youth.

TRIAL REGISTRATION

ClinicalTrials.gov Identifier: NCT04969003.

Promoting Resilience and Well-being Through Co-design (The PRIDE Project): Protocol for the Development and Preliminary Evaluation of a Prototype Resilience-Based Intervention for Sexual and Gender Minority Youth

BACKGROUND

Sexual and gender minority youth (SGMY) are at an increased risk of a range of mental health problems. However, few evidence-informed interventions have been developed specifically to support their mental well-being. Interventions that are evidence-informed for the general population and are fine-tuned specifically with SGMY in mind proffer considerable potential. A particular opportunity lies in the delivery of engaging interventions on the web, where the focus is on enhancing the coping skills and building the resilience of SGMY, in a way that is directly relevant to their experiences. On the basis of earlier work related to an intervention called Rainbow SPARX (Smart, Positive, Active, Realistic, X-factor thoughts), we seek to create a new resource, especially for SGMY in the United Kingdom.

OBJECTIVE

This project has 3 main objectives. First, together with SGMY as well as key adult experts, we aim to co-design a media-rich evidence-informed web-based SGMY well-being prototype toolkit aimed at those aged between 13 and 19 years. Second, we will explore how the web-based toolkit can be used within public health systems in the United Kingdom by SGMY and potentially other relevant stakeholders. Third, we aim to conduct a preliminary evaluation of the toolkit, which will inform the design of a future effectiveness study.

METHODS

The first objective will be met by conducting the following: approximately 10 interviews with SGMY and 15 interviews with adult experts, a scoping review of studies focused on psychosocial coping strategies for SGMY, and co-design workshops with approximately 20 SGMY, which will inform the creation of the prototype toolkit. The second objective will be met by carrying out interviews with approximately 5 selected adult experts and 10 SGMY to explore how the toolkit can be best used and to determine the parameters and user-generated standards for a future effectiveness trial. The final objective will be met with a small-scale process evaluation, using the think out loud methodology, conducted with approximately 10 SGMY.

RESULTS

The study commenced on September 1, 2021, and data gathering for phase 1 began in October 2021.

CONCLUSIONS

A considerable body of work has described the issues faced by the SGMY. However, there is a dearth of research seeking to develop interventions for SGMY so that they can thrive. This project aims to co-design such an intervention.

TRIAL REGISTRATION

Research Registry Reference researchregistry6815; https://www.researchregistry.com/browse-the-registry#home/registrationdetails/609e81bda4a706001c94b63a/.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

PRR1-10.2196/31036.

Gaming Preferences and Motivations Among Bullied Sexual and Gender Minority Youth: An Interview Study

Objective: Game-based interventions can easily disseminate health information to hard-to-reach populations, such as sexual and gender minority youth (SGMY; e.g., gay/lesbian, bisexual, and transgender youth). SGMY disproportionately experience health problems, which have been attributed to greater violence victimization, such as bullying. Nevertheless, few interventions exist to improve health outcomes for bullied SGMY. Since game-based interventions offer economically viable and easily scalable solutions, we explored why bullied SGMY play games, the gaming characteristics they enjoy, and their preferences for future game-based interventions. Materials and Methods: We conducted semistructured qualitative interviews with 20 14- to 18-year-old U.S.-residing bullied SGMY recruited from social media. We asked participants about their current gaming experiences, preferences, and suggestions for future games and then conducted thematic analysis. Results: The majority of SGMY reported playing games to experience positive feelings associated with higher degrees of agency. Through controlling in-game storyline and character customization settings, SGMY described feeling safe and engaged in game play. In addition, SGMY reported playing games as a distraction from the real world. Coping with stress and other negative emotions was a commonly reported motivation for playing games, as was gleaning happiness independent from stress management. Furthermore, SGMY mentioned using games to connect with people, both in-person and virtually, to develop and maintain friendships. Conclusion: This study highlights specific methods of tailoring games to the interests of bullied SGMY. In addition, our findings are preliminary indicators that SGMY may use games to achieve healthy psychosocial developmental milestones. This study may be integral in informing the development of future game-based interventions for SGMY.

