Arts and Social Sciences, Irving K. Barber Faculty of (Okanagan)
Psychology, Department of (Okanagan)
DSpace
UBCO
Halicki-Asakawa, Amané
Master of Arts - MA
University of British Columbia
Despite facing a myriad of adverse health outcomes such as high mortality rates and cardiovascular complications, women with eating disorders (EDs) are less likely to access mental health treatment compared to other clinical populations due to several barriers (e.g., long wait­lists, scarcity of treatment centres, egosyntonicity of pathology). Notably, a significant increase in ED clinic waitlists has been observed since the onset of the COVID-19 pandemic, widening existing treatment gaps. Given that delays in treatment have important clinical correlates (e.g., entrenchment of ED pathology), exploring new methods of mental health service delivery for this population is of critical concern. Mobile app-based motivational interviewing (MI) delivered prior to the start of treatment may be an effective way to improve accessibility by simultaneously addressing structural (e.g., travel costs) and individual (e.g., low motivation) barriers to care. Within the current multiphasic mixed-methods study, MI-Coach: ED, a novel mobile app designed to increase motivation among women waitlisted for ED treatment, was developed and pilot-tested. Phase I adapted the content and interface of an existing mobile app based on evidence-based principles (MI-Coach©) for an ED population. Phase II pilot-tested the mobile app with a sample of treatment-seeking women (n = 11) recruited from ED treatment clinic waitlists in British Columbia, Canada for a four-week period. Descriptive analyses of app use, pre- and post-test clinical characteristics, and thematic content analyses of semi-structured interviews conducted with a subset of participants (n = 8), indicated that most participants found the app acceptable, easy to use, and useful. Themes pertaining to previous experiences navigating treatment, the overall acceptability of the app, impacts of app use, and suggested modifications to the app were generated. Findings from this study support the use of MI-Coach: ED to deliver MI to individuals while waiting for formal treatment and highlight the potential of digital interventions to transform the delivery of ED services.
MOBILE APP-DELIVERED MOTIVATIONAL INTERVIEWING FOR WOMEN ON EATING DISORDER TREATMENT WAITLISTS: PILOT AND FEASIBILITY STUDY by Amané Halicki-Asakawa B.A., McGill University, 2019 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS in THE COLLEGE OF GRADUATE STUDIES (Clinical Psychology) THE UNIVERSITY OF BRITISH COLUMBIA (Okanagan) August 2023 © Amané Halicki-Asakawa, 2023 ii The following individuals certify that they have read, and recommend to the College of Graduate Studies for acceptance, a thesis entitled: Mobile App-Delivered Motivational Interviewing for Women on Eating Disorder Treatment Waitlists: Pilot and Feasibility Study submitted by Amané Halicki-Asakawa in partial fulfillment of the requirements of the degree of Master of Arts. Dr. Maya Libben, Irving K. Barber School of Arts and Sciences Supervisor Dr. Susan Holtzman, Irving K. Barber School of Arts and Sciences Supervisory Committee Member Dr. Lesley Lutes, Irving K. Barber School of Arts and Sciences Supervisory Committee Member Dr. Sarah Purcell, Irving K. Barber Faculty of Science University Examiner Dr. Brian Dalton, Faculty of Health and Social Development External Examiner iii Abstract Despite facing a myriad of adverse health outcomes such as high mortality rates and cardiovascular complications, women with eating disorders (EDs) are less likely to access mental health treatment compared to other clinical populations due to several barriers (e.g., long wait-lists, scarcity of treatment centres, egosyntonicity of pathology). Notably, a significant increase in ED clinic waitlists has been observed since the onset of the COVID-19 pandemic, widening existing treatment gaps. Given that delays in treatment have important clinical correlates (e.g., entrenchment of ED pathology), exploring new methods of mental health service delivery for this population is of critical concern. Mobile app-based motivational interviewing (MI) delivered prior to the start of treatment may be an effective way to improve accessibility by simultaneously addressing structural (e.g., travel costs) and individual (e.g., low motivation) barriers to care. Within the current multiphasic mixed-methods study, MI-Coach: ED, a novel mobile app designed to increase motivation among women waitlisted for ED treatment, was developed and pilot-tested. Phase I adapted the content and interface of an existing mobile app based on evidence-based principles (MI-Coach©) for an ED population. Phase II pilot-tested the mobile app with a sample of treatment-seeking women (n = 11) recruited from ED treatment clinic waitlists in British Columbia, Canada for a four-week period. Descriptive analyses of app use, pre- and post-test clinical characteristics, and thematic content analyses of semi-structured interviews conducted with a subset of participants (n = 8), indicated that most participants found the app acceptable, easy to use, and useful. Themes pertaining to previous experiences navigating treatment, the overall acceptability of the app, impacts of app use, and suggested modifications to the app were generated. Findings from this study support the use of MI-Coach: ED to deliver MI to individuals while waiting for formal treatment and highlight the potential of digital interventions to transform the delivery of ED services. Keywords: eating disorders, motivational interviewing, treatment waitlists, technology iv Lay Summary Eating disorders (EDs) are life-threatening mental illnesses with serious health effects. Despite having the highest death rate of any mental disorder, people with EDs are much less likely to access treatment compared to people with other mental health problems. This is due to a number of barriers such as long wait lists, few treatment centres, low motivation for change, and high rates of treatment dropout. The COVID-19 pandemic has increased these problems, with reports of higher ED rates, longer wait times and lower motivation for ED recovery. Motivational interviewing (MI) is a psychological intervention that addresses many of the treatment issues associated with EDs including difficulties with change and treatment dropout. Furthermore, brief MI interventions, provided before ED treatment, have been shown to improve clinical outcomes. Mobile-phone apps have been suggested as a cost-effective way to deliver such interventions. Despite their potential, there are no studies examining app-based MI to target EDs. The current study created and tested MI-Coach: ED, a mobile app designed to increase motivation among women waitlisted for ED treatment using seven self-guided sessions consisting of videos, articles, and exercises. Phase I adapted an existing app (MI-Coach©) for an ED context and Phase II tested MI-Coach: ED in a sample (n = 11) of women recruited from ED waitlists in British Columbia. Results indicated that participants found the app empowering, acceptable, easy to use, and useful. Suggestions were provided to improve the app’s usability. The findings from this study highlight the ways by which technology can be used to improve the way that ED services are delivered and to support individuals while seeking treatment. v Preface This research was conducted at the University of British Columbia Okanagan and was supervised by Dr. Maya Libben. For the present thesis, I was responsible for designing and developing the research paradigm, training and coordinating research volunteers for data collection, recruitment of participants and communications with project stakeholders, data preparation and analysis, and the written thesis. The Behavioural Research Ethics Board of the University of British Columbia’s Okanagan Campus granted ethics approval for this research. The certificate approval number for the project is H22-02046. To date, the results of this study have not been published. vi Table of Contents Abstract ......................................................................................................................................... iii Lay Summary ............................................................................................................................... iv Preface ............................................................................................................................................v Table of Contents......................................................................................................................... vi List of Tables ................................................................................................................................ ix List of Figures ................................................................................................................................x Acknowledgements ..................................................................................................................... xi Dedication .................................................................................................................................... xii Chapter 1: Introduction .................................................................................................................1 Treatment Barriers ...................................................................................................................... 1 Structural Factors ................................................................................................................ 2 Individual Factors ................................................................................................................ 3 Motivational Interviewing ............................................................................................................ 5 Technology-Based Interventions ................................................................................................ 6 Research Program Objectives .................................................................................................... 8 Chapter 2: Program Development (Phase I) ............................................................................ 10 Rationale ................................................................................................................................... 10 Methodology.............................................................................................................................. 10 MI-Coach© ........................................................................................................................ 10 Program Development ...................................................................................................... 10 Chapter 3: Pilot Test and Evaluation (Phase II) ...................................................................... 12 Rationale ................................................................................................................................... 12 Hypotheses ....................................................................................................................... 12 Research Questions ......................................................................................................... 13 Materials .................................................................................................................................... 13 Demographic Questionnaire ............................................................................................. 14 Sick, Control, One, Fat, and Food (SCOFF) Questionnaire ............................................ 14 Eating Disorder Examination Questionnaire (EDE-Q) ..................................................... 15 Body Shape Questionnaire (BSQ).................................................................................... 15 Readiness and Motivation for Change Questionnaire (RMQ) ......................................... 15 General Anxiety Disorder, 7-Item (GAD-7) ...................................................................... 16 Patient Health Questionnaire, 9-Item (PHQ-9)................................................................. 16 Technology Acceptance Model Questionnaire (TAM) ..................................................... 16 User Version of the Mobile App Rating Scale (uMARS) .................................................. 17 vii eHealth Literacy Scale (eHEALS) .................................................................................... 17 Mobile Device Proficiency Questionnaire (MDPQ) .......................................................... 17 Semi-Structured Interview ................................................................................................ 18 Zoom ................................................................................................................................. 18 Participants ............................................................................................................................... 18 Procedure .................................................................................................................................. 19 Analytic Approach ..................................................................................................................... 20 Quantitative Methodology ................................................................................................. 20 Qualitative Methodology ................................................................................................... 22 Chapter 4: Results ...................................................................................................................... 23 Study Recruitment .................................................................................................................... 23 Sample Characteristics ............................................................................................................. 23 Perspectives on App Use ......................................................................................................... 24 Feasibility .......................................................................................................................... 24 Acceptability ...................................................................................................................... 24 Ease of Use and Perceived Usefulness ........................................................................... 24 Clinical Outcomes Associated with App Use ........................................................................... 25 Changes in Motivation ...................................................................................................... 25 Changes in Associated Clinical Characteristics ............................................................... 27 Clinical Significance of Change ........................................................................................ 28 Qualitative Findings .................................................................................................................. 29 Qualitative Coding Process .............................................................................................. 29 Descriptions of Themes and Subthemes ......................................................................... 29 Summary of Findings ................................................................................................................ 40 Experiences Navigating the Healthcare System .............................................................. 41 Acceptability of App Design .............................................................................................. 41 Impact of App Use ............................................................................................................ 42 Suggested Modifications ................................................................................................... 43 Chapter 5: Discussion ................................................................................................................ 44 Previous Treatment-Seeking Experiences ............................................................................... 44 Feasibility and Acceptability...................................................................................................... 47 Feasibility and Perceived Ease of Use ............................................................................. 47 Acceptability and Perceived Utility.................................................................................... 48 Feasibility of Study Recruitment ....................................................................................... 49 Preliminary Efficacy .................................................................................................................. 50 viii Suggestions to Improve MI-Coach: ED .................................................................................... 53 Limitations and Future Directions ............................................................................................. 55 Conclusion ................................................................................................................................ 57 References ................................................................................................................................... 