Jasmine Bland
HCOMM 515
Prof. Gualtieri & Bradley Moore
July 9, 2015
Tufts Balance:
An m-health intervention addressing anxiety in college
EXECUTIVE SUMMARY
College students face a heightened risk of developing an anxiety disorder as a result
of the financial, social, and academic stress put on them at university. Young adults have
the added burden of experiencing the stress of new responsibilities associated with
emerging adulthood. Although the public has less support for mobile mental health
interventions than traditional therapy, program planners still hope to create successful
apps addressing behavioral health needs, such as anxiety. Tufts Balance is a proposed
intervention that would attempt to decrease college stress by bettering organization and
time management skills in users though and interactive calendar scheduling system. In
addition to improving time management for academics, the app will alert students to
participate in social activities and take regular breaks when studying. The app will also
monitor and track daily anxiety levels over the duration of the program. The development
and piloting period will occur over the course of three years, and the project will be led by
campus academics in a variety of interdisciplinary fields. As students learn more about the
app through a campus resource-based marketing plan, ideally, student stress levels and,
ultimately, anxiety levels will decrease.
MOBILE HEALTH OVERVIEW
Although the formal definition of mobile health can vary, this paper views mobile
health as the utilization of any portable technological device to monitor health, provide
knowledge or expand skills related to health and illness, or in any way directly support the
physical and mental health of the user. Mobile health was first introduced as a concept in
2003, and has grown to become a major aspect of global healthcare systems just over one
decade later (Istepanian, 2014).
The integration of mobile health into mainstream practice is, in part, a result of the
development of the first commercially available smartphone, the iPhone, in 2007. This
development provided a medium, specifically mobile apps, for individuals to find
information and manage their personal health (Istepanian, 2014). As technology continues
to develop, mobile health in enhanced and becomes more accessible to the masses around
the world. Recently, mobile health designers have developed sensors to track vital signs for
advanced health monitoring (Istepanian et al., 2004). When mobile health is more
accessible, there is the potential for a reduction in healthcare costs as well as
improvements in health outcomes in populations utilizing the technology (Kumar et al.,
2013).
Today, mobile health allows for patients and providers to have near-constant health
monitoring by helping people to manage their own health regularly (Kumar et al., 2013).
Many health-related apps provide people with information about their health and
healthcare (Kumar et al., 2013). This can be aimed at general health and wellness or more
specific illnesses, such as diabetes or Depression (Kumar et al., 2013). Most existing health
apps relate to nutrition, fitness, or elderly health (Bert et al. 2014).
MOBILE HEALTH FOR BEHAVIORAL HEALTH
Mobile health provides a platform for people with behavioral health concerns,
including anxiety disorders, to manage their health using apps and other technologies. It is
important to note that, although best practices for such health management programs do
exist, the technologies can advance faster than the literature. Future reviews of the
literature may find more extensive and updated best practices for app developers and
public health officials.
When creating an app, developers must keep in mind the ways in which the app will
serve to improve the lives of the users. Existing treatment methods for managing
behavioral health issues, like therapy, can often be a burden on patients’ schedules and
finances (Newman et al., 2011). By using technology to supplement traditional therapy,
clinicians and patients can avoid time spent on and cost associated with regular visits
(Newman et al., 2011).
Apps intended to address behavioral health concerns can take advantage of a
variety of mobile health functions. Tracking tools allow patients to monitor their emotions
over time, sleep habits, or drastic mood changes (Luxton et al., 2011). Such tracking
information can be shared with mental health professionals to adapt existing treatment
plans, as needed (Luxton et al., 2011). Patients in traditional talk therapy can use
smartphones to record sessions with providers so they can listen to and reflect on the
content of the session at a later time (Luxton et al., 2011). When patients need more
immediate help, they can use apps that employ “virtual therapy” techniques in which apps
can guide the user through mindful breathing or other exercises (Luxton et al., 2011). Users
can also find apps that are information-based and can educate them about the facts of their
health concerns (Luxton et al., 2011).