Information and communication technology-based health interventions for transgender people: A scoping review

In the recent past, there has been a strong interest in the use of information and communication technology (ICT) to deliver healthcare to 'hard-to-reach' populations. This scoping review aims to explore the types of ICT-based health interventions for transgender people, and the concerns on using these interventions and ways to address these concerns. Guided by the scoping review frameworks offered by Arksey & O'Malley and the PRISMA-ScR checklist, literature search was conducted in May 2021 and January 2022 in three databases (PubMed, CINAHL and Scopus). The two searches yielded a total of 889 non-duplicated articles, with 47 of them meeting the inclusion criteria. The 47 articles described 39 unique health projects/programs, covering 8 types of ICT-based interventions: videoconferencing, smartphone applications, messaging, e-coaching, self-learning platforms, telephone, social media, and e-consultation platforms. Over 80% of the health projects identified were conducted in North America, and 62% focused on HIV/sexual health. The findings of this review suggest that transgender people had often been regarded as a small subsample in ICT-based health projects that target other population groups (such as 'men who have sex with men' or 'sexual minority'). Many projects did not indicate whether transgender people were included in the development or evaluation of the project. Relatively little is known about the implementation of ICT-based trans health interventions outside the context of HIV/sexual health, in resource limiting settings, and among transgender people of Asian, Indigenous or other non-White/Black/Hispanic backgrounds. While the range of interventions identified demonstrate the huge potentials of ICT to improve healthcare access for transgender people, the current body of literature is still far from adequate for making comprehensive recommendations on the best practice of ICT-based interventions for transgender people. Future ICT-based interventions need to be more inclusive and specified, in order to ensure the interventions are safe, accessible and effective for transgender people.

Explaining effective mental health support for LGBTQ+ youth: A meta-narrative review

This meta-narrative review on mental health early intervention support for LGBTQ+ ​youth aimed to develop a theoretical framework to explain effective mental health support. Using the RAMESES standards for meta-narrative reviews, we identified studies from database searches and citation-tracking. Data extraction and synthesis was conducted through conceptual coding in Atlas.ti. in two stages: 1) conceptual mapping of the meta-narratives; 2) comparing the key concepts across the meta-narratives to produce a theoretical framework. In total, 2951 titles and abstracts were screened and 200 full papers reviewed. 88 studies were included in the final review. Stage 1 synthesis identified three meta-narratives - psychological, psycho-social, and social/youth work. Stage 2 synthesis resulted in a non-pathological theoretical framework for mental health support that acknowledged the intersectional aspects of LGBTQ+ ​youth lives, and placed youth at the centre of their own mental health care. The study of LGBTQ+ ​youth mental health has largely occurred independently across a range of disciplines such as psychology, sociology, public health, social work and youth studies. The interdisciplinary theoretical framework produced indicates that effective early intervention mental health support for LGBTQ+ ​youth must prioritise addressing normative environments that marginalises youth, LGBTQ+ ​identities and mental health problems.

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Despite elevated rates of poor mental health, LGBTQ ​+ ​youth underutilize mental health services and often experience inadequate support.

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There is a limited evidence-base examining LGBTQ ​+ ​youth early intervention mental health support needs.

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Early intervention services for LGBTQ ​+ ​youth mental health must de-pathologize emotional distress, difficult thoughts and behaviours.

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Early intervention support must address normative environments that marginalises youth, intersectional LGBTQ ​+ ​identities and mental health.

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Mental health support ​providers must understand individual lives, connect with LGBTQ+ youth, facilitate their autonomy and encourage agency.

Establishing a Working Definition of User Experience for eHealth Interventions of Self-reported User Experience Measures With eHealth Researchers and Adolescents: Scoping Review

BACKGROUND

Across eHealth intervention studies involving children, adolescents, and their parents, researchers have measured user experience to assist with intervention development, refinement, and evaluation. To date, no widely accepted definitions or measures of user experience exist to support a standardized approach for evaluation and comparison within or across interventions.