59 Tables and Figures ..................................................................................................................... 73 Appendices .................................................................................................................................. 89 Appendix A: MI-Coach: ED Session Outline ............................................................................ 89 Appendix B: Recruitment Flyer ................................................................................................. 91 Appendix C: Study Measures ................................................................................................... 92 Appendix D: Time 1 Consent Form ........................................................................................ 129 Appendix E: Brief Consent Form ............................................................................................ 133 Appendix F: Qualitative Interview Guide ................................................................................ 137 ix List of Tables Table 1. Study Recruitment 73 Table 2. Participant Demographics 74 Table 3. Characteristics of App Use 75 Table 4. uMARS Qualitative Responses 76 Table 5. Changes in Readiness and Motivation Questionnaire Scores 77 Table 6. Changes in Clinical Characteristics 78 Table 7. Time 1 Variable Correlations 79 Table 8. Time 2 Variable Correlations 80 Table 9. Jacobson-Truax Clinical Significance by Variable 81 Table 10. Qualitative Interview Participant Demographics 83 x List of Figures Figure 1. MI-Coach: ED Adaptations 84 Figure 2. Participant Flow 85 Figure 3. Adapted Technology Acceptance Model Ratings of MI-Coach: ED 86 Figure 4. Correlogram of Time 1 and Time 2 Change Scores for All Variables 87 Figure 5. Individual-Level Clinical Significance Change Scores by Variable 88 xi Acknowledgements I feel so fortunate to have had the opportunity to conduct this research, and it is without question that this project would not have been possible without the support of my supervisor, Dr. Maya Libben. I am eternally grateful for your kindness, wisdom, and general willingness to sit in front of a teleprompter for several weeks during the heat of summer. Thank you for believing in this project, in my research abilities, and for your mentorship. Additionally, I would like to thank my wonderful committee, Drs. Susan Holtzman and Lesley Lutes, for their important insights and contributions to this project, and for Drs. Sarah Purcell and Brian Dalton for their roles as External Examiner and Neutral Chair, respectively. This research project could not have been completed without the support of a small village of colleagues, volunteers, and technological partners. Jason Scott and Taylor Wilson, thank you both for your exceptional cinematography skills, and for helping me unlock the mysteries of the UBC-O Studio; Emily Mayzes-Kotulla, Sarah Sheppard, and Alex Nagy, for your tireless work creating tables, transcribing videos, and ad-hoc emotional support; and Dr. Stan Steindl and the Resiliens Inc. team for laying the groundwork for this project. I am so thankful to my family and friends for showing me the importance of community, especially in times of burnout. In particular, my parents, Kevin and Tomi, for providing the safety net from which I could explore my academic whimsies; my Japanese family, Ojiichan, Obaachan, and Uncle Youta, for their endless love and snacks; my Canadian grandparents, Ann and Gordon, for their unconditional support and for always reading my academic work; Winnie, Amy, Cameo, and Marcus, for showing me that there is indeed life outside of research; and Bella, Kitsey, Dora, and Riley, for providing an essential service without which this project could not have been completed (being so cute, fuzzy, and small). Lastly, I would like to thank my research participants for their vulnerability, honesty, and resilience. Sharing the lived experiences of eating pathology takes remarkable strength, and I hope to continue to advocate on your behalf through my research. xii Dedication My research questions, insights, and analyses are guided by my positionality as a person with lived experience of eating disorder pathology and, fortunately, of successful and maintained recovery. As such, the following thesis project is guided both by the current literature and by my own experiences navigating the healthcare system. Nothing about us, without us. 1 Chapter 1: Introduction Eating disorders (EDs) are serious, life-threatening psychological illnesses that involve disturbances surrounding body image, emotion regulation, and eating behaviours (American Psychiatric Association, 2022; Klump et al., 2009). There is significant heterogeneity in ED symptoms, with the Diagnostic and Statistical Manual of Mental Disorders, fifth edition text revision (DSM-5-TR) identifying several major subtypes of the disorder: binge eating disorder (BED), which involves recurrent episodes of binge-eating behaviour; bulimia nervosa (BN), which involves cyclical patterns of binge-eating followed by subsequent compensatory behaviours, such as vomiting; and anorexia nervosa (AN), which centres on a restrictive eating style and a significantly low weight. AN is further specified to indicate the presence (i.e., binge-eating/purging subtype; AN-BP) or absence (i.e., restricting type; AN-R) of binge-eating and purging behaviour. Further, other specified feeding or eating disorder (OSFED) is used to identify individuals who do not meet the full criteria for an ED but nonetheless experience significant distress and impairment due to their disordered eating behaviour (APA, 2022). ED prevalence rates as high as 4% have been observed internationally (Hoek & van Hoeken, 2003). Within Canada, a 2016 survey found that over 1,000,000 girls and women will experience an ED in their lifetimes, with expectations that this number will continue to increase (Standing Committee on the Status of Women, 2014; Vitagliano et al., 2021). Further, EDs are associated with a high level of psychiatric comorbidity, distress, and psychosocial impairment (Ágh et al., 2016; Mitchison et al., 2012; Weissman & Rosselli, 2017). Considering that EDs are associated with one of the highest mortality indexes of any mental illness, and are associated with a number of deleterious health consequences (e.g., gastrointestinal and cardiovascular complications, osteoporosis, and electrolyte imbalances), EDs are a serious public health issue (Arcelus et al., 2011; Chesney et al., 2014; Klump et al., 2009). Treatment Barriers 2 Despite the severity of these disorders, individuals with EDs are significantly less likely to access mental health services compared to those with other disorders (Innes et al., 2017; Weissman & Rosselli, 2017). It is estimated that those afflicted by EDs will not receive adequate treatment for 2 to 5.6 years following the onset of symptoms (Austin et al., 2021). Further, a recent Canadian study found that body-dissatisfied women at risk of developing an ED were significantly more likely to have unmet healthcare needs, compared to body-satisfied women (Cammaert, 2022). Considering that early intervention within the first few years of ED onset is an important component of recovery, the treatment barriers faced by this population are of critical concern (Ambwani et al., 2020). Structural Factors Several structural barriers have been identified limiting access to ED treatments and services. As EDs require specialized forms of care, treatment centres are typically few in number and primarily located in metropolitan areas. As such, access to services requires significant travel time and associated costs (e.g., costs related to travel and childcare, loss of income due to sick leave). These factors are significantly exacerbated in rural areas, as specialized ED services are especially rare in these regions (Innes et al., 2017; Kazdin et al., 2017; Thompson & Park, 2016). In addition, ED services are not typically covered by insurance providers, and can reach astronomical costs (McLaughlin, 2004). For example, one study conducted using data from a national insurance base in the United States found that the average cost for a 26-day inpatient stay was $17,384 USD, whereas outpatients settings saw a range of $1582 to $2344 USD for 13 to 17 sessions of treatment (Striegel-Moore et al., 2000). Unfortunately, the advent of the COVID-19 pandemic has exacerbated pre-existing barriers and increased the prevalence of ED risk factors (Vitagliano et al., 2021). In particular, disruptions to regular modes of service delivery due to physical distancing requirements have resulted in delays or termination of services (Cooper et al., 2020; Fernández-Aranda et al., 2020; Vuillier et al., 2021). A notable consequence has been a dramatic increase in service 3 demand and subsequent lengthening of waitlist duration, both internationally and domestically (Hansen et al., 2021; Haripersad et al., 2021; Hoye, 2021; Kohly, 2021; Szklarski, 2021). One Canadian news article published in 2021 reported that wait lists for local ED treatment centres were over 18 months long and that the Children’s Hospital of Eastern Ontario was forced to deny 73% of their ED referrals (in comparison to 49% in previous years; Szklarski, 2021). As treatment delays are associated with poorer outcomes following discharge and entrenchment of disordered eating over time, there is an urgent need to address existing structural barriers for this population (Ambwani et al., 2020; Austin et al., 2021). Individual Factors In addition to structural factors, various individual factors contributing to the inaccessibility of treatment have been identified (Ali et al., 2017). Treatment resistance is common among those with EDs, with many individuals reporting complex and ambivalent feelings regarding treatment (Abbate-Daga et al., 2013). Factors leading to treatment resistance are multifaceted and complex; individuals are often unaware of their own ambivalence, with resistance to treatment often presenting unconsciously as denial of illness severity or the over-intellectualization of symptoms (Abbate-Daga et al., 2013; Ali et al., 2017). Indeed, a myriad of additional factors (e.g., internalized stigma, mental health literacy, fears around losing control, cultural norms) have been found to negatively impact help-seeking behaviours (Ali et al., 2017, 2020; Griffiths et al., 2018; Kazdin et al., 2017). Motivation to change has been identified as one of the most salient factors impacting ED treatment, and is most commonly understood according to either the transtheoretical model or self-determination theory (Abbate-Daga et al., 2013; Ali et al., 2017; Denison-Day et al., 2018; Kazdin et al., 2017; Sansfacon et al., 2020). Prochaska and DiClemente’s (1982) transtheoretical model posits that individuals move back and forth sequentially through a series of stages as they engage in health behaviour change. The specific stages are as follows: precontemplation, during which there is no awareness of a need to change; contemplation, in 4 which there are thoughts regarding the change; preparation, in which a decision has been made to change in the near future; action, in which the change is implemented; maintenance, during which the behaviour change is sustained; and relapse, in which there is a return to the old pattern of behaviour (Prochaska & DiClemente, 1982). In comparison, self-determination theory posits that a variety of motivational states, such as autonomous motivation (i.e., engaging in behaviours when they align with personal goals) and external incentives, impact the individual’s motivation to engage in behaviour change (Ryan & Deci, 2001; Sansfacon et al., 2020). Drawing from both frameworks, motivation to address ED symptomatology is typically operationalized according to the individual’s degree of autonomous motivation and the likelihood that they are in the action stage of change (Sansfacon et al., 2020). Previous research has found that individuals with EDs struggle with their motivation to change, often perceiving eating pathology as necessary and adaptive (Clausen et al., 2013; Gale et al., 2006). Further, disordered eating may serve a functional purpose, such as providing a sense of control, or as a coping method for difficult emotions (Denison-Day et al., 2018; Schoen et al., 2012; Williams & Reid, 2010). As such, individuals may feel ambivalent about changing their eating behaviours and participating in treatment (Cockell et al., 2003; Denison-Day et al., 2018). However, levels of motivation have been found to vary according to the individual’s symptom presentation. For example, individuals with BED and BN often experience binge eating symptoms as distressing and are thus more likely to engage in treatment-seeking behaviours (Cassin et al., 2008; Cassin & Geller, 2015). In comparison, AN presentations are typically associated with the lower levels of motivation, given that restrictive eating symptoms are typically ego-syntonic and are highly valued by the individual (Abbate-Daga et al., 2013; Cassin et al., 2008; Cassin & Geller, 2015). Pre-treatment motivation has important clinical implications. For example, individuals with higher levels of motivation show improved treatment outcomes following discharge, longer durations between relapses, and improvements in related psychological symptoms such as 5 depression and anxiety. Given this relationship, improving pre-treatment motivation has been identified as an important target for ED interventions (Clausen et al., 2013). However, the complexities of ED presentations pose a significant challenge to clinicians when addressing motivation in treatment contexts. For example, higher levels of motivation prior to treatment do not lead to improvements across all ED symptoms. Though greater reductions in binge eating, restrictive eating behaviours, and weight gain have been observed in those with higher pre-treatment motivation, purging behaviours may persist at similar or greater frequencies (Clausen et al., 2013; Sansfacon et al., 2020). In order to address these challenges, research has increasingly looked to interventions that have shown success in other complex patient populations to inform treatment. Motivational Interviewing Motivational interviewing (MI) in particular has emerged as a promising way by which to target motivation in ED treatment (Denison-Day et al., 2018). Initially developed by Miller and Rollnick (1991) to address ambivalence within substance use treatment, MI is a person-centred approach that aims to strengthen the individual’s intrinsic motivation to change (Miller & Rollnick, 2012). Conducted using a collaborative, conversational style, the clinician aids the client to explore their ambivalence and identify their reasons for and against change. Through this process, the client is able to autonomously activate their own resources and motivation for change (Miller & Rollnick, 2012). Given the similarities between individuals with substance use disorders and EDs (e.g., ambivalence to change, continued engagement in behaviours despite repeated attempts to stop), MI has been increasingly used to address ambivalence and motivation in ED treatment settings (Denison-Day et al., 2018). A recent systematic review conducted by Denison-Day and colleagues (2018) found substantial support for the use of MI interventions for individuals with EDs. A majority (74%) of the studies reviewed found significant and long-term improvements in motivation as a result of MI interventions. Although MI was found to be significantly more effective compared to 6 psychoeducation and self-help, it was not more effective than cognitive behavioural therapy (CBT). Nonetheless, considering the efficacy of MI as a brief intervention and the importance of pre-treatment levels of motivation (Clausen et al., 2013), the authors concluded that its applications may be best suited for an earlier stage in the treatment process (Denison-Day et al., 2018). Several studies have evaluated the use of MI as a pre-treatment ED intervention (Feld et al., 2001; Geller & Dunn, 2011; Weiss et al., 2013). A pilot study conducted by Feld and colleagues (2001) administered a four-session MI intervention to 19 individuals referred to an intensive inpatient ED program. Improvements were seen in motivation, self-esteem, and depressive symptoms, which were retained at the 6-week follow-up. These findings were replicated and validated through a randomized controlled trial (RCT) conducted by Weiss and colleagues (2013). Individuals waitlisted for intensive ED treatment were randomized to receive hour-long MI sessions over a four-week period, or to a treatment-as-usual control group. The authors found that the treatment group was significantly more likely to complete intensive treatment compared to the control group (69% completion rate vs. 31%; Weiss et al., 2013). These findings have been seen in other treatment settings (Geller & Dunn, 2011). As such, there is evidence supporting the use of MI within pre-treatment contexts (Feld et al., 2001; Geller & Dunn, 2011; Weiss et al., 2013). Technology-Based Interventions Despite the potential for MI interventions to address individual treatment barriers, they are typically conducted through in-person, face-to-face sessions (Denison-Day et al., 2018; Feld et al., 2001; Geller & Dunn, 2011; Weiss et al., 2013). In-person interventions may not adequately address structural treatment barriers, such as costs and scarcity of treatment providers. In order to address this issue, internet and communications