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Latinos report higher rates of depression and anxiety than US whites but are less likely to receive care. Transmedia storytelling interventions accessible on the Internet via smartphones, tablets, and computers hold promise for reducing reluctance to explore or get help for symptoms because they are private, convenient, and can reach large numbers of people, including Latinas with mental health needs.
The purpose of this study was to examine the feasibility, acceptability, and preliminary efficacy of a mental health transmedia intervention for Latinas with elevated symptoms of depression, anxiety, or both.
A total of 28 symptomatic English-speaking Latina women aged 21 to 48 years participated in a 6-week study using a within-group design. All aspects of the study were completed via telephone or Internet. Participants used their personal devices to engage the Web-based transmedia intervention (in English) that included story-based videos, a data-informed psychotherapeutic video, an interactive video sequence, and a blog written from the point of view of one of the characters with links to mental health resources. Perceived confidence to get help and perceived importance for seeking immediate help were both measured using single-item questions. Participants completed surveys at baseline (via telephone) and 1 and 6 weeks after media engagement that measured various factors, including depression (Patient Health Questionnaire; PHQ-9 and PHQ-8) and anxiety (Generalized Anxiety Disorder scale; GAD-7). A telephone interview was conducted within 72 hours of media engagement. Action taken or intentions to get help (single-item question) and talking about the videos with others (single-item question) were measured 1 and 6 weeks after media engagement. Repeated measures analysis of variance was used to assess change in depression (PHQ-8) and anxiety (GAD-7) before transmedia engagement and 1 and 6 weeks after. Spearman correlations evaluated the association of confidence and importance of getting help with action taken, anxiety, and depression.
All 28 Latinas (English speakers) who engaged with the transmedia remained in the 6-week study. Within 1 week of transmedia engagement, 39% of women took action to get help, and 82% discussed the media with others. Symptoms of depression (
Preliminary findings indicate a culturally tailored mental health transmedia intervention is a feasible approach that holds promise for engaging large numbers of symptomatic English-speaking Latina women to begin the process of seeking help, as well as decreasing symptoms of anxiety and depression.
Latinos are the largest ethnic minority group in the United States [
Although only able to reach a small audience, an attractive fotonovela booklet created by Cabassa and colleagues [
Transmedia, a form of digital edutainment, moves beyond telenovela viewing and holds promise for innovative interventions because, as a communication technology, it offers a convenient methodology for reaching and affecting large numbers of individuals including those in need. As Latinos have the highest usage of smartphones among US adults (18-49 years) [
Transmedia that includes health messages has become increasingly popular among the growing numbers of English-speaking Latinos in the United States through Wise Entertainment’s hit show,
With the goal of using transmedia in an intervention, we drew upon our previous research data to enhance understanding of key issues for English-speaking Latinas associated with their experiences of depression or anxiety, as well as resilience and coping. We used those deidentified data to create a transmedia intervention called “Catalina: Confronting My Emotions” that was offered to women struggling with mental health symptoms. The purpose of this study was to examine the feasibility of a mental health transmedia intervention for English-speaking Latinas with moderate-to-severe symptoms of depression or anxiety. The first aim was to examine feasibility in terms of implementation, demand, and acceptability of a 6 week “Catalina” transmedia intervention. The second aim was to test the preliminary efficacy of the transmedia intervention to spur change in symptoms, perceived confidence and perceived importance of seeking help, and actions taken to get help.