OBJECTIVE

We conduct a scoping review with subsequent Delphi consultation to identify how user experience is defined and measured in eHealth research studies, characterize the measurement tools used, and establish working definitions for domains of user experience that could be used in future eHealth evaluations.

METHODS

We systematically searched electronic databases for published and gray literature available from January 1, 2005, to April 11, 2019. We included studies assessing an eHealth intervention that targeted any health condition and was designed for use by children, adolescents, and their parents. eHealth interventions needed to be web-, computer-, or mobile-based, mediated by the internet with some degree of interactivity. We required studies to report the measurement of user experience as first-person experiences, involving cognitive and behavioral factors reported by intervention users. We appraised the quality of user experience measures in included studies using published criteria: well-established, approaching well-established, promising, or not yet established. We conducted a descriptive analysis of how user experience was defined and measured in each study. Review findings subsequently informed the survey questions used in the Delphi consultations with eHealth researchers and adolescent users for how user experience should be defined and measured.

RESULTS

Of the 8634 articles screened for eligibility, 129 articles and 1 erratum were included in the review. A total of 30 eHealth researchers and 27 adolescents participated in the Delphi consultations. On the basis of the literature and consultations, we proposed working definitions for 6 main user experience domains: acceptability, satisfaction, credibility, usability, user-reported adherence, and perceived impact. Although most studies incorporated a study-specific measure, we identified 10 well-established measures to quantify 5 of the 6 domains of user experience (all except for self-reported adherence). Our adolescent and researcher participants ranked perceived impact as one of the most important domains of user experience and usability as one of the least important domains. Rankings between adolescents and researchers diverged for other domains.

CONCLUSIONS

Findings highlight the various ways in which user experience has been defined and measured across studies and what aspects are most valued by researchers and adolescent users. We propose incorporating the working definitions and available measures of user experience to support consistent evaluation and reporting of outcomes across studies. Future studies can refine the definitions and measurement of user experience, explore how user experience relates to other eHealth outcomes, and inform the design and use of human-centered eHealth interventions.

A systematic mapping review of interventions to improve adolescent mental health literacy, attitudes and behaviours

AIM

The onset of mental illness is most common in adolescence, therefore mental health promotion efforts frequently target this age group. Evaluation literature in this area is largely segmented into specific domains in terms of settings, countries, and/or groups of young people, but an overall understanding and comparison across these areas is lacking. The current review aims to provide such an overview of interventions/programs which attempt to improve adolescents' mental health literacy, attitudes/stigma and behaviours.

METHODS

A systematic mapping review synthesized the strengths and weaknesses of published interventions/programs to improve mental health outcomes in youth. Ten databases and grey literature sources were searched, and results were categorized according to sample, location/setting, type of information presented, delivery and testing procedures, mental health outcome/s evaluated, and limitations.

RESULTS

One hundred and forty articles met the inclusion criteria; 126 were original records and 14 were reviews. Mental health literacy and attitudes/stigma were examined most frequently, and studies were predominantly conducted in school-based environments and high income economies. Intervention/program effectiveness varied across outcome/s measured, setting, and control group usage, with mental health literacy exhibiting the most positive changes overall. Common limitations included no long-term follow up or control group inclusion.

CONCLUSIONS

Despite generally positive changes seen throughout studies in this area, effectiveness differed across a range of methodological domains. Most research is conducted in schools and higher income economies, but the lack of investigation in other contexts (i.e., internet or community) or lower income countries suggests our understanding in this area is constrained.

Feasibility of a Web-Accessible Game-Based Intervention Aimed at Improving Help Seeking and Coping Among Sexual and Gender Minority Youth: Results From a Randomized Controlled Trial

PURPOSE

To address the gap in interventions for improving sexual and gender minority youth (SGMY; e.g., lesbian, gay, bisexual, and transgender youth) health, we tested the feasibility of a game-based intervention for increasing help-seeking, productive coping skills, resource knowledge/use, and well-being.

METHODS

We conducted a 2-arm randomized controlled trial testing a theory-based, community-informed, Web-accessible computer role-playing game intervention. Control condition received a list of resources. Primary hypotheses were high levels of implementation success, game demand, and game acceptability.