While mobile health programs aimed at addressing behavioral health concerns may
have benefits, such a new form of treatment may be difficult to accept (Musiat et al., 2014).
Research has shown that such mobile health interventions are perceived as less effective
than traditional therapy because they do not include much personal support and they are
not provided directly by mental health professionals (Musiat et al., 2014). Regardless of the
accuracy of these beliefs, it is important to understand why people may be hesitant to use
these programs to better present and explain the programs to people in the future.
TARGET POPULATION
About 75% of Americans with anxiety first exhibit symptoms by age 22, an age often
associated with college (Mahmoud et al., 2012). Anxiety is of major concern for this
population, as it can lead to depression if left unmanaged, which can, in turn, lead to
suicide, the second leading cause of death in college students (Mahmoud et al., 2012). This
time period is particularly anxiety inducing because of the stress associated with leaving
adolescence and gaining skills and responsibilities associated with entering adulthood
(Mahmoud et al., 2012). Additionally, students enrolled in university, particularly
competitive universities, have the added academic, financial, and social stress of school
(Mahmoud et al., 2012).
Oftentimes, stress in college can be addressed through time management, social
support, positive reappraisal, and leisure pursuits (Misra et al., 2000). Time management is
a particularly important facet of stress management because it addresses stress
immediately and on a longer-term basis. By using effective time management techniques,
students can organize their work and accomplish goals more efficiently (Misra et al., 2000).
Additionally, time management skills can lead to improved academic success, which can
reduce some level of long-term stress (Misra et al., 2000). Through effective use of time
management skills, students have the opportunity to dedicate more of their time to leisure,
social support, and positive reappraisal.
Although some coping skills can be helpful for students to use, other coping
mechanisms may be considered harmful to students’ physical and mental health. Students
displaying maladaptive coping skills may turn to denial about the problems that they face
or, they may exhibits signs to self-blaming (Mahmoud et al., 2012). Some students may
even turn to abusing substances, such as drugs and alcohol, as a means of coping with their
stress (Mahmoud et al., 2012).
The university setting provides program planners with a simple mechanism through
which they can implement interventions for the college-enrolled population. Of individuals
who graduate from high school, 65 percent attend some postsecondary schooling (Hunt et
al., 2010). For those who attend college, their social and academic lives are intrinsically
interwoven with their healthcare systems and wellness management (Hunt et al., 2010).
For ease of program implementation, this mobile health intervention will focus on college
student mental health. Nevertheless, some of the stresses of emerging adulthood impact
individuals who are not enrolled in university, and it is important to take action to protect
the health and wellbeing of this population.
In order to best understand how a mobile health intervention aimed at addressing
anxiety would impact different members of a college community, it is important to develop
personas of potential app users and measure how their persona traits would impact their
use of the app. All personas for this intervention represent undergraduate students at Tufts
University in Medford, MA at the start of a new academic year.
Emily
Emily is first-year student at Tufts in her first week of new student orientation.
Emily is excited to be on campus surrounded by new people who share her passions and
intellectual curiosity. Since childhood, she has worked hard, often under challenging
circumstances, and she hopes that she will graduate successfully.
A native of Texas, Emily is both a first-generation United States citizen, and a firstgeneration college student. She was born and raised in a small immigrant community
where few, if any of the residents went on to post-secondary education. The few people
who did go on to post-secondary education would eventually return home without
completing their degrees as a result of financial and academic struggles. Her mother and
father, a seamstress and cook, respectively, are very proud of Emily and look forward to
seeing Emily accomplish her childhood goal of becoming a doctor.
Despite Emily’s excitement about starting school, she does fear that she will be
unsuccessful at achieving her goals, just as the other students from her neighborhood were
unsuccessful. Emily recognizes how proud her parents are of her, and she fears that she
will disappoint them if she drops out of school. She has hopes that she will be able to take
care of her family’s financial needs once she become a doctor, but is concerned that her
parents will remain members of the working class if she does not find a way to help them.