With guidance from the University of California, Los Angeles Institutional Review Board (UCLA IRB), we used deidentified data from the Principal Investigator’s (PI) previous mental health studies with English-speaking and second generation Latinas as groundwork for creating composite characters and a storyline. Then, the PI teamed up with a Latino writer-director from Hollywood who created the scripts (in English) for the drama. Content validity for scripts was obtained from a community advisory board of four mental health therapists in two waves of critique, with a focus on making the scripts realistic and culturally appropriate. All four therapists had experience working with English-speaking adult Latinas and two of the four were Latinas themselves. The script was revised after each wave of input from the therapists. Casting was done in Hollywood, Latino or Latina actors were hired, and the video scenes were filmed and edited. Theater testing was done using preliminary versions of the videos, with a community sample of 19 Latina adults. Feedback regarding relatability of the characters and cultural appropriateness of the storyline was collected using focus groups and individual interviews. Feedback led to the final editing of the media. Simultaneously, a computer programmer collaborated with the PI to create an interactive feature and the Web page that was designed to match the look and feel of the videos. It included photos, captions, and links to all the videos and the resource-rich blog, including contact information and links to local and Web-based resources plus hotlines for mental health services.
Approval was granted by the UCLA IRB for a mixed-methods study with a one-group pretest and posttest design in a particular geographic target zone (approximately 22-mile diameter) within a much larger metropolitan area of Southern California. Purposive sampling methods were used for community-based recruitment from May 2015 to August 2015. The research was designed so that participants could complete all aspects of the study entirely over the phone and Internet.
Inclusion criteria limited enrollment to those who self-identified as Latina women aged 21 to 55 years who read and spoke English and who scored above the threshold at screening for depression on the Patient Health Questionnaire (PHQ-9) [
A total of 63 women called the study phone. Of the 63 callers, 28 were ineligible based on the inclusion criteria, including 6 who expressed suicidal ideation (they were further screened and referred using a suicide protocol), 10 who scored below threshold for both depression and anxiety, 4 who did not speak English, 2 who did not identify as Latinas, 4 who did not complete the screening, and 2 who reported they had only called to inquire for a friend. Thus, 35 women moved on to be screened and met eligibility requirements. Of them, 4 did not complete the Web-based informed consent after screening, 2 consented but did not participate beyond giving consent, 1 consented but later contacted the research assistant (RA) to report she could not gain access to the Internet on her phone. A final total of 28 eligible women moved beyond consent, and all of them completed the study; that is, there was no attrition over the 6 weeks of data collection.
Fliers were distributed at nine partner sites including women’s health clinics, parenting centers, social service sites, and a large catholic church in the geographic target zone. The fliers, printed in color and featuring a photo of the Latina main character from the story, invited adult Latinas who were struggling with feelings of sadness or worry to call if they wanted to participate in a media-based study. After giving verbal consent, callers were screened by the RA, a psychiatric mental health nurse practitioner (second author). The RA administered the PHQ-9 [
All enrolled participants were assigned a confidential identification number for deidentification purposes, and media was made accessible via a password protected “Catalina” website after they completed the Web-based informed consent using a link sent to them in a text message (short message service, SMS) or email. Participants first completed at time 1 the online survey and then accessed the website that included an introductory video along with a series of links that were sequentially arranged to guide the viewer.
Link number five led to a series of coordinated short video segments wherein Veronica (the nurse-therapist character) directly asked the viewer specific questions inspired by motivational interviewing (MI) [
At all points, viewers were free to decide if and when they would click any links to engage with the surveys or media. The Web page included a reminder for participants to call the study phone after engaging with the media to schedule a one-to-one interview with the RA within 72 hours of media exposure. The qualitative telephone interview explored women’s perceptions of the media in a way that protected women’s privacy. As reported elsewhere (in process), the individual interviews were audiorecorded, transcribed, and analyzed. Participants were sent a text message 1 and 6 weeks after engaging in the media, which provided a link to Web-based surveys (time 3 and time 4) that included the PHQ-8 and GAD-7 plus survey questions about perceptions related to the importance of getting immediate help, confidence they could get help, and intentions or action taken. To compensate for their time, gift cards to a local retailer were mailed, emailed, or texted to participants at three points (see
As few studies have examined the integration of health information into transmedia storylines, Bowen’s [
Timeline of data collection and gift card distribution time points.
Screenshots of smartphone view (3 of 3 screenshots).