technology (ICT)-based interventions have been proposed as a low-cost and accessible form of delivering ED 7 interventions (Bauer & Moessner, 2013; M. Cooper et al., 2020; Shingleton et al., 2013; Weissman et al., 2020). A few preliminary studies have begun investigating the use of ICTs to deliver MI interventions (Hötzel et al., 2014; Leung et al., 2012; Muir et al., 2017; Shingleton et al., 2016). These interventions are primarily delivered through the internet, though one study by Shingleton and colleagues (2016) found motivational text messages to have mixed effects on motivation in participants undergoing adjunctive CBT. ICT-based interventions have shown promising preliminary results. A study by Leung and colleagues (2012) evaluating the benefits of an internet-based self-help program found support for the use of technology-based interventions to increase motivation, though their findings are limited due to a lack of a control group. A subsequent RCT by Hötzel and colleagues (2014) found stronger evidence for the benefits of technology-delivered MI, with their treatment group experiencing a significant improvement in motivation, self-esteem, and ED symptoms. Mobile apps have been increasingly suggested as a cost-effective and scalable alternative to internet-based interventions, as they are easy to use, require low effort, and become habitual over time. Further, unlike other ICT-based interventions, they have high hedonic motivation (i.e., they are enjoyable to use), which increases their use and adoption (Chandrashekar, 2018; Yuan et al., 2015). In addition, the interactive components embedded within mobile apps (e.g., modules, graphic design, diverse multimedia content) have been shown to significantly improve adherence to interventions and reduce dropout rates (Linardon et al., 2022). Thus, mobile apps have the potential to address the barriers impacting access to ED treatment (Ellison et al., 2015; Marques et al., 2011; Sadeh-Sharvit et al., 2018). Despite preliminary findings suggesting that mobile apps may be an acceptable means of delivering ED services, there is a paucity of effective, evidence-based apps available for use (Juarascio et al., 2015; Kim et al., 2018, p. 2; Sadeh-Sharvit et al., 2018; Tregarthen et al., 2019). Further, most publicly available mobile app interventions are based on CBT and 8 behavioural self-monitoring principles, and are limited in efficacy compared to when delivered using traditional methods (Ahmadiankalati et al., 2020; Juarascio et al., 2015; Linardon et al., 2020). As such, there is a need to expand the use of mobile-apps for the delivery of a wider range of evidence-based psychological interventions, such as MI. Additionally, flexible consideration of the ways by which mobile apps are used to deliver interventions (e.g., within adjunctive and pre-treatment settings vs. as primary interventions) is needed, given that their efficacy remains limited compared to face-to-face modalities (Ahmadiankalati et al., 2020; Juarascio et al., 2015; Linardon et al., 2020) Considering the accessibility of mobile apps and their wide adoption in various health and social contexts (Lee et al., 2018), they may be an effective mode of delivery for pre-treatment MI contexts. Help-seeking individuals waiting for formal services likely do not have access to in-person treatment options, despite their urgent need for services. Further, as they have not yet started formal ED treatment, receiving a pre-treatment MI intervention may significantly improve treatment outcomes. For example, such interventions may increase motivation to stay on the waitlist, and/or to adhere to treatment once services are received. A mobile app-based MI intervention thus has the potential to simultaneously address structural and individual treatment barriers. Despite the potential benefits, to date, no research has investigated the use of mobile app-based MI pre-treatment interventions for EDs. Research Program Objectives The current study developed and pilot-tested the MI-Coach: ED mobile app for women on ED treatment waitlists through two phases. Phase I adapted an existing self-help app developed using evidence-based MI principles (MI-Coach©) for use with ED populations. Phase II evaluated the app’s feasibility and acceptability through a pilot test evaluation. The final mobile app, MI-Coach: ED, consists of a self-guided MI intervention broken down into seven modules containing videos, exercises, and articles. Participants are instructed to identify their values and reflect on the ways in which their ED symptoms may interfere with value-driven 9 behaviour. The intervention targets a broad range of ED pathology (e.g., binge-eating, purging, compulsive exercise) and is amenable to any of the major ED subtypes (i.e., AN, BN, BED, EDNOS). Qualitative thematic analysis was used to analyze participant feedback collected using semi-structured interviews and qualitative questionnaire data following a four-week use of the MI-Coach: ED app. Descriptive statistics provided additional information regarding changes to recovery motivation, body dissatisfaction, ED symptoms, and depressive and anxiety symptoms using quantitative data collected before and after app use. 10 Chapter 2: Program Development (Phase I) Rationale Phase I of the study consisted of the development of the MI-Coach: ED mobile app intervention. The content and interface of the existing MI-Coach© app was used with consent from the developers (Resiliens Inc.) as a template from which the adaptation was based. Methodology MI-Coach© MI-Coach© is a self-help mobile app created by Resiliens Inc. (https://resiliens.com/) targeting motivation to engage in health behaviour change (e.g., exercising, smoking cessation, sleep hygiene), and is widely available on both Apple and Android app stores. Developed in collaboration with a clinical psychologist and MI expert from the University of Queensland (Stan Steindl, Ph.D.), the app features eight modules, consisting of over 35 interactive lessons led by a registered clinical psychologist with accompanying exercises. In addition, the app includes short articles, mood and behaviour assessments, mindfulness-based audio tracks, summary screens and analytics, community-based discussion groups, and the ability to communicate directly with a trained mental health professional. Program Development For the purposes of the current study, the content of MI-Coach© was tailored for an ED population. As a first step, the author and two trained research assistants identified aspects of the app content that were inappropriate for an ED-context (e.g., references to weight-loss and exercise behaviours as examples of health behaviour change goals). Subsequently, a literature review was conducted to identify MI topics and ED behaviour change goals used in previous interventions (e.g., Fursland et al., 2018; Hötzel et al., 2014). Based on the findings of this review, the app content was adapted to include health behaviour change goals relevant to an ED recovery context (e.g., reduction of the frequency of restrictive eating, binge eating 11 behaviours, and purging behaviours, ambivalence regarding recovery, identification of goals and values relevant to recovery; Clausen et al., 2013). The overall structure and MI principles used in the original mobile app were retained given their demonstrated effectiveness within an ED context (Denison-Day et al., 2018). All video lessons were then re-filmed using the University of British Columbia Okanagan’s studio and equipment. The new videos featured project supervisor and clinical psychologist (Maya Libben, Ph.D., R.Psych) to reduce discrepancies between the original and adapted app content (e.g., clinical expertise, years of training). Once adaptation of mobile app content was complete, a new section was built into the interface of the existing MI-Coach© app by technological partners (Resiliens Inc.) to house the adapted content. Several components of the base app (i.e., assessments, audio tracks, analytics, discussion groups, and communication with the mental health professional) were removed to reduce the scope of the project and to protect participant confidentiality. The final adapted MI-Coach: ED mobile app consisted of seven modules targeting motivation to engage in ED recovery behaviours (e.g., help-seeking, values exploration, self-acceptance) covering the following topics sequentially: ambivalence and behaviour change, self-acceptance, and compassionate motivation, exploring possible behaviour change goals, sustain and change talk, commitment language, and relapse prevention (see Appendix A for additional details). 12 Chapter 3: Pilot Test and Evaluation (Phase II) Rationale Phase II of the current study was the active pilot testing phase and followed a pre-post design. Participant feedback was gathered and analyzed using qualitative and descriptive statistics to determine the acceptability and feasibility of the MI-Coach: ED mobile app. Hypotheses The evaluation of MI-Coach: ED mobile app’s acceptability and feasibility was guided by the Technology Acceptance Model (i.e., that an ICT’s acceptability is determined by its perceived ease of use and usefulness; Davis, 1989). Given the primary focus of the mobile app is on enhancing motivation, we hypothesized that participants’ motivation rather than eating behaviour would be impacted by app use. As such, the current study examined the following four primary hypotheses using a mixed-methods study design: 1. The MI-Coach: ED mobile app would demonstrate feasibility as reported through attrition rates (i.e., the proportion of participants that dropped out of the study following enrolment), frequency of mobile app use, retention through the active trial period, and module completion. 2. The MI-Coach: ED mobile app would be rated as acceptable as reported through participant feedback. 3. Greater perceived usefulness and ease of use of MI-Coach: ED would lead to greater use and engagement with the app. 4. The MI-Coach: ED mobile app would be associated with a clinically significant increase in motivation to engage in ED treatment following four-week use of the app. Considering the novelty of the app, a priori rates of app use could not be generated. As such, feasibility and acceptability were determined by evaluating both quantitative and qualitative pilot test data. 13 Additionally, given the mobile app does not directly target core ED psychopathology, the following research question was explored to capture changes in clinical variables associated with eating pathology: 1. What changes were observed in participants’ clinical characteristics (i.e., ED symptomatology, body dissatisfaction, depression, anxiety) across the four-week span? Research Questions A secondary aim of the current study was to explore participants’ perceptions of the MI-Coach: ED mobile app. Using a mixed-methods study design, the following research questions were explored: 1. In what ways did the MI-Coach: ED mobile app differ from participants’ expectations prior to the start of the study? 2. How acceptable did participants find the MI-Coach: ED mobile app in terms of content, parameters (e.g., length of videos, number of sessions), and user interface? 3. What changes would participants like to see in future iterations of the MI-Coach: ED mobile app? 4. What barriers and facilitators did participants encounter when using the MI-Coach: ED mobile app? Materials Several self-report questionnaires were used during the pilot test portion of the study. The Sick, Control, One, Fat, and Food questionnaire (SCOFF; Morgan et al., 1999) was used to evaluate the presence of ED symptoms to establish eligibility. Additionally, the Eating Disorder Examination Questionnaire (EDE-Q; Fairburn & Beglin, 1994), the Readiness and Motivation for Change Questionnaire (RMQ; Geller et al., 2013), the Body Shape Questionnaire (BSQ; P. J. Cooper et al., 1987), the Patient Health Questionnaire (PHQ-9; Kroenke et al., 2001) and the General Anxiety Disorder 7-Item (GAD-7; Spitzer et al., 2006) were used to evaluate sample clinical characteristics (i.e., eating pathology, recovery motivation, body dissatisfaction, 14 depression and anxiety symptoms). Technological literacy was evaluated using the Mobile Device Proficiency Questionnaire (MDPQ; Roque & Boot, 2018) and the eHealth Literacy Scale (eHEALS; Norman & Skinner, 2006). Acceptability of the MI-Coach: ED mobile app was assessed using an adapted version of the Technology Acceptance Model (TAM) Questionnaire (Davis, 1989) and the User Version of the Mobile App Rating Scale (uMARS; Stoyanov et al., 2016). A demographics questionnaire was used to characterize the study sample. See Appendix C for questionnaires. Demographic Questionnaire Participants completed a demographic questionnaire querying their gender identity, age, level of education, ethnicity, and socioeconomic status. In addition, medical information pertaining to their weight and height, history of ED treatment, age of ED onset, presence of cognitive difficulties, sensory deficits, history of traumatic brain injury, and other mental health diagnoses were collected. Finally, all participants were asked questions pertaining to their experiences waiting for ED services (i.e., duration of wait, nature of the service, number of services on which they are waitlisted). Sick, Control, One, Fat, and Food (SCOFF) Questionnaire The SCOFF questionnaire (Morgan et al., 1999) was developed as a brief assessment tool to screen for the presence of EDs. Designed to assist non-psychologist professionals detect a possible ED, the screener consists of five dichotomous questions (i.e., “do you make yourself sick because you feel uncomfortably full?”, “do you worry you have lost control over how much you eat?”, “have you recently lost more than one stone (i.e., around 15 pounds) in a 3 month period?”, “do you believe yourself to be fat when others say you are too thin?”, “would you say that food dominates your life?”). Each item endorsed is given one point, with a score of two or more indicating the likely presence of an ED. The SCOFF questionnaire has strong psychometric properties and has been validated for use with women experiencing threshold or subthreshold ED symptoms (Kutz et al., 2020). 15 Eating Disorder Examination Questionnaire (EDE-Q) The EDE-Q is a 28-item questionnaire that assesses the presence of ED symptoms in the last 28 days (Fairburn & Beglin, 1994). The instrument is composed of the following four subscales: Restraint, Eating Concern, Shape Concern, and Weight Concern. In addition, the questionnaire assesses the presence of several behaviours, such as binge-eating, self-induced vomiting, and compulsive exercise. The EDE-Q generates frequency data on the number of episodes per ED behaviour, as well as a subscale score reflecting the severity of each subtype (Fairburn et al., 2014). The measure has acceptable psychometric properties and has been validated for the assessment of ED symptoms (Berg et al., 2012). Body Shape Questionnaire (BSQ) The BSQ is a 34-item questionnaire that evaluates the presence of body dissatisfaction (Cooper et al., 1987). The measure asks respondents to indicate their feelings about their appearance in the previous four weeks using a 6-point Likert scale (i.e., 1 indicating that the individual has never experienced the feeling in question, 6 indicating that the individual always experiences the feeling). The BSQ has acceptable psychometric properties and is a sensitive measure of body dissatisfaction (Cooper et al., 1987; Pook et al., 2008). Readiness and Motivation for Change Questionnaire (RMQ) The RMQ is a measure that assesses readiness to change in regard to ED symptoms and behaviours (Geller et al., 2013). The instrument provides a total and symptom-specific score (i.e., cognitive, bingeing, compensatory strategies, and restriction) in four categories (i.e., precontemplation, action, internality, and confidence). Precontemplation and action stages represent separate stages of motivation, whereas internality and confidence assess whether the change is due to intrinsic factors and their confidence in their ability to change. In addition, the RMQ uses diagnostic items from the EQE-Q, and respondents are asked to skip ED symptoms that are not applicable. Scoring on the RMQ ranges from 0 to 100. High scores on internality indicate intrinsic vs. extrinsic reasons for change, whereas high scores on confidence indicate 16 the individual’s confidence in their ability to change. In addition, higher scores on precontemplation and low scores on action indicate that the respondent has a low motivation to change. The RMQ has acceptable reliability and validity, and has been found to be the most appropriate measure for symptom-specific motivation to change in ED populations (Geller et al., 2013; Hoetzel et al., 2013). General Anxiety Disorder, 7-Item (GAD-7) The GAD-7 is a seven-item brief questionnaire that assesses for symptoms of anxiety (Spitzer et al., 2006). The instrument asks respondents to rate the presence of anxiety symptoms over the previous 2 weeks using a 4-point Likert scale (i.e., 0 indicating the absence of the symptom, 3 indicating the presence of the symptom nearly every day). A total score is obtained by adding the score for each question, with scores of 5 to 9 indicating mild anxiety, 10 to 14 indicating moderate anxiety, and scores greater than 15 indicating severe anxiety. The GAD-7 has been validated for use in several clinical and research contexts, and has strong psychometric properties (Plummer