Most of Emily’s self-doubt stems from her concerns about transitioning to such a
high-caliber university from her Title 1 high school. She knows that most of the students at
Tufts have taken AP or IB classes and have had extensive tutoring and mentorship. Emily
feels that she is not properly equipped with the knowledge and skills she needs to be
academically successful enough to “keep up” with her peers from wealthier backgrounds.
The extrinsic and intrinsic pressures associated with the academic transition are causing
Emily to feel more stressed and anxious. Emily has never sought out help for these feelings
of anxiety because she knows that her family would not approve of her getting mental
health help.
Jacob
As a sophomore, Jacob has completed his transition to life and learning at Tufts, and
is ready to move onwards in his education. Jacob expected a major in Psychology to be
straightforward and simple, but he quickly learned during his freshman year that the
historical theories and experimental design associated with Psychology studies is more
complicated than initially expected. This year, Jacob is taking more rigorous classes than
the subjects he studied in his freshman year, so he is concerned that his grades will decline
even further as his classes become more rigorous. Grades are particularly important to
Jacob because he plans on attending graduate school to advance him towards a career in
psychology.
Since Jacob is a sophomore, he knows that he should dedicate some of his time to
experiential learning. Many of his friends are spending their time doing research or
internships on and off campus. Jacob wants to be able to take on such a project and is
currently applying to programs. He knows that an added time commitment will make it
more difficult to manage his rigorous classes, and he questions whether or not he is ready
to take on such a responsibility. Ready to catch up with the rest of is classmates, Jacob feels
that he can take on an internship or research position and work on time management skills
later, when he has more free time.
When Jacob isn’t studying or working, he plans on spending his free time
communicating with his boyfriend in California. The time difference can make
communicating effectively a challenge. They try to dedicate time to talk to each other every
day for at least one hour, but Jacob often cancels the Skype or phone calls to address other
commitments that he has made. Jacob is worried that his relationship will be further
strained as he takes on additional projects. At present, Jacob’s greatest fear is his
relationship and academics failing because he is overcommitted. He has occasionally found
himself hyperventilating when he studies for exams, but he has not connected this to his
feelings of stress and anxiety.
Hannah
A dedicated athlete, Hannah is busy year-round with practices and competitions.
Hannah has participated in sports every semester since she first took up soccer in middle
school. All of her friends and family use sports as a way to bring people together, and she
does not think that she would enjoy college as much if she was unable to play sports. Now,
Hannah is captain on both the Tufts rugby team and the track team. In her spare time, she
also organizes a more casual club soccer team. Several weeks ago, Hannah injured herself
playing rugby, and she sustained a concussion. Her clinicians have recently cleared her to
play sports again, but have cautioned her to slowly transition back into life as an athlete in
aggressive sports.
Hannah is an English major and enjoys her studies, especially her classes
surrounding Shakespeare’s works. In order to better understand this subject, she plans on
going abroad to England next fall. The paperwork and application process for her study
abroad trip is complicated and time consuming, because she needs to temporarily enroll in
another university to take advantage of their study abroad program. Regardless, Hannah is
not concerned about balancing the application process, her academics, and sports. If
necessary, Hannah is prepared to stay up late nights and sacrifice her sleep to accomplish
everything that she needs to do. Hannah’s doctors, however, are concerned that staying up
late nights and balancing many activities will cause her stress levels to increase over time.
They are concerned that increased stress and a lack of rest may lead to delays in her
recovery time. The doctors told Hannah that she must manage her time so she does not find
herself stressed to the point to physical harm.
Michael
Michael believes that his senior year as a Chemical Engineer will be his most
stressful year of college. Since Chemical Engineers have very rigid schedules, he still needs
to complete several credits in order to graduate. Michael waited to take his most
challenging classes, so he has a full course load made up of his most difficult requirements.
If Michael is not successful in his schoolwork, he will not graduate with his class. In the
past, Michael has always received some of the highest scores in his classes, but this fact
does not reduce his anxiety.
Along with senior year comes many unique responsibilities, most notably, applying
for jobs. Michael recognizes that he is a competitive applicant for jobs in his field, but he
also knows of many classmates who might be hired over him. He wants to spend a
significant portion of his time working on job applications but he feels uncomfortable
spending more time on job applications and neglecting his schoolwork.