Web-based questions for interactive video sequence based on Rollnick and Miller’s (2008) motivational interviewing ruler.
The PHQ-9 [
After screening, the PHQ-8 was used to measure the severity of depression over the past 2 weeks [
The GAD-7 is a 7-item questionnaire for anxiety and was used to screen for and measure the severity of anxiety over the preceding 2 weeks in this study [
For the interactive video sequence with Veronica, questions were fashioned after Rollnick and Miller’s [
Action taken and intentions to take action to get mental health care or support were assessed using Web-based surveys at time 3 and time 4 (see
Included in the time 2 telephone interview (scheduled after engaging the transmedia intervention) was a single-item Likert question with a 10-point range that was used to measure how much the women related to the main character (Catalina). Possible responses ranged from 1 to 10, with 1 meaning they did not relate to her at all and 10 meaning they completely related to her. Another single-item Likert question was asked to measure how comfortable women would be seeing someone such as the nurse-therapist character (Veronica) for counseling (1 indicated there were not comfortable and 10 indicated they were very comfortable).
Women were asked if they thought about or talked about the videos with family members, friends, or anyone else since viewing the media. These questions were asked as part of the Web-based surveys 1 and 6 weeks after engaging with the media (time 3 and 4, respectively; see
Participants were asked if and how they used Veronica’s resource-rich blog about where to seek services for support or therapy. Actions taken and intentions to act were measured as part of the Web-based surveys 1 and 6 weeks after engaging with the media (time 3 and 4, respectively; see
Web-based analytics tracking was used to measure the number of women who, without contacting the RA for assistance, (1) accessed the transmedia intervention Web page, (2) accessed and watched all videos, (3) completed all minutes of each video, and (4) answered the Web-based MI interactive questions.
Descriptive statistics were computed for sample characteristics. To assess feasibility in terms of implementation, descriptive statistics were used to compute how many women accessed, engaged, and navigated the Web page and answered the MI interactive questions (by typing within answer boxes) without assistance. To assess demand, descriptive statistics were used to compute how many women watched and completed all minutes of each video. To assess acceptability, descriptive statistics were used to compute relatability to the main character, desirability of seeing the nurse-therapist character, and the number of women who used or shared information on Veronica’s blog. Limited efficacy was assessed using repeated measures analysis of variance to assess change over time for anxiety and depression symptoms and Spearman correlations to evaluate the association of perceived confidence and importance of getting immediate help with anxiety, depression, and action taken.
Of the 28 participants who completed the Web-based consent form and accessed the media Web page (see
See
In terms of TV viewing habits, most participants reported that they watched TV shows about characters in a comedy or drama on a weekly basis. Over half of the sample watched story-based dramas or comedies several times weekly, and over three-quarters of the sample watched telenovelas on a weekly basis. In terms of the Internet, all participants reported that they watched videos, movies, or story-based shows via a smartphone, tablet, or computer on a weekly basis (see
As noted above (see Participants), 1 woman enrolled in the study but did not have Internet access on her phone so did not stay in the study. Of the 28 women who enrolled and had access to the Internet, all engaged the media using a smartphone, tablet or computer, and all stayed in the study throughout the 6 weeks.
In terms of Bowen’s feasibility criteria of implementation [
The website tracker of user plays for each video showed that all 28 women in the sample watched all the videos. Of the total, 27 women completed all minutes of all videos; however, 1 woman stopped the 14-min video approximately 2.5 min before its ending.
The mean relatability score for how much women related to the main character (Catalina) was 6.95 on a 10-point scale. The mean desirability score for how comfortable women would be seeing the nurse-therapist character for counseling (Veronica) was 8.13 on a 10-point scale. Within 6 weeks of viewing, 20 of the 28 women (71%, 20/28) used or shared with others the blog or information from the blog.
Depressive symptom levels decreased significantly across time (
For anxiety symptoms, there was a significant reduction across time (
Sample demographics (N=28).