RESULTS

We randomized 240 SGMYs aged 14-18 years into the intervention (n = 120) or control (n = 120) conditions. Participants completed baseline (100%), 1-month follow-up (T2; 73.3%), and 2-month follow-up (T3; 64.4%) surveys. Among intervention participants, 55.8% downloaded and played the game. Of those who played, 46.2% reported a desire to play it again, and 50.8% would recommend it. Game acceptability exceeded hypothesized benchmarks, wherein participants reported high positive affect (M = 2.36; 95% confidence interval [CI]: 2.13, 2.58), low negative affect (M = 2.75; 95% CI: 2.55, 2.95), low tension/annoyance (M = 3.18; 95% CI: 2.98, 3.39), and high competence (M = 2.23; 95% CI: 2.04, 2.43) while playing the game. In multivariable intent-to-treat analyses of 38 secondary/tertiary outcomes, intervention participants reported significantly larger reductions than control participants in cyberbullying victimization (T2 b = -.28; 95% CI: -.56, -.01), binge drinking frequency (T2 b = -.39; 95% CI: -.71, -.06), and marijuana use frequency (T3 b = -2.78; 95% CI: -4.49, -1.08).

CONCLUSIONS

We successfully implemented a Web-accessible game trial with SGMY. The game-based intervention was feasible and acceptable to SGMY, and preliminary results show it improved several health-related behaviors. A larger scale trial is needed to test whether the game-based intervention can reduce health inequities for SGMY.

eHealth Interventions to Address Sexual Health, Substance Use, and Mental Health Among Men Who Have Sex With Men: Systematic Review and Synthesis of Process Evaluations

Background

Men who have sex with men (MSM) face disproportionate risks concerning HIV and other sexually transmitted infections, substance use, and mental health. These outcomes constitute an interacting syndemic among MSM; interventions addressing all 3 together could have multiplicative effects. eHealth interventions can be accessed privately, and evidence from general populations suggests these can effectively address all 3 health outcomes. However, it is unclear how useable, accessible, or acceptable eHealth interventions are for MSM and what factors affect this.

Objective

We undertook a systematic review of eHealth interventions addressing sexual risk, substance use, and common mental illnesses among MSM and synthesized evidence from process evaluations.

Methods

We searched 19 databases, 3 trials registers, OpenGrey, and Google, and supplemented this by reference checks and requests to experts. Eligible reports were those that discussed eHealth interventions offering ongoing support to MSM aiming to prevent sexual risk, substance use, anxiety or depression; and assessed how intervention delivery or receipt varied with characteristics of interventions, providers, participants, or context. Reviewers screened citations on titles, abstracts, and then full text. Reviewers assessed quality of eligible studies, and extracted data on intervention, study characteristics, and process evaluation findings. The analysis used thematic synthesis.

Results

A total of 12 reports, addressing 10 studies of 8 interventions, were eligible for process synthesis. Most addressed sexual risk alone or with other outcomes. Studies were assessed as medium and high reliability (reflecting the trustworthiness of overall findings) but tended to lack depth and breadth in terms of the process issues explored. Intervention acceptability was enhanced by ease of use; privacy protection; use of diverse media; opportunities for self-reflection and to gain knowledge and skills; and content that was clear, interactive, tailored, reflective of MSM’s experiences, and affirming of sexual-minority identity. Technical issues and interventions that were too long detracted from acceptability. Some evidence suggested that acceptability varied by race or ethnicity and educational level; findings on variation by socioeconomic status were mixed. No studies explored how intervention delivery or receipt varied by provider characteristics.

Conclusions

Findings suggest that eHealth interventions targeting sexual risk, substance use, and mental health are acceptable for MSM across sociodemographic groups. We identified the factors shaping MSM’s receipt of such interventions, highlighting the importance of tailored content reflecting MSM’s experiences and of language affirming sexual-minority identities. Intervention developers can draw on these findings to increase the usability and acceptability of integrated eHealth interventions to address the syndemic of sexual risk, substance use, and mental ill health among MSM. Evaluators of these interventions can draw on our findings to plan evaluations that explore the factors shaping usability and acceptability.