An additional time commitment senior year is senior themed events, including
senior week. Michael does not plan on going to these events because he believes that he
should prioritize academics and the job search over social events. Michael’s friends and
family are concerned about Michael, because he is known to isolate himself when he is very
stressed. He has had difficulties with stress and anxiety in the past, and he attended
therapy sessions sporadically during his freshman year. Michael ultimately stopped
attending the therapy sessions because he did not have enough time to commit to the
meetings.
COMPETITIVE ANALYSIS
A competitive analysis is an important tool that allows app developers to
1
1. App or
device
name, logo,
url
2.
Objective at
a glance
What is the
objective,
problem, or
challenge the
app or device
seems to be
addressing?
2
3
MindShift
Anti-Anxiety
Calm
Anxiety
management—
including everyday
anxiety and more
specific types of
anxiety
Monitor and address
stress to reduce
anxiety
Increase user
relaxation and instill
sense of calm
The name of the app
very clearly ensures
that the user
understands that this
app will address
anxiety. The imagery
alone might confuse
some people, as the
arrows’ purpose isn’t
intuitive. In
conjunction with the
name, the purpose is
quickly made clear.
N/A
Again, the name of
the app ensures that
the user knows that
this app can be used
for relaxation and
increasing a sense of
calm. The blue
image also enforces
a sense of calm.
4 stars (30 ratings)
Most people liked the
content, but the app
had a glitch in which
users were unable to
scroll down on the
pages.
5 stars (5 ratings)
Several reviews
mentioned that the
app saved the users’
lives. The developers
responded to all
negative comments
and fixed any
glitches
6.
Downloads
and use
How many
users/downloa
ds are there? Is
there data about
retention?
50,000-100,000 on
Android
Unsure of retention
or Apple data
10,000-50,000 on
Android
Unsure of retention
or Apple data
4.5 stars (51
ratings)
The reviews are
overwhelmingly
positive. The most
negative comments
surrounded
customer service.
Most people said
that it effectively
helped them
meditate regularly.
500,000-1,000,000
on Android
Unsure of retention
or Apple data
7.
Professionals from a
nonprofit dedicated
to mental health and
professionals from
The app has
executives from
business, medical,
psychological, and
3.
Purpose
and Goals
How clear are
the purpose and
goals of the app
or device at a
glance from
name, tagline,
and imagery?
Does it match
the objective at
a glance?
4.
Users
Is there any
information
about users
through
descriptions,
images, stories,
testimonials, or
usage data?
5.
Ratings and
reviews
What are the
ratings, reviews,
and feedback?
Research
Was there any
research,
evidence-based
MindShift is a clever
title, but purpose of
the app is not
expressed through it.
A user would need to
read the full
description of the app
to understand its
goal.
The user data is not
available, but it is
meant to be used by
teens and young
adults.
Although this data is
not available, some
schools, including
Tufts actively
encourage the use of
this app
Data unavailable
guidelines, or
experts
involved?
8.
Design
How
professional or
attractive is the
design?
9.
Layout and
navigation (for an
app)
What sections
does the app
have and are
they delineated
by content type,
roles, or user
needs? How
usable and
organized are
the layout and
navigation
(including
labels and
menus)? Do
they make
options
apparent?
10.
Branding
and external
affiliations
Who created the
app or device
and why? Is
there
organizational
branding,
accreditation,
sponsorship, or
the British Columbia
government served
as experts.
public health
backgrounds
working on the
project.
Clean lines with very
little clutter. The blue
color theme is
relaxing. Icons have
pictures and symbols.
The layout and
design are outdated.
The earthy color
scheme matches the
theme of the
organization, but it
does not convey a
sense of calm.
The nature scenes
have the potential
for being
overwhelming and
clichéd, but they
remain effective and
professional. The
design is otherwise
simple.
The home page has
the following options:
anxiety 101, my
situations, check
yourself, thinking
right, chill out tools,
active steps,
inspiration, settings,
and help.” The page
has a simple layout
with a basic icon and
the name of the
option below it.