et al., 2016). Patient Health Questionnaire, 9-Item (PHQ-9) The PHQ-9 is a nine-item questionnaire that assesses symptoms of major depressive disorder (Kroenke et al., 2001). Respondents indicate the presence of depressive symptoms in the previous two-weeks using a 4-point Likert scale (i.e., 0 indicating the absence of the symptom, 3 indicating the presence of the symptom nearly every day). Total scores are summed from all items, with scores of 5 to 9 indicating mild depression, 10 to 14 indicating moderate depression, 15 to 19 indicating moderately severe depression, and 20 to 27 indicating severe depression. The PHQ-9 is a well-validated measure of depression and has strong psychometric properties (Carroll et al., 2020). Technology Acceptance Model Questionnaire (TAM) The original 28-item TAM questionnaire developed by Davis (1989) was adapted to evaluate MI-Coach: ED. The original instrument is composed of two subscales: Perceived 17 Usefulness, and Perceived Ease of Use. Each item was modified to fit the research question and sample characteristics of the present study (e.g., “Using CHART-MASTER in my job would enable me to accomplish tasks more quickly” was modified to “Using MI-Coach: ED allowed me to access mental health services more quickly”). Several studies have deemed adaptations of the measure to have acceptable psychometric properties and to be a valid measure of the acceptability of ICTs in healthcare contexts (Holden & Karsh, 2010). User Version of the Mobile App Rating Scale (uMARS) The uMARS is a 20-item measure that assesses end-users’ perspectives on the quality of mobile apps (Stoyanov et al., 2016). It consists of four objective (i.e., engagement, functionality, aesthetics, information quality) and one subjective quality subscale. All items are rated on a five-point scale, ranging from inadequate to excellent. Higher scores indicate increased acceptability of the mobile app under review. In addition, the instrument includes an open-ended question to regarding users’ experiences with the app. The uMARS has strong psychometric properties and has been validated for use with mobile-app end-users (Stoyanov et al., 2016). eHealth Literacy Scale (eHEALS) The eHEALS is an 11-item questionnaire that evaluates respondents’ opinions and experiences on using the internet to seek health-related information (Norman & Skinner, 2006). The instrument asks participants to rate their internet-use behaviours on a five-point Likert scale (i.e., ranging from Strongly Agree to Strongly disagree) and has acceptable psychometric properties (Norman & Skinner, 2006). Mobile Device Proficiency Questionnaire (MDPQ) The MDPQ is an eight-part questionnaire evaluating participants’ proficiency in using mobile apps for a variety of purposes (i.e., basic functions, communication, data and file storage, internet-browsing, calendar features, entertainment, privacy, and general troubleshooting; Roque & Boot, 2018). Though originally designed for geriatric populations, the 18 MDPQ has been used in a variety of young and middle adult populations (e.g., Zimmer et al., 2018). Semi-Structured Interview A semi-structured interview was conducted with participants to assess their experiences with the app and to further evaluate the feasibility and acceptability of MI-Coach ED. An interview guide was developed based on previous literature (Hoskins et al., 2019; Muir et al., 2017) and through discussions with the research team. The guide was used to assess the following aspects of user experience: (1) overall experience with the app; (2) perceived impact on ED symptoms and motivation to change; (3) aspects that they liked or disliked; (4) barriers or features that impacted their ability to use the app; (5) suggestions for improvement; (6) likelihood that they will continue to use the app or recommend it to a friend. Zoom Zoom (https://zoom.us/), a secure video-conferencing platform, was used to conduct all onboarding sessions and exit interviews. A UBC-licensed version of the platform was employed. All exit interviews were recorded and transcribed verbatim by trained research assistants, after which they were deleted permanently. Participants A total of 22 female adults with EDs were recruited from waitlists for a variety of treatment settings in British Columbia (BC), Canada. ED treatment providers and clinicians located in BC were contacted by email and asked to distribute study recruitment flyers providing an overview of the study, incentives, and instructions to contact the study team to indicate their interest to clients on their waitlists (see Appendix B). Flyers were also distributed online (e.g., the National Eating Disorder Information Centre website, social media). Eligibility criteria included: (1) being on a waitlist to receive services for an ED-specific concern and not for a separate mental disorder in BC (2) at least 18 years of age; (3) self-identifying as a woman; (4) fluency in written and spoken English; (5) meeting the criteria for a diagnosis of a threshold or 19 subthreshold ED (i.e., BN, AN-R, AN-BP, BED, OSFED); (6) absence of psychosis or diagnosis of a schizophrenia-spectrum disorder; and (7) absence of cognitive impairments or sensory deficits that may interfere with technology use (e.g., hearing impairments, recent traumatic brain injury). Procedure Ethics approval was obtained from the University of British Columbia Okanagan prior to the start of the current study (H22-02046). Participants were recruited between November 2022 and April 2023. Clinicians and administrators working in a range of ED treatment settings (e.g., provincial health authorities, non-profit charities, private practice clinics) were contacted via email and asked to share the recruitment advertisement (see Appendix B) with clients on their waitlists. Interested participants were asked to communicate with the study team via email to enroll in the study and to provide a phone number at which they could be reached. Once initial contact was established, a 15-minute telephone screener was conducted by the author to assess participants’ eligibility for the study and to provide additional details regarding the study. The SCOFF questionnaire was used to evaluate the presence of ED symptoms. Once eligibility was established, consent and baseline measures were collected through Qualtrics, including a demographics questionnaire, the EDE-Q, the RMQ, the PHQ-9, the GAD-7, and the BSQ. Consent forms are provided in Appendices D and E. Following this, an onboarding session was conducted through a secure videoconferencing platform (i.e., Zoom). Participants were provided an opportunity to ask questions regarding the study and consent measures, provided a demonstration on how to download and use MI-Coach: ED using the video-conferencing platform’s screen-share feature, and provided log-in access to the mobile app. The subsequent pilot-test portion of the study consisted of a four-week period during which participants were invited to use the mobile app in a naturalistic way. To reduce the impact of possible confounds (e.g., financial motivation), participants were informed that their 20 compensation would not be impacted by their app use during the pilot test phase and that there was no minimum requirement for app use. Once the pilot test was complete, a second brief consent form (see Appendix E) and post-test questionnaires assessing self-reported clinical features (i.e., the EDE-Q, RMQ, PHQ-9, GAD-7, BSQ) and feedback regarding the mobile app (i.e., the adapted TAM-Q, uMARS) were completed through Qualtrics. Finally, participants were invited to participate in a videoconferencing-based exit interview to provide additional feedback on their experience with the study author. The semi-structured interview guide was used as an outline to standardize the interview process across participants (Kallio et al., 2016). All interviews were recorded and transcribed verbatim by the research team and verified for accuracy by the author. Following study completion, participants were provided with a debriefing form regarding the project and a guide to accessible and low-barrier ED resources in B.C. Participants were compensated $10 CAD for each study portion completed (i.e., baseline questionnaire package, onboarding session, post-test questionnaire package, exit interview), receiving up to $40 CAD through the online Tango Card rewards platform (https://www.tangocard.com). Mobile app use during the trial period was not compensated and did not affect the final dollar amount received. Analytic Approach A mixed methods approach combining quantitative and qualitative statistical methods was used to evaluate the MI-Coach: ED mobile-app. Quantitative Methodology All quantitative analyses were conducted using the R statistical package, version 4.2.0. Descriptive analyses of post-test feedback questionnaires, attrition data, and sessions completed were used to determine the feasibility and acceptability of the MI-Coach: ED mobile app. Means, standard deviations, ranges, and percentages were calculated for all descriptive variables (i.e., age, ethnicity, BMI, height and weight). In addition, total and mean scores were calculated for app acceptability measures. Pre-post treatment effect sizes were calculated using 21 simple difference scores from the RMQ, EDE-Q, BSQ, GAD-7, and PHQ-9. An average-based change approach was employed using Cohen’s d effect sizes, in which a pre-post difference score from each measure was calculated and divided by the standard deviation of the difference (Cohen, 2013; Estrada et al., 2019). Effect sizes were then corrected using Hedge’s g to reduce the likelihood of generating biased estimates (Cohen, 2013). Additionally, Pearson bivariate correlations were conducted to evaluate relationships between variables at pre-test, post-test, and between change scores. Finally, overall app use (i.e., number of modules completed, days that the app was used, assessments and exercises completed, and logins) were calculated using in-app data provided by Resiliens Inc. Given the small sample size and limited power of the present study, parametric methods of testing statistical significance were not appropriate. As such, tests of clinical significance (Jacobson & Truax, 1992) and permutation-based randomization tests (Edgington & Onghena, 2007) were used to evaluate changes in clinical presentation across time points. The Jacobson-Truax method was used to calculate the clinical significance of individual change for all clinical variables (Jacobson & Truax, 1992). Firstly, a reliable change index (RCI) was calculated by dividing differences in RMQ scores from pre- to post-test by the standard error of the differences to produce the RCI. An RCI score greater than 1.96 indicates that the change is statistically unlikely to be due to chance. Following this, normative scoring was used to determine if participants’ functioning fell within the non-clinical range at post-test (Fairburn & Beglin, 1994). The following categorizations were used to identify whether change is clinically significant: reliably improved, in which there is reliable change and the clinical cut-off is no longer met; reliably deteriorated, in which there is a reliable change in the disordered direction and the individual’s score falls within the clinical range; and unchanged, in which neither criteria of the Jacobson-Truax method are met (Jacobson & Truax, 1992; Lambert & Bailey, 2012). Permutation-based randomization tests do not rely on traditional normal distributions used in parametric tests (Edgington & Onghena, 2007; Kratochwill & Levin, 2014). Rather, they 22 generate their own statistical distributions using random permutations generated within the data for null hypothesis testing. A test statistic is first computed using the experimental data, following which the dataset is permuted and then re-analyzed repeatedly. The resulting distribution of test statistics is then used to evaluate the proportion of permutations that fall above or below the obtained experimental results, thus determining the p-value (Edgington & Onghena, 2007). Given their reliance on non-parametric methods, randomization tests have been used widely to evaluate data with small sample sizes and for single-case designs (Edgington & Onghena, 2007; Kratochwill & Levin, 2014; Zhang & Zhao, 2023). The present study thus used randomization tests to determine the statistical significance of pre-post changes in primary outcome variables (i.e., RMQ total and subscale scores) following app use. Qualitative Methodology Qualitative analyses were conducted using the NVivo software package, version 12, to assess in-depth feedback regarding MI-Coach: ED’s feasibility and acceptability. Prior to analysis, interview audio recordings were transcribed verbatim by two trained research assistants and reviewed by the author. A thematic content analysis was subsequently conducted to analyze the qualitative responses from the open-ended uMARS questionnaire and semi-structured interview data. Braun and Clarke’s (2006) framework was used, which involved the following six steps: (1) all interviews were transcribed and reviewed; (2) initial codes were generated; (3) broad themes in the data were identified; (4) themes were reviewed; (5) themes were defined; (6) findings from the qualitative analysis were reported. A bottom-up theoretical approach was used, in which the analysis was driven by the data generated through the semi-structured interviews (Braun & Clarke, 2006; Maguire & Delahunt, 2017). 23 Chapter 4: Results Study Recruitment A total of 131 ED treatment centres were identified, though only a subset (68%) provided information through which they could be contacted. Of the clinical sites that could be reached, response rates were low, with a small subset of sites (6%) agreeing to disseminate information regarding the study to their clients. Sites that agreed to share study materials included: public treatment centres (38%), advocacy organizations (38%), individual clinicians (12%), and private treatment centres (12%). Study materials were also posted on online websites (i.e., the National Eating Disorder Information Centre, Twitter pages), and added to existing flyers distributed by the Women’s Health Research Institute and the Looking Glass Foundation. Additional information pertaining to study recruitment is reported in Table 1. Sample Characteristics Overall, 22 female-identifying adult women with self-identified EDs were recruited for the present study. One participant was ineligible to participate as she was not actively seeking ED treatment, and five chose not to enrol following the initial phone screen despite meeting eligibility criteria. Four participants dropped out during the pilot test phase, and one participant did not complete the Time 2 questionnaire and was removed from the analyses, resulting in an attrition rate of 31% (see Figure 2 for additional details). The final study sample included 11 Caucasian participants ranging from 23 to 39 years old (M = 33.4, SD = 7.7). ED pathology endorsed included: restriction (100%), cognitive symptoms such as over-evaluation of shape and weight (100%), compensatory strategies (100%), and binge-eating (58.3%). Mean age of disorder onset was in adolescence (M = 16.8, SD = 8.4) with an average disorder duration of 16.5 years (SD = 7.3), and most had previously sought treatment. All participants were currently waiting for ED treatment, with waitlist duration ranging from 4 to 104 weeks (M = 24.5, SD = 29.9). Self-reported proficiency (M = 39.2, SD = 1.2) and comfort (M = 3.5, SD = 0.5) with mobile technology was high. Additional sample characteristics are reported in Table 2. 