A Gamified, Social Media-Inspired, Web-Based Personalized Normative Feedback Alcohol Intervention for Lesbian, Bisexual, and Queer-Identified Women: Protocol for a Hybrid Trial

BACKGROUND

Sexual minority women are more likely to drink alcohol, engage in heavy drinking, and experience alcohol-related problems than heterosexual women. However, culturally tailored interventions for this population have been slow to emerge.

OBJECTIVE

This type 1 effectiveness-implementation trial examines the feasibility and efficacy of a gamified, culturally tailored, personalized normative feedback (PNF) alcohol intervention for sexual minority women who psychologically identify as lesbian, bisexual, or queer (LBQ).

METHODS

The core components of a PNF intervention were delivered within LezParlay, a fun, social media-inspired, digital competition designed to challenge negative stereotypes about LBQ women and increase visibility. The competition was advertised on the web through social media platforms and collaboration with LBQ community organizations. After 2 rounds of play by a large cohort of LBQ women, a subsample of 500 drinkers already taking part in the competition were invited to participate in the evaluation study. Study participants were randomized to receive 1 of 3 unique sequences of PNF (ie, alcohol and stigma coping, alcohol and control, or control topics only) over 2 intervention rounds. Randomization was fully automated by the web app, and both researchers and participants were blinded.

RESULTS

Analyses will evaluate whether PNF on alcohol use reduces participants' drinking and negative consequences at 2 and 4 months postintervention; examine whether providing PNF on stigma-coping behaviors, in addition to alcohol use, further reduces alcohol use and consequences beyond PNF on alcohol alone; identify mediators and moderators of intervention efficacy; and examine broader LezParlay app engagement, acceptability, and perceived benefits.

CONCLUSIONS

This incognito intervention approach is uniquely oriented toward engaging and preventing alcohol-related risks among community populations of LBQ women who may view their heavy drinking as normative and not in need of change because of the visibility of alcohol use in sexual minority community spaces. Thus, this intervention strategy diverges from, and is intended to complement, more intensive programs being developed to meet the needs of LBQ women already motivated to reduce their consumption.

TRIAL REGISTRATION

ClinicalTrials.gov NCT03884478; https://clinicaltrials.gov/ct2/show/NCT03884478.

INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID)

DERR1-10.2196/24647.

Generating Intervention Concepts for Reducing Adolescent Relationship Abuse Inequities Among Sexual and Gender Minority Youth: Protocol for a Web-Based, Longitudinal, Human-Centered Design Study

Background

Sexual and gender minority youth (SGMY; eg, lesbian, gay, bisexual, and transgender youth) are at greater risk than their cisgender heterosexual peers for adolescent relationship abuse (ARA; physical, sexual, or psychological abuse in a romantic relationship). However, there is a dearth of efficacious interventions for reducing ARA among SGMY. To address this intervention gap, we designed a novel web-based methodology leveraging the field of human-centered design to generate multiple ARA intervention concepts with SGMY.

Objective

This paper aims to describe study procedures for a pilot study to rigorously test the feasibility, acceptability, and appropriateness of using web-based human-centered design methods with SGMY to create novel, stakeholder-driven ARA intervention concepts.

Methods

We are conducting a longitudinal, web-based human-centered design study with 45-60 SGMY (aged between 14 and 18 years) recruited via social media from across the United States. Using MURAL (a collaborative, visual web-based workspace) and Zoom (a videoconferencing platform), the SGMY will participate in four group-based sessions (1.5 hours each). In session 1, the SGMY will use rose-thorn-bud to individually document their ideas about healthy and unhealthy relationship characteristics and then use affinity clustering as a group to categorize their self-reported ideas based on similarities and differences. In session 2, the SGMY will use rose-thorn-bud to individually critique a universal evidence-based intervention to reduce ARA and affinity clustering to aggregate their ideas as a group. In session 3, the SGMY will use a creative matrix to generate intervention ideas for reducing ARA among them and force-rank the intervention ideas based on their potential ease of implementation and potential impact using an importance-difficulty matrix. In session 4, the SGMY will generate and refine intervention concepts (from session 3 ideations) to reduce ARA using round robin (for rapid iteration) and concept poster (for fleshing out ideas more fully). We will use content analyses to document the intervention concepts. In a follow-up survey, the SGMY will complete validated measures about the feasibility, acceptability, and appropriateness of the web-based human-centered design methods (a priori benchmarks for success: means >3.75 on each 5-point scale).