The bottom of the
screen has all the
buttons to navigate.
The options are as
follows: assess,
resources, Ptracker,
reports. Since the
options are always at
the bottom of the
page, the app is very
easy to navigate.
The app is used
mainly for
meditation, so there
are not many
options available for
users to choose
between other than
type and length of
meditation. The
layout is very simple
because of this. Most
of the interface is
made of soothing
nature photos.
Joint collaboration
between the
nonprofit AnxietyBC
and British
Columbia’s mental
health department.
Developed by a
mobile mental health
developer called
SoundMindz. The
app is one small part
of the organization.
Data unavailable
advertising?
11.
Expert
content
What are the
expertgenerated
components, if
any, available
(including text,
graphics, audio,
video, blogs,
directions, ask
the expert,
glossary, quiz,
chat with an
expert)? Does
expert content
identify the
author and date
written and
reviewed?
12.
Oversight
Is there an
advisory board
or clinician
involvement?
13.
Literacy
and readability
Is the content in
the app clear
and easy to
understand?
What about any
descriptions or
instructions for
an app or
device?
14.
Usergenerated content
and sharing
What are the
user-generated
Dr. Arthur P.
Ciaramicoli, Ed.D.,
Ph.D. is the expert
advisor for the app.
Experts developed
the diagnostic
questionnaire and
informational videos.
Data unavailable.
Calm.com was
created by an app
developer, not a
medical group
(unlike the other
apps).
The provincial health
services authority is a
part of this project
and oversaw some of
the app development.
The app would be
easy to understand
for people with some
high school
background. Phrases
like “performance
anxiety” may be
difficult for some
people to understand.
There is an advisory
board of doctors and
lawyers with
experience in public
health and medicine.
The app would be
difficult to read for
anyone without a
high school diploma.
It uses words like
“dissipates” and
“affirmative.”
Data unavailable
Users are allowed to
add to a list of
situations that make
then uncomfortable
so they can create a
Users can use the
progress tracker,
which is a journal to
monitor progress in
managing anxiety.
Users do not have
the opportunity to
input data, but they
can choose between
different types of
The anxiety 101,
check yourself, and
chill out tools
sections are all based
on expert content.
The author is not
listed.
Yes. Most of the app
is made of audio, so
it does not require a
high literacy level.
components
(including
discussion
forums, blogs,
videos, “likes”,
comments,
ratings, and
reviews)?
Which, if any,
social media is
used?
15.
Policies
Are there
explicit privacy
policies or ones
for how
information is
used at
registration?
16.
Registratio
n
Do users
register and, if
so, what can
they do before
and after
registering?
What
information is
tracked or
displayed? How
is personal
information
used?
17.
Cost
Is there a cost
for the app or
device? Are
there premier
features?
18.
Devices and
websites
Does the app or
device tie into
any others apps,
personalized plan to
learn new coping
skills. Users can also
use a check yourself
feature to monitor
mood over time.
meditation.
N/A
N/A
N/A
Yes. The user has an
account that saves
information about
their mood and
anxiety struggles.
Yes. The user must
register personal
information so that
app can tailor
responses to the
user’s needs.
No
Free
Free
Free. Upgrades and
subscriptions range
from $0.99-49.99.
The app is connected
to the Anxiety BC
non-profit, which
provides additional
resources for
The app is connected
to the SoundMindz
website which offers
additional apps and
resources to address
Calm.com is also a
website, so users
can access it without
the app.
devices, social
media, or
websites?
19.
Support
and feedback
Is there a
website or
support forum
for users? Is
there a way to
provide
feedback? Is
there a feedback
survey?
20.
Overall
assessment
What are the
overall best and
worst features
of the app or
device?
managing anxiety.
a variety of mental
health concerns.
Users can email the
developer with any
feedback. Many of the
reviews surrounded
feedback, but they
were not addressed
by the developer.
Users are
encouraged to email
the soundmindz
admin with any
concerns.
Users have the
option to email the
developer for
support help.
Users had concerns
about an inability to
scroll, which is a
major bug in the app.