Demographic variables | n (%) | ||
Some high school (but not all) | 3 (10.7) | ||
Graduated from high school or earned a general educational development certificate | 7 (25) | ||
Some technical, trade, or vocational school after high school | 3 (10.7) | ||
Attended some college | 8 (28.6) | ||
Graduated with an associate degree | 1 (3.6) | ||
Graduated with a bachelor’s degree | 3 (10.7) | ||
Graduated with a master’s degree | 2 (7.1) | ||
Chose not to answer the question | 1 (3.6) | ||
Not difficult | 3 (10.7) | ||
Somewhat difficult | 6 (21.4) | ||
Very difficult | 19 (67.9) | ||
Choose not to answer | |||
Depression: PHQ-9a score ≥10 | 3 (10.7) | ||
Anxiety: GAD-7b score ≥10 | 4 (14.3) | ||
Depression and anxiety scores each ≥10 | 21 (75) |
aPHQ-9: Patient Health Questionnaire 9-item.
bGAD-7: Generalized Anxiety Disorder scale 7-item.
Mean depression (Patient Health Questionnaire 9-item, PHQ-9 or 8) and anxiety (Generalized Anxiety Disorder scale 7-item, GAD-7) scores at screening, 1 week (time 3) and 6 weeks (time 4) after engagement with the transmedia intervention (PHQ-9 at screening; PHQ-8 at time 3 and time 4).
Media viewing habits of sample using television (TV) and Internet (N=28).
Media viewing habits | n (%) | |
Never | 1 (3.6) | |
Once a week | 5 (17.9) | |
Several times a week | 15 (53.6) | |
Everyday | 7 (25) | |
Never | 6 (21.4) | |
Once a week | 5 (17.9) | |
Several times a week | 13 (46.4) | |
Everyday | 4 (14.3) | |
Never | 0 | |
Once a week | 7 (25) | |
Several times a week | 12 (42.9) | |
Everyday | 9 (32.1) | |
Never | 5 (17.9) | |
Once a week | 8 (28.6) | |
Several times a week | 9 (35.7) | |
Everyday | 5 (17.9) |
Mean scores (standard deviation) for depression and anxiety (n=28) 1 and 6 weeks after engagement with transmedia intervention.
Mental health scores | Screening Mean (SDa) | 1 week after media (time 3) Mean (SD) | 6 weeks after media (time 4) Mean (SD) |
Depression PHQ-9b | 13.2 (3.9) | - | - |
Depression PHQ-8c | - | 11.0 (5.6) |
9.3 (6.7) |
Anxiety GAD-7d | 13.9 (3.4) | 9.5 (4.6) |
8.6 (6.1) |
aSD: standard deviation.
bPHQ-9: Patient Health Questionnaire 9-item.
cPHQ-8: Patient Health Questionnaire 8-item
dGAD-7: Generalized Anxiety Disorder scale 7-item.
Six weeks after media exposure, symptoms of depression and anxiety were both significantly correlated with perceived confidence that participants could take action to get immediate help. That is, higher levels of confidence were associated with lower levels of depression symptoms (Spearman ρ (rho): −.399,
Six weeks after media exposure, women’s perceived level of importance of getting help for their emotions was not significantly correlated with anxiety symptoms (Spearman ρ: −.288,
Within 1 week of media exposure, participants had changed their behavior. Specifically, 11 women (39%) reported they had already used the resources from the blog including links and contact information of local resources for support or therapy and hotline numbers. In addition, within 1 week, 25 women (89%, 25/28 of the sample) reported thinking about the videos during the week, and 23 women (82%, 23/28) reported they had already talked about the videos and transmedia with friends or family. Six weeks after exposure to the media, 8 women (28.5%, 8/28) reported they had used resources from the blog, and 21 women (75%, 21/28) reported they were still spending time thinking about the videos. At time 4, a total of 22 women (79%, 22/28) reported they had talked about the videos since time 3 when they completed the last set of Web-based questions 5 weeks earlier.