Results

This study was funded in February 2020. Data collection began in August 2020 and will be completed by April 2021.

Conclusions

Through rigorous testing of the feasibility of our web-based human-centered design methodology, our study may help demonstrate the use of human-centered design methods to engage harder-to-reach stakeholders and actively involve them in the co-creation of relevant interventions. Successful completion of this project also has the potential to catalyze intervention research to address ARA inequities for SGMY. Finally, our approach may be transferable to other populations and health topics, thereby advancing prevention science and health equity.

International Registered Report Identifier (IRRID)

DERR1-10.2196/26554

Theories of change for e-health interventions targeting HIV/STIs and sexual risk, substance use and mental ill health amongst men who have sex with men: systematic review and synthesis

BACKGROUND

Sexual risk, substance use, and mental ill health constitute a syndemic of co-occurring, mutually reinforcing epidemics amongst men who have sex with men (MSM). Developed since 1995, e-health interventions offer accessible, anonymous support and can be effective in addressing these outcomes, suggesting the potential value of developing e-health interventions that address these simultaneously amongst MSM. We conducted a systematic review of e-health interventions addressing one or more of these outcomes amongst MSM and in this paper describe the theories of change underpinning relevant interventions, what these offer and how they might complement each other.

METHODS

We identified eligible reports via expert requests, reference-checking and database and Google searches. Results were screened for reports published in 1995 or later; focused on MSM; reporting on e-health interventions providing ongoing support to prevent HIV/STIs, sexual risk behaviour, substance use, anxiety or depression; and describing intervention theories of change. Reviewers assessed report quality, extracted intervention and theory of change data, and developed a novel method of synthesis using diagrammatic representations of theories of change.

RESULTS

Thirty-three reports on 22 intervention theories of change were included, largely of low/medium-quality. Inductively grouping these theories according to their core constructs, we identified three distinct groupings of theorised pathways. In the largest, the 'cognitive/skills' grouping, interventions provide information and activities which are theorised to influence behaviour via motivation/intention and self-efficacy/perceived control. In the 'self-monitoring' grouping, interventions are theorised to trigger reflection, self-reward/critique and self-regulation. In the 'cognitive therapy' grouping, the theory of change is rooted in cognitive therapy techniques, aiming to reframe negative emotions to improve mental health.

CONCLUSIONS

The synthesised theories of change provide a framework for developing e-health interventions that might holistically address syndemic health problems amongst MSM. Improving reporting on theories of change in primary studies of e-health interventions would enable a better understanding of how they are intended to work and the evidence supporting this. The novel diagrammatic method of theory of change synthesis used here could be used for future reviews where interventions are driven by existing well-defined behaviour and behaviour change theories.

SYSTEMATIC REVIEW REGISTRATION

PROSPERO CRD42018110317.

Effectiveness, Acceptability, and Feasibility of Digital Health Interventions for LGBTIQ+ Young People: Systematic Review

BACKGROUND

Young people (aged 12-25 years) with diverse sexuality, gender, or bodily characteristics, such as those who identify as lesbian, gay, bisexual, transgender, intersex, or queer (LGBTIQ+), are at substantially greater risk of a range of mental, physical, and sexual health difficulties compared with their peers. Digital health interventions have been identified as a potential way to reduce these health disparities.

OBJECTIVE

This review aims to summarize the characteristics of existing evidence-based digital health interventions for LGBTIQ+ young people and to describe the evidence for their effectiveness, acceptability, and feasibility.

METHODS

A systematic literature search was conducted using internet databases and gray literature sources, and the results were screened for inclusion. The included studies were synthesized qualitatively.