The personalized
features and variety
of resources
(monitoring,
researching
information,
gathering need
specific skills) are
welcomed.
Anti-Anxiety does
not have a creative
name or a beautiful
interface, but it is
easy to use and
allows the user to get
validated
information and
track their mental
health effectively.
Calm.com is not an
extravagant app, but
it is very effective in
its simplicity. It may
benefit from having
more individualized
features.
INTERVENTION OF INTEREST: TUFTS BALANCE
The target intervention, Tufts Balance, looks to decrease stress and anxiety levels in
undergraduate college students at Tufts University. It is important to recognize that
students’ high stress levels are often related to their busy schedules and long lists of
commitments. In order to best manage this, the intervention will be based on the structure
of an organizational app of some kind. Users will be able to input their schedule into a
calendar, just as they would for an existing mobile calendar. While some people use
calendar apps to schedule only their special events and deadlines, users of this app will be
encouraged to schedule all of their hours, including sleep, meals, and free time, into the
calendar. When inputting information into the calendar, users will need to use some level
of color-coding to distinguish between academic commitments, social commitments, etc.
Users can also input assignment deadlines into the app along with a reminder notification.
A student, for example, might have short reflection paper do on October 19th, so they might
set a reminder for October 12th to start working on the paper. This is meant to reduce
procrastination.
Using the information submitted by users, the app will serve to remind students of
the importance of time management and leisure time. If a user tries to schedule many
academic events consecutively without a social event, the app will prompt the student to
schedule a social event. The app will be connected to the university special events calendar,
and will suggest various events that seem similar to events that the student has scheduled
in the past. For example, a student who regularly attends a cappella concerts would receive
recommendations from the music department, such as the gospel choir concert or chamber
singers.
During finals, the students my attempt to schedule continuous study time, but the
app will automatically send an alert every 45 minutes to remind the student to take a short
10 minute study break. The app will then recommend a 10 minute activity that is weather
appropriate. In the wintertime, the app might recommend calling a close relative to say
hello or preparing a cup of tea. In warmer weather, the app might suggest taking a walk
outside.
The app will also monitor student activity and emotional status to best reduce
symptoms of anxiety. All in-app prompts can be dismissed easily. If the app recognizes that
a student is dismissing prompts for study breaks or social events, it will begin to send
information about time management and leisure to the students so the user recognizes the
importance of properly preventing anxiety. At the end of every day, the app will ask the
user to fill out a short questionnaire to gauge stress and anxiety levels and will add them to
the calendar so the user can visualize trends in behavioral health. If students respond to
the questionnaire and indicate that they are experiencing extreme stress, the app will
automatically load a mindfulness meditation module. The app will also use this information
to measure the reasons that people are citing as the cause of their anxiety. If possible, the
app will follow up send recommendations for skill building workshops on campus that
address the skills that the users need.
Ideally, this app will be successful because it follows best practices set forth for
coping with anxiety on college. The calendar component of the interaction addresses
students’ need for time management assistance to reduce stress and improve the likelihood
of academic success. The app also works to help students build in time for leisure time,
which is also an opportunity to seek out social support. Both social support and leisure
time are also effective coping mechanisms for stress.
Tufts Balance effectively builds upon the stress management techniques set forth by
MindShift, Calm, and Anti-Anxiety. The Calm App served as a model for the mindfulness
meditation module that loads when users are very stressed. Tufts Balance improved upon
the Calm model because it does not wait for the user to indicate an interest in using a
module, rather, it automatically loads when the user indicates extreme stress. MindShift’s
best quality is its ability to personalize features to the needs of the user. The app of interest
has similar personalization abilities that tailor the prompts to the needs and patterns of the
user. The Anti-Anxiety app’s anxiety level questionnaire is similar to the Tufts Balance daily
questionnaire in that both ask a serious of questions to determine stress level and tailor the
app’s future actions based on the results of the questionnaire. Tufts Balance, unlike AntiAnxiety does not use the questionnaire responses as the primary means of personalizing
the app because it is important to recognize that college results in many seasonal ups and
downs in stress level, so the app should not be heavily influenced by a high stress
questionnaire outcome if high-stress is considered normal, given the circumstances.