24 App use was high, with most (71%) of the sample completing at least five of the seven available sessions (M = 3.9, SD = 2.39). Completion of the exercises varied (M = 11.18, SD = 9.30), with one participant completing 34 exercises throughout the pilot test period. One participant did not complete any of the sessions or exercises but completed both the Time 2 measures and the semi-structured interview. Characteristics of app use are reported in Table 3. Perspectives on App Use Feasibility Acceptability Likert-style responses (1 = minimal agreement to 5 = very high level of agreement) on the uMARS indicated that participants found MI-Coach: ED to be engaging and interesting to use (M = 3.60, SD = 0.68), appropriately functional (M = 4.10, SD = 0.60), aesthetically pleasing (M = 4.30, SD = 0.57), and contained a reasonable amount of high-quality information (M = 4.60, SD = 0.42). Regarding subjective app quality, participants indicated that they would recommend the app to at least a few people that may benefit from its use, with a portion of those respondents (36%) indicating that they would recommend the mobile app to everyone. All participants estimated they would use the app anywhere between 10-50 times over a 12-month span, and most (n = 8) indicated that they would pay to use the mobile app. MI-Coach: ED’s overall app quality was rated highly (M = 4.2, SD = 0.46), and all participants (n = 10) who provided an overall star rating (one star = “one of the worst apps [they’ve] ever used,” to five stars = “one of the best apps [they’ve] ever used”) gave the app either a four (44%) or five (56%) star review. Qualitative responses from participants regarding the app’s quality are presented in Table 4. Ease of Use and Perceived Usefulness Participant perceptions of MI-Coach: ED’s ease of use was high, with endorsement on statements pertaining to the app’s clarity, flexibility, and ease with which proficiency at using the app could be developed ranging from 77-85%. Perceptions of MI-Coach: ED’s usefulness was 25 varied, with the endorsement of statements regarding the app’s ability to modify ED pathology, motivation, attitudes regarding recovery, and treatment access ranging from 61-79%. Additional information regarding perceptions of MI-Coach: ED’s perceived ease of use and usefulness are presented in Figure 3. Clinical Outcomes Associated with App Use A Shapiro-Wilk test conducted prior to data analysis indicated that assumptions of normality were not met for a portion of the clinical outcome variables. Considering the small sample size and non-normality of several clinical outcome variables, non-parametric paired-samples t tests were conducted using a randomized permutation-based distribution to examine whether clinical outcome variables varied significantly between Time 1 and Time 2. To create the randomized distribution, the data set was first permuted into 10,000 combinations. Paired-sample t tests were then conducted on each permuted data set, generating a probability distribution to which t scores from the current analyses were compared. An α criterion of .05 was used to determine whether outcome variables differed significantly between time points. Hedge’s g was used to correct Cohen’s d effect sizes to reduce the likelihood of generating biased estimates of population effect sizes (Cohen, 2013). Changes in Motivation Correlations between Time 1 and Time 2 motivation variables indicated that internal motivation scores at pre-test were strongly positively correlated with precontemplation, confidence, and action scores across both global and domain-specific areas of ED pathology at post-test. In contrast, precontemplation scores in the bingeing and restriction symptom domains at Time 1 were negatively correlated with confidence scores in bingeing, cognitive, and compensatory symptom domains at Time 2. Change score correlations indicated that change scores in global and domain-specific areas of confidence were negatively associated with internality and precontemplation change scores in motivation. All other change variables were 26 positively correlated in the expected direction. Change score correlations are presented in Figure 4. Given that the RMQ assesses facets of motivation across a range of ED symptom domains (i.e., restriction, cognitive, bingeing, and compensatory strategies), respondents are encouraged to skip items that are not applicable to their current presentation. As such, the total n of respondents varies across RMQ total and symptom domain scores. All randomization-based significance scores and Hedge’s g effect sizes are reported in Table 5, along with means and standard deviations of RMQ scores. Small effect sizes were seen in changes to overall motivation, with the magnitude of change for action (g = -0. 228) and internal change scores (g = -0.148) indicating that participants felt slightly less prepared and were less internally motivated to change their eating behaviour. Statistically significant changes were not observed across most total and symptom domains, apart from the compensatory strategies domain. Motivation to address compensatory strategies. Randomization-based t tests revealed a statistically significant increase (p = .032, g = 1.005) in precontemplation change scores between Time 1 (M = 38.9, SD = 21.1) and Time 2 (M = 65.0, SD = 28.1), indicating that participants experienced a very large magnitude of increase in their desire to address compensatory strategies following the four-week period. No other statistically significant changes were observed within this symptom domain, and effect sizes fell within the minimal range. Motivation to address binge-eating behaviours. A medium effect size was observed for precontemplation change scores (g = 0.663) in the bingeing domain, indicating that participants experienced a moderate desire to address binge-eating behaviours across the study period. Small to medium effect sizes in the negative direction for both action (g = -0.236) and internal change scores (g = -0.397) indicated that participants felt moderately less prepared to address binge-eating behaviour and felt less internally (vs. externally) motivated. 27 Motivation to address cognitive symptoms. Small to medium effect sizes were observed for precontemplation (g = 0.270) and Internal change scores (g = -0.266) in the cognitive domain, indicating that participants experienced a moderate increase in their desire to address cognitive ED symptoms (i.e., fear of gaining weight, feelings of fatness, the importance of shape and weight) and were slightly less internally-motivated to engage in recovery. However, a medium effect was seen in confidence change scores (g = 0.321), indicating that participants experienced a moderately large increase in their confidence regarding their ability to reduce cognitive ED symptoms. Motivation to address restrictive eating behaviours. A medium effect size was seen in precontemplation scores (g = 0.321), indicating that participants experienced a moderately large increase in their desire to address restrictive eating following the study period. Small effect sizes were seen in precontemplation (g = 0.270) and internal scores (g = -0.266), indicating that participants experienced a small decrease in their intrinsic motivation to address cognitive symptoms and a small increase in their readiness for change. All other correlations fell within the minimal range. Changes in Associated Clinical Characteristics All clinical outcome variables at both Time 1 and Time 2 were correlated in the expected direction and are reported in Tables 7 and 8. Depression and anxiety change scores were negatively correlated with confidence scores, with decreases in depressive and anxiety symptomatology associated with increases in confidence scores. Correlations between clinical change scores in other domains (i.e., eating pathology, body dissatisfaction, depression, and anxiety) were in the expected direction and reported in Figure 4. Pre-post analyses of Time 1 and Time 2 variables using a randomization-based paired-samples t test did not find significant changes in clinical presentation across all secondary clinical outcome variables (i.e., eating pathology, body dissatisfaction, depression, anxiety). However, small to moderate effect sizes were observed for eating (g = -0.320) concern change 28 scores, indicating that participants experienced a moderate decline in symptoms such as preoccupation with food, fear of losing control over eating, and feelings of guilt surrounding food. Small effect sizes were seen for shape (g = -0.179) and weight concern change scores (g = -0.195), indicating that participants experienced a small decline in their preoccupation, dissatisfaction, and discomfort surrounding their shape and weight. Small to moderate effect sizes were found for depression (g = -0.491) and anxiety change scores (g = -0. 233), indicating that participants experienced a moderate decline in depressive and anxiety symptoms following the study period. Means, standard deviations, significance values, and effect sizes for Time 1 and Time 2 clinical outcome variables are reported in Table 6. Clinical Significance of Change Reliable change scores were calculated to assess the direction and magnitude of observed changes in motivation and associated characteristics (Jacobson & Truax, 1992). Criterion values were obtained from normative psychometric data (Criterion C) or generated from participant data when normative data was not available for a given measure (Criterion A; Jacobson & Truax, 1992). The frequency of clinically significant change is reported for each outcome variable in Table 9. Analyses revealed significant heterogeneity in participant outcomes at Time 2, with clinically significant improvements, deteriorations, and non-significant changes observed across the majority of motivation-based outcome variables. A subset of the study sample reported improvements in motivation at post-test. Clinical significance was most commonly observed in confidence scores, with a portion of respondents (9-27%) reporting improvements to self-confidence regarding their capacity for ED recovery across a range of symptom domains at post-test. In terms of symptom-specific motivation, the largest clinically significant improvements were observed in precontemplation motivation to address compensatory strategies (36%). In contrast, clinically significant deteriorations were most frequently observed in bingeing (21%) 29 and cognitive (12.5%) symptom domains of motivation, with declines observed in action, internal, and confidence change scores at post-test. Clinically significant improvements were observed in a subset of individuals across most secondary outcome measures (ranging from 8-25% of the study sample). Improvements in shape concerns, body dissatisfaction, depression, and anxiety symptoms were most consistently reported at post-test. However, deteriorations were also reported across all associated clinical variables (18-33%), indicating a split in participant outcomes at post-test. Given the variety of outcomes reported by participants, individual clinical significance for each participant is reported in Figure 5. Qualitative Findings Qualitative Coding Process The theoretical underpinning of the following qualitative analysis was based in a constructionist and experiential approach, in which meaning is generated from the data in an interactive and reflexive process (Braun & Clarke, 2006; Maguire & Delahunt, 2017). Eight semi-structured interviews were completed ranging from 27 to 48 minutes (M = 36.4, SD = 7.1) in duration. All qualitative interviews were audio and video recorded and transcribed verbatim by an undergraduate research assistant and subsequently verified for accuracy by a separate research assistant. Transcripts were subsequently reviewed and coded by the author and an undergraduate research assistant familiar with the project. Rather than establishing an inter-rater reliability coefficient, both coders met regularly to discuss and review codes and themes that were generated in order to ensure mutual understanding of the data (Braun & Clarke, 2006). This method allowed for fidelity to the constructive assumptions underlying the analysis. Descriptions of Themes and Subthemes Four themes were generated from the qualitative interview data regarding participants’ experiences using MI-Coach: ED: (1) experiences navigating the healthcare system; (2) acceptability of app design; (3) impact of app use; and (4) suggested modifications to improve 30 the usefulness of the app. Theme 1 (experiences navigating the healthcare system) included sub-themes concerning difficulties accessing appropriate ED treatment and previous experiences using mental health apps. Theme 2 (acceptability of app design) included sub-themes of pertaining to the flexibility of app design, and views regarding app aesthetics and design. Theme 3 (impact of app use) included subthemes regarding experiences gaining new insights into ED pathology, feeling empowered despite experiencing long wait times for treatment, and perceptions of the app as an addition to the recovery toolbox. Theme 4 (suggested modifications to improve the app) included subthemes regarding suggestions to add psychoeducational content covering additional relevant topics, addressing factors currently interfering with app use, adding features to personalize the app, and creating opportunities for virtual connection with other app users. Theme 1: Experiences Navigating the Healthcare System. All participants disclosed chronic and enduring ED histories necessitating multiple in-person and virtual interactions with the healthcare system. However, subthemes were generated regarding the aversive nature of these experiences. Difficulties Accessing Appropriate ED Treatment. A subtheme concerning significant challenges accessing treatment was generated from the data, with many participants noting a lack of service access, particularly in remote and rural locations. One participant (P8) described that she had “done lots of um sort of looking for, you know, what’s available, and there’s not much.” P5: In [my city], at least, there’s only one walk-in clinic. And when you go to that walk-in clinic, you have to get there a couple hours before it opens and people line up. So, I usually get there at like, 6am. And it opens at eight. And then you line up, and oh, I feel so bad for people that have little kids. But yeah, you wait, and then you get a, a number. It’s usually about a five hour wait, or they’ll just say no, we’re done. We’re full...it’s tough to access healthcare in general in [my city]. Long wait times were reported, with one participant (P1) noting that she was waiting for treatment for “over two years,” with others disclosing similar wait periods. 31 P2: right now, I’m in [rural city], and I’ve been on this waitlist for over a year…they don’t have like a psychologist or psychiatrist or something for the program, and so it’s um unknown how long it will be. Further, participants described a lack of transparency and clarity in accessing services, resulting in administrative redundancies and subsequent delays in receiving treatment. P9: I get somebody saying, oh, you should go to the walk-in clinic. And then the walk in clinic will say that they need a referral from a [general practitioner] to be able to get access to the psychiatrists…so then I call the [general practitioner] and they’re like, you don’t need a referral for the psychiatrist. There’s just like, a weird cycle of not actually receiving the correct information, or not being able to speak to the right people to be able to get help unless, like, you’re critical and your [body mass index] is so messed up, or so severe that you need to be, like, hospitalized or something. I find it quite difficult to get any kind of A) straight answer and B) help. When participants were successfully able to access treatments, they felt that services were ill-suited to their needs, and at times led to harmful outcomes. P1: I deal with a lot of feelings of frustration with the system. I’m not sick enough for this, but I’m too sick to receive this help. So what do I do in the meantime? To be honest, I’m not keen to go back to inpatient treatment. My treatment team is like, we think that’s where you need to be right now. And this time, I would really prefer to be given a shot to deal with this in my own home. It’s so hard for people to transition from their home into the hospital. P7: I actually had a doctor gaslight me when I was trying to see a psychologist, because a lot of people with this type of bulimia don’t go up and down very much. Clearly, I’m losing more weight now, which messes with your mind, too. He looked at me and he’s like, are you sure you have an eating disorder? That sent me – well, it sent me back hardcore. Previous Experiences Using Mental Health Apps. An additional subtheme pertained to previous experiences using mental health apps. Participants reported some use of apps addressing other mental health concerns but noted that they did not often use them for prolonged periods of time. P2: It’s pretty common for me to like something for a little bit, and then I’ll just get saturated with it and feel like, “no I don’t want to listen to this person anymore.” Like, I would actually get pretty annoyed at the ‘chatbot-ness’ of it. 32 When participants did use mental health apps specifically targeting disordered eating, many reported experiencing iatrogenic effects due to the app’s focus on tracking food and eating behaviours. P2: I did try [an app] in the past that was for eating disorders, um, but then it was a lot about logging food. I just felt like I couldn’t deal with it, I was like, I don’t like this. One participant (P1) described that “the only other eating disorder apps [she’s] seen are literally like tracking all your behaviors and foods, which can really be a double-edged sword for eating disorders.” Another participant (P5), who was seeking an app to increase calorie count. Noted that the apps she used were “all about decreasing calories. And [she] just didn’t know that that will be healthy for [her] long term. Right. Like, [she doesn’t] want to get the motivational ads on the side for weight loss drugs.” Theme 2: Acceptability of App Design. The majority (n = 8) of participants shared their perspectives on the acceptability of app design, with many reporting that the flexibility, aesthetics, content, and design of the app was acceptable. However, a subset (n = 2) noted that the app did not meet their specific treatment needs and highlighted the challenges of meeting the heterogenous needs of app users. Flexibility of App Design. Several participants reported that the accessibility and portability of the app enabled them to use it flexibly and integrate it easily into their lives. P6: It wasn’t like I was setting aside planned time [to use the app] during my day. I was like, oh, “I will now use the app.” It was more of, like, if I had time, when I was sitting on the sky train, I would open it up and start flipping through. Or in the evenings, if I was just on my phone, I would pick it up and kind of check into the app then. Um yeah, so it wasn’t planned I guess, it was more like, when it occurred to me that I had time to use it. P6: I liked having it on my phone because when it did occur to me to be interested in going in and reading some content, or actively making notes, then it was right there. So there was no barrier to getting in. Further, the flexibility of the app permitted participants to access the content at times when they felt best equipped to engage with recovery-related topics. One participant (P7) shared that she 33 liked being able to use the app when she “felt like [she] was okay.” Participants also expressed positive views regarding the range of modalities through which the app content was presented, noting that it permitted greater flexibility of use depending on their preferences and lifestyle circumstances. P2: I liked the videos, they were good. I liked like the variety, being able to listen to it and then also being able to read it. I did like that I could have it on while I did other things. P1: I liked that there were different things in it. So like, some days, I’d be like, “you know what, I’m not in a private environment, I just want to read this” and then at other times I didn’t have the attention span to read. And I just would, like, listen to the video, or sometimes I would watch the video. But I liked having these options for engaging with the content. P5: And there’s pictures and everything, so you could go back to it. It kind of made me more present when I was doing them because I knew I didn’t have to memorize it in that one go. The brevity with which the content was presented was viewed positively, with participants noting that it increased the ease with which they felt they could use the app. One participant (P3) noted that she “liked how they were relatively bite size. Like it wasn’t like, okay, I need to do this for hours.” Aesthetics and Design. Overall, participants expressed positive views regarding the aesthetics and user interface of the app, highlighting that an aesthetically pleasing design felt important to their continued app use. One participant (P5) noted that she “knows that it shouldn’t matter. But it kinda does with apps. Like it was really nice to look at you know [the app’s] graphics, and colors.” P3: I actually like the bubble body contrast. I really liked it. And the colors were like, it helps with your vision, too. It was a very nice beige. And like, very cool colors. So, I liked it. Perspectives were mixed regarding the aesthetics of the videos. One participant felt that the video composition and tone was overly clinical, which interfered with their desire to use the app in their home environments. 