RESULTS

The search identified 38 studies of 24 unique interventions seeking to address mental, physical, or sexual health-related concerns in LGBTIQ+ young people. Substantially more evidence-based interventions existed for gay and bisexual men than for any other population group, and there were more interventions related to risk reduction of sexually transmitted infections than to any other health concern. There was some evidence for the effectiveness, feasibility, and acceptability of these interventions overall; however, the quality of evidence is often lacking.

CONCLUSIONS

There is sufficient evidence to suggest that targeted digital health interventions are an important focus for future research aimed at addressing health difficulties in LGBTIQ+ young people. Additional digital health interventions are needed for a wider range of health difficulties, particularly in terms of mental and physical health concerns, as well as more targeted interventions for same gender-attracted women, trans and gender-diverse people, and people with intersex variations.

TRIAL REGISTRATION

PROSPERO International Prospective Register of Systematic Reviews CRD42020128164; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=128164.

School Climate & Sexual and Gender Minority Adolescent Mental Health

Sexual/gender minority (Sexual/gender minority people are also referred to as Lesbian, Gay, Bisexual, Transgender, Queer) youth are more likely than cisgender heterosexual youth to exhibit depressive symptoms and be victimized. School climate research indicates that the presence of a Gay-Straight Alliance (a Gay-Straight Alliance or Gender-Sexuality Alliance is also referred to as a GSA and is a youth group to support sexual/gender minority youth), a supportive school climate, and seeking help from teachers are associated with more positive mental health outcomes; however, they are not typically measured together. This study uses a survey that measures all four measures of school environment with a national sample of 240 sexual/gender minority high school students ages 14-18 (mean age 15.77) where 53% of participants had a Gay-Straight Alliance in their school. The sample is 53% cisgender, 100% sexual minority and 62% white. Adjusting for demographics and presence of a Gay-Straight Alliance, fewer depressive symptoms were associated with lower help-seeking intentions for suicidal thoughts. The presence of Gay-Straight Alliance was not statistically associated with past-month help-seeking intentions or behaviors. Additionally, a more supportive school climate was associated with lower anxiety and depressive symptoms. However, the presence of a Gay-Straight Alliance was not statistically associated with anxiety or depressive symptoms. These findings suggest that a supportive school climate and supportive school personnel may be important for supporting the mental health of sexual/gender minority students.

Mental Health, Drug, and Violence Interventions for Sexual/Gender Minorities: A Systematic Review

CONTEXT

Compared with cisgender (nontransgender), heterosexual youth, sexual and gender minority youth (SGMY) experience great inequities in substance use, mental health problems, and violence victimization, thereby making them a priority population for interventions.

OBJECTIVE

To systematically review interventions and their effectiveness in preventing or reducing substance use, mental health problems, and violence victimization among SGMY.

DATA SOURCES

PubMed, PsycINFO, and Education Resources Information Center.

STUDY SELECTION

Selected studies were published from January 2000 to 2019, included randomized and nonrandomized designs with pretest and posttest data, and assessed substance use, mental health problems, or violence victimization outcomes among SGMY.

DATA EXTRACTION

Data extracted were intervention descriptions, sample details, measurements, results, and methodologic rigor.

RESULTS

With this review, we identified 9 interventions for mental health, 2 for substance use, and 1 for violence victimization. One SGMY-inclusive intervention examined coordinated mental health services. Five sexual minority-specific interventions included multiple state-level policy interventions, a therapist-administered family-based intervention, a computer-based intervention, and an online intervention. Three gender minority-specific interventions included transition-related gender-affirming care interventions. All interventions improved mental health outcomes, 2 reduced substance use, and 1 reduced bullying victimization. One study had strong methodologic quality, but the remaining studies' results must be interpreted cautiously because of suboptimal methodologic quality.

LIMITATIONS

There exists a small collection of diverse interventions for reducing substance use, mental health problems, and violence victimization among SGMY.

CONCLUSIONS

The dearth of interventions identified in this review is likely insufficient to mitigate the substantial inequities in substance use, mental health problems, and violence among SGMY.