Women’s level of perceived confidence in their ability to seek help was significantly associated with intentions or taking action to get help both 1 week after (Spearman ρ: .513,
Women’s perceptions of the importance of getting help for their emotions was significantly associated with intentions or taking action to get help both 1 week after (Spearman ρ: .487,
Preliminary findings indicate that an Internet-accessible transmedia storytelling intervention is a feasible approach for engaging and helping English-speaking Latina adults with symptoms of depression, anxiety, or both. Such interventions hold promise for reaching much larger numbers of Latinas, including those who are underserved but need help. To our knowledge, this is the first mental health transmedia intervention, and findings suggest that women found the intervention compelling, therapeutic, and resourceful. Participants engaged with all features of the intervention, and all of them remained in the study for the entire 6-week duration; there was no attrition after initiation of the study.
Importantly, women in our sample took action, and within 1 week, more than a third (39%, 11/28) used resources from the resource-rich blog. This included referral sites and hotlines that women used to gain knowledge about the available resources, to gather information, or to make an appointment for services. Moreover, the participants found the transmedia to be socially valuable, with the majority (82%, 23/28) sharing it with those in their social circle within days of viewing it for the first time. Rather than keeping their experience of the transmedia to themselves, most of the women in our sample told friends and family about the transmedia intervention without delay. These findings highlight the convenient and strategic design of the transmedia website. Participants who determined that they (or a friend) could benefit from services just as Catalina did, could readily access resources.
Finally, the intervention was therapeutic in that symptoms reduced after engagement with our transmedia storytelling intervention. Our 6-week intervention led to a statistically significant improvement of the debilitating symptoms of depression and anxiety. This drop in symptom levels over the 6-week intervention illustrates how a digital storytelling intervention using the Internet can make a measurable difference in an individual’s life. This is even more important because of our sample’s vulnerability; 75% (21/28) of our Latina participants reported co-occurring depression and anxiety, which is commensurate with the literature [
Compelling, story-based content that individuals find appropriate, desirable, and easily accessible via the Internet provides a way to reach thousands of people about topics that are often considered taboo. For example, the
It is key for story-based edutainment to have realistic stories set in a believable world that is socioculturally relevant with a main character that viewers can relate to [
In conjunction with symptom reduction, transmedia storytelling interventions may also serve as catalysts that help women take action to seek mental health services. For our sample, both perceived confidence (self-efficacy) and importance were associated with increased actions taken to get help 1 and 6 weeks after viewing the media. On the basis of Bandura’s social cognitive theory, self-efficacy is a psychological determinant of behavior change commonly targeted in health promotion interventions [
This was a feasibility study with a one-group pretest posttest design. Thus, results cannot be generalized beyond this sample until an attention control and usual care are added to the research, as necessary, to verify the efficacy for this transmedia intervention. With the surveys and the qualitative interview administered by the RA, a psychiatric mental health nurse practitioner, the possibility of a therapeutic effect exists.
Because telenovelas have long been enjoyed by Latina audiences and because of the success of
Future implications of this study include advancements in the use of transmedia, such as further development of more interactive Web-based activities to access other evidence-based therapeutic help for women to make strides in managing their symptoms. This research and development may provide insight into how to refine and tailor future evidence-based Web-based treatment programs for Latinas. A recent review of Internet-based cognitive behavioral therapy (iCBT) supports the efficacy of iCBT to successfully treat depression and anxiety and particularly in overcoming the barriers that often preclude treatment [
Generalized Anxiety Disorder scale 7-item
Internet-based cognitive behavioral therapy
motivational interviewing
Patient Health Questionnaire 9-item
research assistant
standard deviation
University of California, Los Angeles Institutional Review Board
This study was funded in part by an Intramural Grant from the UCLA School of Nursing and by the National Institutes of Health/National Institute for Nursing Research T32 NR007077 (for the second author).
None declared.