34 P9: I mean, I actually want to use it, rather than thinking like, “oh, well I’m here in my bed or on my couch, and this person [in the video] is in what looks to be like, an office or something.” It’s like a degree of separation that makes you feel alienated to the content that you’re watching or trying to digest. Therefore, consciously or subconsciously, you’re not necessarily going to connect to it in a way. Others felt that the videos conveyed warmth and clinical expertise, contributing to a feeling of rapport and collaboration despite the asynchronous presentation of the content. One participant (P8) described that the tone with which the information was presented was helpful, noting that “it felt genuine when [the clinician] was speaking. And you could tell it was, yeah, like, she like, you felt like she cared.” P2: I liked the transparency of it. It’s like, “hey, we’re gonna figure out motivation, and people don’t like being told what to do.” I liked that the dynamic because it felt very, like, collaborative and equal. Usually, treatment spaces can be very much like, behaviorist or kinda, “that’s the eating disorder voice.” And it’s this very dismissive [tone]. P8: As I was starting to go through it, in many respects, I felt lucky that I was getting what felt like professional care, and not being charged for it too. Because I have to say, it was so well done, and I was thinking, “wow, I’m, I’m really happy that I’m having a chance to do this,” because it felt like it was better than other things I’ve tried and paid for. Several participants disclosed that they resonated with the app’s content, and that it matched their lived experiences of ED pathology. P8: I found it really helpful. It was one of the first things I’ve looked at online where I felt like it matched where I was at. Like, even though it has a large target audience, it felt like one of the first things that I sort of interacted with where I thought, “this is where I’m at.” In contrast, participants were mixed on whether they found the course-based format of the app helpful. Some found that the progressive nature of the app to be helpful to their learning. P8: And it’s nice to have it sort of structured in a way where you can see that it builds as you go along too, and like, “okay, now I understand when she’s talking about this, because that was in the first section.” And so the language and the terminology sort of keeps building too as you go through. Others disclosed that the structure led to feelings of perfectionism and overwhelm, leading to feelings of obligation to use the app and of resentment. 35 P6: Yeah, and if I got stuck on any stuck on any particular [video], then that’s where I stopped. Because I didn’t then feel like I could just skip it, although I totally could have. But, that’s something that happened in my brain. P9: I think there’s definitely a level of like, overwhelm, when it comes to starting something. And then speaking personally, there’s an element of failure when you aren’t able to complete it. It’s almost, kind of like, feeding into those negative emotions, because you’re like, “oh I can’t even finish watching some videos that are a couple of minutes long, like, I’m not able to achieve that, because I got overwhelmed or whatever.” So it’s kind of like, you know, you’re trying to get better, but then when you can’t finish a course, which is supposed to help give you tools to feel better. Then you feel even worse, because you’re like, “well, well I can’t even complete your course.” Additionally, two participants noted that the content and design of the app did not feel as though it matched their current needs or relationship to recovery. P6: Yeah, no, I don’t think for me it would have had any impact on staying on the waitlist. I mean, just trying to think if I was in a different state. Like if I was earlier in my recovery process, or whatever we’re calling it, then it might have been a different case. P9: And I do also recognize that having spoken with my counselor and naturopath, they’re both very much of the mindset that I already have the motivation and determination to want to change…it’s more just, kind of like, implementing it. Theme 3: Impact of App Use. Nearly all participants (n = 8) stated that their app use had a positive impact on their mental well-being, prompting new insights into their relationship to ED pathology and providing an internal locus of control regarding their recovery. Gaining New Insights into Eating Disorder Pathology. Several participants shared new insights that they gained following use of the app into the current state of their ED and related psychopathology. P1: I’ve have been having trouble acknowledging that I was in a relapse. Cause I was like, oh, you know, it’s only been a few weeks of this, like, I’m gonna snap out of it. Th is is fine. And I just really had a hard time coming to terms that it was a relapse. And so I think in my mind, I was like, “this is just a thing.” And then I think that section [of the app] was really good for me. Okay, well, actually, this has now been going on for months. And this severity, I’ve kind of jumped back into kind of the worst part of my eating disorder…I think [the app] just brought it to the forefront of my mind, which made me more aware of my eating disorder behaviors, and that they’re happening. 36 P7: Y’know it’s funny, because you think you’re the only one really having these thoughts or like, anything like that. And then seeing like, literally, in writing, the things I used to say to myself, or do to myself, it was just very like, “oh, huh. Yeah.” For several participants, it was disclosed that the app provided a helpful introduction to the role of motivation in recovery, and that it was helpful in managing their symptoms in other areas of their lives. P2: I think it was helpful, just on a very broad sense, to just have it spelled out, kind of like a model of motivation that does work. And then to contrast that with what I’ve experienced in the past and be like, “okay, it makes sense.” So that was helpful for like, self-compassion. P5: In the goal setting [exercise], one of the goals that I set for myself was to kind of broaden my horizons, like to try out more foods, because I’m really sensitive to textures and things, so, I found it made me more aware of like, “oh, I should chunk that into pieces.” Not just wake up and go, “okay, try more foods today.” Instead, “try this one specific food today,” right, one thing at a time, baby steps. Additionally, several participants emphasized that the app prompted self-reflection regarding their core values, and the ways by which they could leverage their values to maintain motivation to recover. P1: I think one of the best things this app did for me was, like, it really had me thinking about why I do the coping things that I do. Kinda where they’re getting me and like, what purpose they serve, but also how they like, don’t serve me. I don’t know, I did a lot of reflecting this month. P3: This app kind of made me realize, like, the things that work – not just my own motivations to change, like about the eating disorder and the reasons for it, but also the reasons for change. When I take the lens that the app takes, I found it very much like, informational., looking more objectively [at my eating disorder], I guess. I don’t know if it’s also just the timing in my life, like, “this is a good time for me to be doing this.” It kind of flipped a switch that’s never happened before. P8: What’s different now is really seeing my values, and realizing what’s been happening with the eating disorder has taken me away from so much of what I value. And that’s much more at the forefront of my motivation now, using that to try to make the changes that I know I need to make. 37 Feeling Empowered Despite Experiencing Long Wait Times for Treatment. A prominent subtheme that emerged pertained to feelings of empowerment that emerged from using the app and engaging with the content. P7: It just helped me to really look back on myself, and that’s what I really needed to like, keep moving forward. Especially because I was kind of like, “maybe I haven’t really progressed as much as I thought I have.” But then, [the app] was like, “oh, do you do this, this?” I was like, “oh, I did. But I don’t anymore.” So okay, I’ve come a little further. P3: I believe, like, this app has mentally prepared me a lot and how to work on [the eating disorder]. It has given me a lot of, can I say, wings, how to work on things and fly. So, I’m really prepared for the next steps of what to do. This app has made me a very strong person. Overall, it was, like, very empowering. Many participants described the act of using the app as beneficial, describing that it helped generate an internal locus of control regarding their recovery. One participant (P6) noted that using the app felt like “taking action” and mitigated feelings of powerlessness while waiting for treatment. P6: I think it’s empowering to be able to be the one that accesses [the app] on your own accord. Like sometimes in those moments, you can feel really stuck. Like there’s nothing I can do to shift this. And like, whether or not [the app] works, opening the app, it’s like, I have taken an action, like I’ve tried. I think the main thing that I had come into [the interview] wanting to communicate was that there was a sort of an empowered feeling about being able to access it anytime. P7: Just the beginning [session], I think because it just hit me really hard, like, it really opened my eyes to where I was…I think it’s important and needed. Especially, I can’t advocate enough for up here where there’s nothing. P8: Yeah, so um, I’ve been really struggling for quite a few years, especially these last few months. And um, feeling like there’s not a lot for me, right now. There’s waitlists, and it’s also, I’ve been feeling very stuck, so it was encouraging to feel like there was something that I could be doing to feel like I’m working towards some steps for recovery. Adding a Tool to the Recovery Toolbox. Broadly, participants described the app as useful to other areas of their lives, with one participant (P6) noting that the app was now “another tool in the toolbox, toolbox, to be used with my other tools.” 38 P3: These are [topics] that I think are really going to work for me, and I would intend on bringing them into my future appointments. I found this app so interesting. And I’ve been applying it to so many other areas of my life, like, not related to my eating disorder. I can literally use this in so many different parts of my life. P5: You know, I didn’t realize the exercises were going to be so useful. I thought it was going to give you some mindfulness techniques on just like, self-acceptance stuff. I didn’t realize it was going to dive so far into setting goals and things, which is really good. P8: And that was sort of nice too, having [the app] to work on, instead of just trying to scroll through the internet, trying to find what I could use that could be helpful – because there’s too much, and too many things out there. And it was good to not I didn’t even need to try to look for anything, because I felt like I had something that made sense to me to try. Theme 4: Suggested Modifications to Improve the App. Most participants (n = 6) provided suggestions to improve the app’s ease of use and usefulness, citing technological and design-related factors that could be addressed to increase the app’s functionality. Addressing Factors Currently Interfering with App Use. Several participants highlighted small glitches with the overall app that could be addressed to improve the app’s usability. P1: I found the writing part of [the exercises] glitchy. Like when I was writing something, I couldn’t see what I was typing. And I also like, couldn’t see the question. So like, it was something that was glitchy about the screen. So it actually made the writing part, like, kind of cumbersome. One participant (P6) stated that having “a couple notifications might prompt me to re-engage” and use the app more consistently over time. Others noted that the synchrony between the video content and related exercises could be modified to make the app more intuitive to use. P2: In some videos, it would say like, “go do this exercise.” Um, but then, I wouldn’t want to stop and go to the exercise, since I’m like, I don’t want lose my place. P1: The one thing I found a bit challenging with the app was like, ’cause I’d sometimes just do a little bit a day, like I’d watch one video, and then I wouldn’t know which videos to watch [next], or like where I was at in that [previous video]. And some of them related directly to exercises, but then I wouldn’t be able to necessarily find them. So then, I’d end up doing the exercise way after [the videos]. 39 Additionally, introducing features such as captions and time estimates of video duration were suggested as possible ways by which the end user experience could be improved. One participant (P2) shared that “there could have been captions on the videos, I’m not always in the mood to listen to someone’s voice. P2: Sometimes, I wouldn’t know how long [the video] was going to take, it would be helpful to know beforehand. So you’re like, “okay, it’s seven minutes, I’m going to do the unload the dishwasher for seven minutes” or whatever. P5: [If you] could pause them in between, because most of the videos have like three or four sections in them…if they were like separated, and then you could go back just to the meditation, or go back just to them, because I found when I would replay it, it would start from the beginning. One participant (59783) indicated that the articles and videos could be edited to reduce redundancies in the app’s content, such as “repeated information…just making it as concise as possible.” Suggestions to Add Additional Psychoeducational Content. Several participants suggested the addition of psychoeducational content pertaining to other topics relevant to ED recovery, such as information pertaining to symptomatology and nutrition. P2: I guess that’s more where I was, like, hoping for [eating disorder] information, because those are pieces of information that, when you’re in a disorder, you don’t make those connections. So yeah, that part, I started to get, like, a bit overwhelmed. I think it can even be hard to differentiate between like, what is disordered or not, because everything is so muddled. P9: Maybe having some information on macros, and helping people understand that it is a brain gut connection, and focusing on working on the internal stuff as well as the brain…and just really, like teaching and educating people on how they can work internally to help battle some of their struggles. One participant (P7) suggested that aspirational content could be helpful to remind users that “the journey is long and you’re gonna have fallbacks.” Additionally, suggestions to integrate content regarding behavioural strategies to manage distress would be a helpful addition to the app’s content. 