The four personas would all successfully use the Tufts Balance app to schedule their
lives while still finding time to enjoy themselves on campus.
Emily
Emily ended her freshman year with a 3.10 GPA. Although this is not as high as her
GPA in high school, she is content with the outcome of her hard work. During orientation,
she came across the open hours for Counseling and Mental Health Service and learned
about the Tufts Balance app. She thought that the app would be a good way to start
addressing her mental health concerns since she is still uncomfortable with the stigma
surrounding therapy. Emily most enjoyed the app’s basic calendar functioning, as Emily
had never used a mobile calendar before. This allowed her to plan an extensive study and
tutoring schedule and visualize the time that she had free to make friends and enjoy her
first year of college. With the help of the app, Emily found that she had enough time to join
the Minority Association of Pre-health Students. There, Emily found a group of people who
have similar backgrounds and goals to her, which reduced her stress regarding her ability
to succeed at Tufts.
Jacob
Several weeks into the school year, Jacob went to his Resident Assistant to express
his frustrations about his academic and work life balance. His RA then recommended the
new Tufts Balance app. Jacob struggled with the app at first, because he knew that
successfully using the app would require some level of consistency. Jacob’s favorite feature
of the app is the procrastination prevention tool. After using the tool, Jacob quickly learned
that he was struggling in his classes not because the course material was too challenging,
but because he had been starting all of his assignments late. At the start of each semester,
Jacob went to office hours and asked his professors to estimate the amount of time it would
take to prepare each assignment. With that information, he set multiple reminders for his
study goals. Although he was not able to completely eradicate procrastination, Jacob found
that by starting his work earlier, he was able to have more free time to partake in leisure
activities, like talking to his boyfriend via Skype. Jacob did find a research position in a
Psychology lab on campus, and he uses the Tufts Balance app to ensure that he has a fair
balance of social, academic, and research time.
Hannah
Hannah’s doctors at Health Service were concerned about the effect that her stress
levels may have had on her recovery from a concussion. Since Hannah was unwilling to
give up any of her activities, Health Service and Counseling and Mental Health Service
worked together to find a plan of action that would address Hannah’s needs without adding
another major time commitment to her schedule. Despite her initial resistance, Hannah
found that she enjoyed using the app because it allowed her to visualize the best times for
study abroad planning meetings and club soccer practices. Hannah most benefitted from
the app’s prompts that reminded her to take regular study breaks. She enjoyed getting
outside and moving after reading or writing for long periods of time. Hannah also noticed
that she retained more information and worked more efficiently when she took the
recommended study breaks than when she tried to work for long hours without stopping
at all. Hannah managed to complete her study abroad paperwork and will be returning
from London soon.
Michael
Michael successfully graduated from Tufts prepared to enter the workforce. Once he
realized that the stress of applying for jobs, finishing classes, and saying goodbye to his
classmates would be overwhelming, he scheduled an appointment with a staff member at
Counseling and Mental Health Service. Despite having very little free time, Michael
managed to set sporadic appointments to discuss his anxiety. In the interim period
between appointments, Michael used the Tufts Balance app as his primary method of stress
reduction. Michael organized all of his commitments into the app and worked to avoid
straying from the schedule. At his meetings with the counseling staff, Michael shared and
discussed the results of the questionnaire tracking to quickly measure any trends and
adjust the work-social balance in his calendar. Michael’s favorite app feature was the social
event prompting because it often reminded him of the importance of social support and
interpersonal connections. The app usually recommended senior events throughout the
year, which decreased Michael’s feelings of isolation. Upon graduating, Michael began a job
with a pharmaceutical research and development lab.
