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The effectiveness of internet-based interventions for managing stress and anxiety in students in higher
education
Astrid Coxon, University of East [email protected] // @astridcoxon
Background & Rationale
• Record numbers of stressed students seeking support• University counselling services over stretched• High attrition rate attributed to student stress
Background & Rationale
• Brief interventions can help – but student needs to seek help• Many more students reluctant to seek help• Embarrassment• Play down severity• Aware services over stretched
• On reflection, students regret not seeking support sooner• Web-based interventions may “fill the gap”
Background & Rationale
• Increasing popularity of digital interventions• PROS:• No waiting list & available 24/7• Totally anonymous & confidential• Cost-effective• Well-liked• In-built data collection tool…!
Aims
• Evaluate web-based interventions for students experiencing stress• Effects, both short- and long-term• Comparison to traditional interventions
• Implications..?
Inclusion Criteria• Randomised wait-list
control trials• Web-based interventions• University students – work-
related stress/anxiety
Exclusion criteria• Students with pre-existing
diagnoses of mental ill-health / undergoing formal treatment• Primary focus of depression• Investigated risk of suicide
Search strategy
• Electronic database search including Cochrane, PsycINFO, Medline, Psychology & Behavioural Sciences Collection• General internet search & Google scholar• Hand search deemed unnecessary• Combination of search terms related to “students”, “stress”,
“online”, “intervention” etc.• Reference lists of key articles• Nov 2013
Results
2,651 articles
from initial search
77 abstracts screened
11 articles obtained in
full
5 articles included in
review
Results
• Five articles met all criteria – 3 in Canada [A-C; D; R], 1 in USA [Ch], 1 in UK [D]• [A-C] & [R] used the same intervention
• Sample sizes ranged 47-239• Control & intervention groups similar sizes within all studies• Greater number of female participants• Two studies had two different levels of intervention [ A-C; Ch]
Table 1 Characteristics of studies included in reviewStudy Design &
NNature and length of intervention
Main findings
Arpin-Cribbie et al (2011)
29 CBT/26 GSM/22 controls
Online CBT (13 modules) vs. Online GSM (7 modules)10 weeks
CBT group showed significant reduction in ASI and ATQ score, but not BAI score.GSM group showed significant reduction in ASI score but not ATQ or BAI score.
Cavanagh et al (2013)
54 int/50 controls
"Learning Mindfulness Online" 10mins, daily2 weeks
Intervention group showed reduction in PSS score and symptoms associated with anxiety and depression (PHQ-4 score).Self-report of reduced stress & anxiety.
Chiauzzi et al (2008)
78 int/83 CW/78 controls
MyStudentBody-Stress website vs. controlMin. 4 x 20mins
MyStudentBody-Stress group showed reduction in CAS-Anxiety score and increased HPLP-Stress Management. Not maintained at 6-month follow-up.
Day et al (2013)
33 int/33 controls
5 compulsory & 6 optional modulesAvailable for 6 weeks
Intervention group showed significantly lower DASS-21. Maintained at 6 months.
Radhu et al (2012)
22 int/25 controls
Web-based CBT12 weeks
Intervention group showed significant changes to scores in subscales of ATQ. Participants also gave self-report of lowered anxiety and stress.Control group ASI scores increased from baseline to post-test after waiting period
Quality• Varied in quality• Only one study specified participant age restriction [Ch]• One study gave no indication of age [R]• Oldest participant 51 years old
• One study did not specify minimum baseline score for participation [C]• 3 studies appropriate power analyses, sufficient initial
recruitment [A-C; Ch; D]• 1 stated “adequately powered RCT” but no details given [C]• 1 gave no indication re: how or why group size reached [R]
Quality
• Two studies single-blinded [A-C; Ch}• All studies used self-report measures• Social-desirability bias? Curious wait-list effect… [R]• Could also be regression to mean [D]
• Internal consistency of measures given, good justification for measures used• [A-C] also reported reliability analyses & checks of therapy
credibility & expectancy validity
Intervention compliance?• Self-managed programmes• [A-C] did not track material usage but attempted to measure post-
hoc• Results not analysed due to questionable validity
• [R] did not track material usage• [Ch] tracked usage, prompted if fell below set minimum• [C] sent reminder emails every 3 days• [D] provided trained coaches to provide email/tel encouragement &
usage guidance
Findings
• All studies some significant improvement in stress reduction• Maintained at 6-month follow-up [D]
• 2 studies improved with regards Negative Automatic Thoughts [A-C; R]• [A-C] saw no reduction in anxiety but noted improved Anxiety
Sensitivity score – longer-term implications?
Other findings• Drop out/attrition rates high• [C] over half failed to complete both pre- & post-intervention
questionnaires• [Ch] factored 10% attrition into initial recruitment – counter under-
powering• [R] had 24.1% drop out in intervention, 10.7% in control• No study explored reasons for drop out
• Only 2 studies with follow-up• [D] observed maintained effects at 6-months• [Ch] effects not maintained
Discussion
• Important data missing, i.e.:• Long-term effects• Frequency & duration of intervention necessary• Participant usage data
• Variety of measures, limits meaningful comparisons between studies• However:• Even short (2-week) can have positive effect• Longer intervention, with coach support = better results, maintained
Conclusions?
• Web-based interventions can be helpful, but not necessarily long-term• May provide a good bridge for struggling students awaiting
formal support• Cannot (in current form) replace traditional counselling or
therapy
References
• Arpin-Cribbie C, Irvine J, Ritvo P; Psychother. Res. 2012;22(2):194–20 • Cavanagh K, Strauss C, Cicconi F, Griffiths N, Wyper A, Jones F; Behav. Res. Ther. 2013;51(9):573–8• Chang EC, Zumberg KM, Sanna LJ, Girz LP, Kade AM, Shair SR, et al.; Pers. Individ. Dif. 2007;43(4):925–36• Chew-Graham CA, Rogers A, Yassin N; Med. Educ. 2003;37(10):873–80• Chiauzzi E, Brevard J, Thum C, Decembrele S, Lord S J; Health Commun. 2008;13(6):555–72• Currie SL, McGrath PJ, Day V, Comput. Human Behav. 2010;26(6):1419–26• Davies EB, Morriss R, Glazebrook C, J Med Internet Res. 2014;16(5)• Day V, McGrath PJ, Wojtowicz M., Behav. Res. Ther. 2013;51(7):344–51• Erkan S, Ozbay Y, Cihangir-Cankaya Z, Terzi S., Sci. Theory 2012;12(1):35–42• Radhu N, Daskalakis ZJ, Arpin-Cribbie C, Irvine J, Ritvo P; J Am. Coll. Health. 2012;60(5):357–66• Ryan ML, Shochet IM, Stallman HM., Adv. Ment. Heal. 2010;9(1)• Slaa E, Bewick B, Barkham M, Miles J, Koutsopoulou G., Stud. High. Educ. 2010. p. 633–45
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Thank you for listening!Any questions?
Astrid Coxon, University of East [email protected]
@astridcoxon