40 P9: Um I think like, helping change the energetic state that you’re in, because when you’re stressed, you’re so highly strung that you can’t really see any other way. Anything outside of your current situation. So maybe some tools to help remind you to take yourself out, or to like, change your energy, which will then in turn, help lower your cortisol, or whatever it is. Adding Features to Personalize the App. Modifying the app to allow for increased personalization was emphasized as an area of improvement to increase the app’s usefulness. P6: if you had an individual who you knew, like, primarily, the challenges were restriction, then you could have like, prompts that were related to that. Whereas if you knew an individual was primarily having issues with, like, impulsivity, then you would have examples that are more related to that. So you could like, slightly more individualize it. P3: Every session, there should be a questionnaire for yourself, so that you can see where you are….so if you’re investing your time, body, and brain and everything, there should be a something as a result we can see. Creating Opportunities for Virtual Connection with Other App Users. Many participants expressed interest in creating opportunities through the app to connect other individuals recovering from EDs, and to communicate directly with a live facilitator. P7: It’d be cool if like, it was a way to connect with other people too, like to have discussions about the topics to like, be able to reflect more. And yeah…I think that would be really powerful too, to help with support. Because I think you can be powerful in community. P9: You [could] have somebody to actually speak to rather than just watching videos. So that, like, the human element is dialed up in [the app]. And then they’re able to, since they still have all of the knowledge from the app, they can say, “oh, well, have you tried this? Have you tried that?” So when you’re in crisis mode, rather than going into an app to watch a video, you can dial in and be like, “oh, is anybody around that they can pair me up with right now? Because I really need to speak to somebody.” Summary of Findings The findings from the current study indicate that participants had an overall positive perception of the MI-Coach: ED app, though some heterogeneity was seen in the app’s appropriateness for a subset of participants. Four themes concerning participants’ experiences navigating the healthcare system, the perceived acceptability of the app’s design, impacts of 41 app use on participant functioning, and suggested modifications to improve the app were generated from the data. Experiences Navigating the Healthcare System Participants shared their previous experiences seeking in-person and virtual mental health services, with several subthemes generated from their responses. Nearly all participants disclosed substantial difficulties accessing appropriate ED services in a timely fashion. Treatment barriers were exacerbated in rural and remote regions, with many participants noting the complete absence of ED services where they resided. Additionally, participants faced long wait times sometimes spanning several years when seeking treatment, with little information or transparency on when they would enter treatment. When participants were able to access treatment, it was noted that healthcare professionals were often insensitive to their needs, at times resulting in iatrogenic and harmful effects. Most participants had some previous experience using mental health apps. However, limited engagement was reported with apps addressing broad mental health concerns. Though some use of apps specifically designed to address ED-related concerns was noted, it was highlighted that all available apps included a tracking component regarding eating behaviours that perpetuated disordered eating thoughts and behaviours. Acceptability of App Design Perspectives regarding the acceptability of the app design were largely positive, though some participants indicated that the structure and content of the app did not fit their specific treatment needs. Many participants shared that the mobile-app design of MI-Coach: ED permitted flexibility in the way with which they engaged with the app. The brevity of content and ability to use the app at times that felt most convenient for participants (e.g., while riding public transportation, when in a positive head space) were emphasized as a strength of the app-based design. 42 The aesthetics of the app’s interface was seen as positive for most participants and contributed to their continued engagement with the app. Some heterogeneity was noted regarding the video content. While many participants indicated that the content of the app resonated with their own lived experiences of ED pathology, others noted that the app’s content did not align with their current stage of recovery and covered topics with which they were already familiar. Though many participants indicated a positive response to the warmth and professionalism of the clinician featured in the app, one participant indicated that the clinical tone of the videos made it difficult to engage with the content when in their home environment. In addition, perspectives were mixed regarding the course-based format with which the app’s content was presented. Some participants indicated that the format aligned with their learning styles, while others described feelings of overwhelm and perfectionism when completing the sessions in sequential order. Impact of App Use Nearly all participants emphasized the clinical gains that they experienced while using the app. Many cited that the app prompted novel insights into their relationship to their eating pathology and into the importance of motivation when engaged in ED recovery. Notably, several participants indicated that they gained valuable insights into their values, and described the ways by which they were planning to leverage their intrinsic motivation to support their recovery efforts. Feelings of empowerment were highlighted by many as an important outcome of using the app. Participants emphasized the role that the app played in recognizing their strength and resilience and noted that their use of the app mitigated feelings of powerlessness while waiting for services. Additionally, the app’s applicability to other domains of functioning outside of ED pathology was described as a valuable way by which participants were impacted by MI-Coach: ED. 43 Suggested Modifications Several suggestions were provided by which the app’s usefulness could be improved. Addressing existing technological glitches was emphasized as a priority for future iterations of the app. The addition of other technological factors such as video captions and estimated durations of each video were highlighted as ways by which the app could be made accessible to a broader audience. Further, some participants noted some asynchrony between the videos and exercises that interfered with the ease of use of the app. Many participants suggested that additional features could be incorporated to broaden the scope of the app, such as psychoeducational content regarding other relevant topics (e.g., behavioural strategies, eating symptomatology, nutrition). The ability to personalize the app to meet unique treatment needs and to track progress was suggested to increase the app’s perceived usability. Additionally, several participants indicated that the ability to interact with other app users would be beneficial, as it would allow for the creation of community and peer connections to support recovery efforts. Overall, results from the qualitative analysis indicate that participants found the MI-Coach: ED to be an empowering and powerful way by which they could be supported while waiting for formal ED treatment. These findings support the project’s feasibility and acceptability, and provide important recommendations for future iterations of the app. 44 Chapter 5: Discussion Individuals with eating disorders (EDs) are in urgent need of treatment, given the serious and long-term physical and psychiatric complications associated with eating pathology (Arcelus et al., 2011; Treasure et al., 2003). However, treatment-seeking women often face substantial barriers to accessing appropriate care, such as long wait times, scarcity of treatment options, and low motivation to engage in recovery efforts (Ali et al., 2017). Waitlists in particular have been associated with harmful effects, such as high attrition rates and poorer outcomes once individuals enter treatment (Austin et al., 2021). Motivational interviewing (MI) and mobile-app-based interventions have both been suggested as ways by which treatment barriers may be addressed (Denison-Day et al., 2018). Pre-treatment MI interventions have been associated with increased treatment adoption and adherence upon entry into services, and mobile-apps offer a low-cost and barrier-free option to deliver interventions (Juarascio et al., 2015). However, in isolation, both MI and mobile interventions do not adequately address treatment barriers. For example, in-person MI interventions may be inaccessible to individuals in rural and remote locations, and interventions currently delivered through mobile apps have limited evidence to support their efficacy (Juarascio et al., 2015). As such, the current study aimed to simultaneously address individual and structural treatment barriers by developing and pilot testing an MI-based mobile app intervention for women on waitlists for ED treatment. Phase I of the study developed MI-Coach: ED, adapted from an existing MI-based mobile app to suit the treatment needs of women with EDs. Phase II of the study examined the feasibility and acceptability of the app through a pilot test evaluation conducted with a sample of waitlisted women seeking treatment from a variety of clinical sites across the province of British Columbia. In addition, preliminary efficacy of the app was explored. Previous Treatment-Seeking Experiences The characteristics of the study sample indicated a high level of eating pathology among participants. In alignment with previous research, the average age of ED pathology onset was in 45 late adolescence for most participants (Klump et al., 2009). Further, disorder duration exceeded a decade for most of the sample, with one participant disclosing that she had lived with her ED for over 29 years. A high degree of medical and psychiatric comorbidity was also found, with a significant majority of participants reporting medical and/or psychiatric comorbidities such as Ehlers-Danlos syndrome, obsessive-compulsive disorder, and post-traumatic stress disorder. These findings are in line with other reports indicating that EDs are chronic and enduring for many individuals (Arcelus et al., 2011). Additionally, a robust literature indicates that EDs are associated with a high degree of comorbidity, further exacerbating the severity of the disorder and complicating treatment (Klump et al., 2009). Concerningly, average reported wait times for treatment exceeded 6 months, with one participant disclosing that she had waited over two years for services. The wait times found in the present study corroborate anecdotal reports of increasing wait times in Canada, particularly in the aftermath of the COVID-19 pandemic. Given the high degree of pathology reported by the study sample, the exceedingly long waiting periods endured by participants are of elevated concern. Notably, a range of annual incomes were reported, ranging from below $29,000 per year to upwards of $100,000. A portion of participants reported annual incomes falling below the poverty line (as indicated by the Market Basket Measure, an objective measure used to determine the minimum income needed to meet basic needs; Statistics Canada, 2017). Though high financial costs associated with ED treatment have been consistently cited as a major treatment barrier (Weissman & Rosselli, 2017), the range of financial circumstances reported by study participants highlights the array of barriers (e.g., scarcity of treatment centres) impacting access to services in addition to high costs. Qualitative analyses provided additional details regarding participants’ experiences waiting for services and navigating the healthcare system. All participants reported waiting at least several months for treatment, and little clarity on when to expect entry into services. A lack of transparency and communication from treatment providers was reported, with many 46 participants reporting little to no contact once placed on waitlists. Additionally, a prominent subtheme that emerged pertained to the significant barriers faced by participants when seeking treatment. Many participants shared negative experiences with the healthcare system, such as experiencing weight bias from providers, a scarcity of accessible treatments, and a lack of clarity regarding criteria needed to access appropriate treatment providers. One participant shared that a lack of clarity in the referral process between treatment sites resulted in significant delays and additional administrative burden as she was referred back and forth between clinical sites. Though barriers were reported for all participants, service access was particularly challenging in rural and remote regions of the province. Many located in coastal island regions noted the complete absence of healthcare professionals trained in ED care available to them. Treatment barriers were further exacerbated by difficulties accessing health care, broadly. For example, one participant shared that accessing basic medical care at a walk-in clinic necessitated a five-hour waiting duration, with no guarantee of successful contact with a healthcare professional. Alarmingly, previous research has found that longer waiting periods are associated with poorer outcomes upon entry into treatment, as pathology and motivation have been shown to deteriorate the longer individuals wait for services (Austin et al., 2021). Given the significant waiting periods reported by participants, the findings of the present study highlight the seriousness of the current treatment landscape in BC. Many participants shared that their previous experiences using mobile-app-based mental health interventions were unsatisfactory. Overall, participants shared a lack of engagement with apps and general feelings of dissatisfaction, citing that many apps did not feel engaging to use. Concerningly, several participants disclosed experiencing iatrogenic effects after using mobile apps specifically designed to address EDs given their focus on tracking ED behaviours and foods. These findings are in line with current evidence suggesting that available mental health apps often rely on behavioural monitoring and demonstrate limited efficacy 47 (Linardon et al., 2020). Further, significant gaps exist between evidence-based apps developed by researchers, and apps available to end users on app stores (Juarascio et al., 2015; Linardon et al., 2020). Given the iatrogenic effects associated with using such apps reported by the current sample, these apps may be harmful to recovery efforts, particularly when framed as specifically targeting ED-related concerns. Additional resources providing guidance on safe and appropriate mental health apps are needed to mitigate the possible harms associated with using apps lacking evidence to support their efficacy. Overall, participants voiced significant frustration with their previous treatment-seeking experiences. Many shared the distress and sense of urgency they felt in response to the current healthcare system and stressed the importance of finding alternative ways to deliver ED treatments. These findings emphasize the current unmet treatment needs of individuals in BC, and the urgency with which such barriers need to be addressed in research and policy. Feasibility and Acceptability Feasibility and Perceived Ease of Use The overall feasibility of the MI-Coach: ED app was supported by the present study, as indicated by the characteristics of participants’ use of the app, attrition rates throughout the pilot test period, self-report measures, and semi-structured interviews. A high rate of engagement was observed, with participants using the app consistently throughout the four-week period. A significant portion of in-app exercises were completed, with one participant completing 34 of the available 38 exercises. Additionally, the overall attrition rate seen in the present study is comparable to rates seen in previous in-person and digital ED interventions (Linardon et al., 2020). App use data is corroborated by self-report ratings indicated that participants learned to use the app and developed competency with ease, with high overall ratings of the app’s ease of use and flexibility. Overall, these findings are in line with the Technology Acceptance Model, which posits that perceived ease of use and usefulness of technology leads to greater engagement and adoption by end users (Davis, 1989; Holden & Karsh, 2010). 