WIREFRAMES
EVALUATION PLAN
Throughout the semester, the app will collect information about the user’s anxiety
levels. Such data is one way that the intervention can be evaluated. If the program is
effective, the user’s anxiety should not remain high over an extended period of time
because the intervention should personalize suggestions and prompts to better assist the
student. If student anxiety levels don’t remain low or moderate, the intervention is not as
effective as it should be. Perhaps the personalized features are not tailored enough to
address the specific needs every user. During the evaluation phase, it is important to
recognize that it is expected that student anxiety levels increase during key times, such as
finals period. To best be able to distinguish between normal trends and deficiencies in the
program, the development stage will involve gathering a control group of student anxiety
levels without the app for comparison.
Program planners will also evaluate the perceived successes and challenges of the
program through a three surveys throughout the academic year. Program participants will
complete the first survey at the start of the academic year to share their perceptions about
mobile health and mobile mental health interventions. A mid-year survey will be sent to the
participants at the end of the fall semester, after all of their finals have been completed, and
before they return for the spring semester. This survey will focus on their perceived
benefits, barriers, and anxiety level changes. Information about perceived anxiety level
changes can stand in comparison to the actual data on anxiety level changes. Finally,
students will complete a final survey at the end of the academic year, which will focus on
perceived benefits, barriers, and anxiety level changes as well as opinions about the
effectiveness and ease of use of mobile mental health interventions.
DEVELOPMENT PLAN
Since the intervention is intended for use at a college campus, the app should be
developed on a college campus. Research faculty in the Psychology, Computer Science, and
Engineering Psychology departments can work together on the various components of the
app. Psychologists may work on the anxiety questionnaire and facts about self-care.
Computer Science faculty may work on developing the technology needed for the app.
Engineering Psychology faculty may develop the interface for the app to ensure that it is
user friendly. The faculty members may also choose to take on undergraduate and graduate
research assistants to gather data and complete other tasks throughout the project. By
utilizing the talent that already exists on college campuses, the cost of developing this app
will be lower than other apps of this variety.
App development will take place over the course of three years. For the academic
year (September-May) of Year 1, the team will continue to research common anxiety apps
and conduct a thorough review of the literature surrounding this topic. The team will also
collect data from students across the campus to measure their anxiety levels on a semiregular basis. Counseling and Mental Health Services as well as Health Service will both
continue to use their existing mental illness screening tools used at the start of every
appointment, which will become the data used to find trends in anxiety levels. The
following summer, the team will analyze this data and map trends in calendar and evenbased trends. During the academic session of Year 2, the team will begin developing the
app and organizing its content. Once the summer begins, the team will work with campus
partners on the marketing plan. The university will implement the pilot program in
academic Year 3.
MARKETING PLAN
To recruit a large number of students for the program, the marketing plan needs to
closely involve campus leaders. To best reach first year students, the app should be publicly
announced during orientation. If students hear about the intervention as soon as they
arrive on campus, the stigma surrounding mental health help might decrease as students
see that seeking help for anxiety follows a social norm on many college campuses. To set
this app apart from many other resources introduced at orientation, Counseling and Mental
Health Services can hold a raffle in which any student who downloads the free app can be
entered to win a prize. Possibly prizes may be free textbooks up to a certain dollar amount
or a new tablet.
Resident Assistants are another campus resource who can advertise the app to
students. Since they are responsible for organizing bulletin boards, they can work to ensure
that information about the app is always posted and readily available if students need it.
RAs can also refer students to the app if they notice that certain students are facing high
levels of stress. Staff and faculty across the campus can also refer students to the app if they
notice concerning stress levels. All staff who work directly with students should receive
information about the app so they are prepared to refer students when necessary.
LIMITATIONS
The Tufts Balance app follows many of the evidence-based guidelines for mobile
mental health interventions and borrows from and improves upon features of existing
apps. Nevertheless, the app has some limitations that may be addressed after the program
planners complete the pilot evaluation. Some cultures disapprove of discussing mental
health and mental illnesses, as seen in Emily’s family. If people have been socialized to
avoid this subject, they may be less willing to participate. It is also important to note that
this intervention is not an all-encompassing treatment plan for all diagnoses. Some people
may have clinical anxiety stemming from genetic or biological roots. In this situation, the
user may benefit from medication of traditional therapy in addition to the app. This app
should not be a replacement for professional help.
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