48 Qualitative themes generated regarding the acceptability of the app provide further support for the app’s feasibility and ease of use. Responses indicated that the design of the app permitted flexibility with which participants used the app. Participants noted that the multiple modalities (i.e., videos, articles, exercises) through which content was presented enabled them to access the app in a variety of contexts, such as when using public transportation or completing household chores. The accessibility of delivering the content using a mobile-app enabled participants to integrate the app into their existing schedules and to use the app at times when they felt best equipped to engage with the content (e.g., weekend mornings). Participants highlighted that in-person treatments are typically constrained by therapist schedules, resulting in additional barriers to engaging in recovery (e.g., cognitive exhaustion following the workday). Further, one participant requiring in-patient care indicated that the transition to the hospital environment was often aversive and that she preferred to engage in recovery efforts in the comfort and safety of her home environment. Indeed, the accessibility and ease of access of mobile apps have been touted as a major strength supporting their use in service delivery (Chandrashekar, 2018). The present findings are in line with previous research in this regard (Bauer & Moessner, 2013), and provide support for the feasibility and ease of use of this modality. Acceptability and Perceived Utility Both self-report measures and qualitative responses supported the acceptability of the mobile app. Participants rated the mobile app highly, with average star ratings falling in the four-to-five-star range. Further, findings indicated that participants would use the app in the future and that they would pay for continued use given the perceived quality of the app. However, survey responses indicated some mixed findings regarding the app’s perceived usefulness, with a subset of participants indicating the app did not affect their motivation to stay on waitlists or improve their ED symptoms. 49 The heterogeneity In perceptions of the app’s utility also emerged in the qualitative data, with two participants indicating that the app felt overly clinical and ill-suited to their treatment needs. Notably, these participants shared that they had accessed treatment on several occasions prior and had thus been previously exposed to the content covered in the app. Both individuals shared that they felt the app would be appropriate for individuals earlier in their recovery journeys, and that the ineffectiveness of the intervention strategies in the app (e.g., mindfulness, finding reasons for change) for their specific needs contributed to their perceptions of the project. Additionally, they shared that the course-based structure of the app led to feelings of perfectionism and obligation to continue app use. In contrast, other participants reported favourable responses to the app’s aesthetic, design, content, and course-based format. Many indicated feelings of rapport with the clinician featured in the videos, and that the content resonated with their own lived experiences of eating pathology. These contrasting perspectives regarding the app’s acceptability and perceived usefulness highlight the heterogeneity of needs across individuals with EDs, and the challenges of designing interventions that are well-suited to the preferences of all app end-users. Additionally, these findings highlight the various needs within treatment-seeking samples. Though individuals at earlier stages of recovery may benefit from psychoeducation regarding motivation, others at later stages likely have different needs, such as strategies to maintain motivation over time, or a greater focus on preventing relapse. Similarly, variability was seen in the perceived usefulness of the app, with a subset of individuals with chronic EDs perceiving the app as less suited to their needs. As such, though these findings provide general support for the app’s acceptability and usefulness for most participants, additional research is needed to better identify ways by which the needs of all treatment-seeking individuals can be met. Feasibility of Study Recruitment 50 The present study highlighted the challenges associated with conducting research with clinical sites. Despite the large number of sites contacted, overall response and recruitments rates were low. Many sites did not provide means through which they could be contacted, with some indicating that referrals and communications were conducted through internal channels. Notably, the difficulties faced by the research team in communicating with clinical sites mirror the challenges highlighted by study participants when seeking treatment. Improving channels of communication between treatment sites and external stakeholders may be an important way through which treatment-seeking experiences can be improved for this population. Interestingly, heterogeneity was observed in the ways by which each clinical site defined their waitlists. Many individual clinicians that declined to share recruitment materials cited that they did not have the means to communicate with or track individuals put on their waitlists. Given this variability, additional research is needed to explore the structure of waitlists across clinical sites, and to better understand their impacts on wait times for services. Preliminary Efficacy Quantitative (i.e., randomization-based t tests, pre-post effect sizes, Jacobson-Truax tests of clinical significance) were conducted to explore the preliminary impact of MI-Coach: ED on motivation to recover, eating pathology, and associated clinical characteristics. However, given the very small sample size of the present study, interpretations regarding the app’s efficacy are largely speculative and should be interpreted with caution. Overall, the results of the present study revealed significant heterogeneity across outcome variables following app use. Statistically significant increases were seen in motivation to address compensatory strategies, and both clinically significant improvements and deteriorations were observed across most clinical variables. Additionally, a significant portion of participants did not experience any clinically significant changes across variables. Similarly, though a small non-significant decline in overall motivation to address ED pathology was observed, participants were less likely to be in the precontemplation stage of motivation regarding restrictive eating behaviours and felt more 51 confident in their ability to address cognitive symptoms of pathology. Changes in the confidence to address both overall eating pathology and symptoms (i.e., binge eating, compensatory strategies, and restrictive behaviours) were negatively associated with extrinsic reasons for change, precontemplation motivation, and associated clinical variables. The overall decrease in motivation observed following the pilot test period aligns with previously established associations between wait time duration and clinical outcomes (Austin et al., 2021). Longer waitlist durations are associated with entrenchment of pathology and clinical deterioration and are associated with feelings of powerlessness and hopelessness (Austin et al., 2021; Sansfacon et al., 2020). Additionally, the heterogeneity observed in clinical outcomes highlights the ambivalence and complexities of motivation known to impact treatment-seeking individuals (Williams & Reid, 2010). Attachment to eating pathology is commonly reported in ED samples, particularly in those with chronic and enduring EDs (Cockell et al., 2003; Hay & Touyz, 2015). Given the duration of eating pathology and adverse treatment experiences reported by the study sample, these findings are unsurprising. Additionally, factors such as weight status and ED subtype have been found to impact motivation (Shingleton et al., 2013), and may have impacted participants as they used the mobile app. However, given the small sample size of the present study, additional research is needed. Notably, increases in confidence regarding the ability to address eating pathology were associated with increases in precontemplation motivation, extrinsic (vs. intrinsic) reasons for change, body dissatisfaction, eating pathology, depression, and anxiety scores. Qualitatively, many participants reported feelings of empowerment following use of the app, which has been associated with decreased eating pathology and body image concerns (Kinsaul et al., 2014). Further, many reported that their use of the app became a behavioural strategy to help cope with distress, and that increased feelings of self-efficacy mitigated feelings of powerlessness while waiting for treatment. Previous research has found that confidence in the ability to change eating pathology is an important predictor of clinical outcomes in ED populations (Iyar et al., 52 2019). Given the associations between confidence, feelings of empowerment, and psychopathology, it is possible that app use may have contributed to downstream effects in other areas of functioning. However, this interpretation is tentative given the possible impact of other unmeasured structural barriers, and thus these findings should be interpreted with caution. Medium to large effect sizes were seen in precontemplation motivation to address compensatory strategies and binge eating behaviours, indicating that participants experienced an increase in the desire to target these symptom domains in treatment. This finding is in alignment with previous findings that individuals with binge-type EDs typically report higher levels of motivation to address binge eating behaviours compared to restrictive subtypes (Cassin & Geller, 2015). Surprisingly, moderate increases were also observed in participants’ confidence to address restrictive eating behaviour. This finding is unexpected given that individuals with restrictive EDs (e.g., anorexia nervosa) typically present with the lowest recovery motivation in treatment settings compared to individuals with other subtypes of eating pathology. However, recent research has highlighted the importance of identifying values in samples of patients with restrictive EDs, providing preliminary support for the use of values-oriented treatment for this population (Mulkerrin et al., 2016). Notably, many participants in the present study cited insight into their values as an important outcome that they experienced from using the app. Further, reflecting on the misalignment between eating pathology and personal values was identified as a strategy by which participants intended to increase their recovery motivation and leverage clinical change. As such, the present study provides preliminary support for the use of values-oriented work to address both restrictive and binge-spectrum eating pathology in treatment. Further, a significant majority of participants did not experience any clinically significant declines or improvements in clinical symptoms. Given that participants would be expected to decline over time given the harmful outcomes associated with treatment waitlists (Austin et al., 2021), the lack of change may be suggestive of protective factors associated with app use. 53 Indeed, many participants stated that the app protected against feelings of powerlessness while waiting for treatment. Though the study design does not permit causal conclusions to be made, preliminary evidence suggests that use of MI-Coach: ED may provide some degree of psychological support for waitlisted individuals. Suggestions to Improve MI-Coach: ED Several suggestions were provided to improve future iterations of the MI-Coach: ED app. One major suggestion was to address technological factors that interfered with app use, such as minor technological glitches, asynchrony between exercises and videos, and difficulties using the keyboard function when completing exercises. Many cited factors associated with the videos (e.g., difficulties identifying which videos had been completed, losing their place in videos) that interfered with their use. Additionally, participants noted that the accessibility of the app could be improved by adding captions and time estimates to videos for users with cognitive and sensory difficulties. Indeed, research has found that technological glitches can serve as a major barrier to the adoption and adherence to digital interventions (Linardon et al., 2022). Improving the ways by which the app can be accessed to better address the needs of disabled and sensory-impaired users is an important consideration for future iterations of MI-Coach: ED. Participants also suggested a variety of additional components that could be integrated into the app. Psychoeducation on a variety of relevant topics such as ED symptomatology, behavioural strategies to cope with distress, and the importance of physical health and nutrition were emphasized as important additions to the app. Adding such topics may increase the perceived usefulness of the app, particularly for those who may be seeking treatment for the first time and who may not have access to other psychoeducational resources. Additionally, suggestions to add features allowing greater personalization of the app were put forth as a helpful modification. Participants noted that the ability to keep track of goals set within the app would be a helpful way to maintain recovery motivation and engage with the content. Some suggested that clinical data regarding ED symptoms could be collected and used to personalize 54 the app’s content for each user’s needs. Indeed, other research has demonstrated that opportunities to personalize app content have been linked to greater adoption and use of interventions (Linardon et al., 2022). Incorporating features that allow for personalization is an important consideration for future iterations of MI-Coach: ED. Relatedly, addressing the heterogeneity of end-user needs, such as the clinical tone of the videos and the addition of additional app components, is an ongoing challenge for future adaptations of the app. Some heterogeneity was seen in the present study pertaining to the structure and content of the app. These findings highlight the challenges of developing interventions for individuals presenting with an array of eating pathologies and treatment needs. For example, though some participants indicated that they found the course-based structure helpful, others noted that the sequential order of content generated feelings of perfectionism and did not align with their broader relationship to recovery. Of note, several participants indicated that they viewed recovery as a life-long process, and that the time-limited nature of the app design felt at odds with this understanding of ED pathology. Indeed, conceptualizations of recovery as a “lifelong journey” have emerged in other qualitative examinations of treatment experiences (Misluk-Gervase, 2020). With respect to the mobile app, framing the content as a tool that can be accessed repeatedly rather than as a time-limited course may be a helpful way to increase the app’s applicability to a wider range of perspectives. However, additional research is needed to identify the structure that is best suited for the widest range of app users. Though many participants noted that the warmth and personability of the clinician featured in the videos generated feelings of rapport and support, many noted that the opportunity to interact in real-time with other users and clinicians would improve the overall app experience. For example, suggestions were made to include a peer-support facilitator to support engagement with the app’s content and to provide additional opportunities for connection. Indeed, research has found that including a technological navigator is associated with increased adoption and use of digital interventions (Linardon et al., 2020, 2022). As such, future research 55 investigating the feasibility and acceptability of including a peer-support component to the mobile app is needed. Additional challenges are present in the incorporation of suggested changes into future iterations of MI-Coach: ED. Most notable are the financial costs associated with making changes to the app’s design and content. As researchers often work collaborative ly with private technological partners, the use of resources to implement changes is often controlled by private parties, rather than by the research team (Juarascio et al., 2015). Within the context of the present project, the ability to implement changes is a collaborative decision made in partnership with Resiliens Inc., and therefore additional considerations regarding the company’s capacity and resources must be considered when developing future iterations of the app. Participants also shared that the ability to interact with other app users may be a powerful way by which recovery efforts could be supported. Indeed, previous research has demonstrated that virtual pro-recovery communities can lead to feelings of empowerment and downstream clinical improvements in eating pathology and body image (Aardoom et al., 2014). However, the potential iatrogenic effects of adding interactive components to the app must be carefully considered, given the widespread engagement with harmful pro-ED communities in virtual spaces (Mento et al., 2021). A relatively robust relationship between engagement with such communities and entrenchment of eating pathology has been found in the literature (Mento et al., 2021; Yom-Tov et al., 2016). As such, the benefits of introducing opportunities for peer interaction must be clearly considered in relation to the possible harms of engaging with other app users. Limitations and Future Directions The present pilot test evaluation has several limitations. Firstly, a lack of ethnic, gender, and physical diversity was seen in the sample of participants recruited. Though significant efforts were made to recruit across a broad range of treatment settings, all participants identified as Caucasian and cis-gendered women. Given that people with multiple intersecting 56 marginalized identities have been found to be particularly affected by treatment barriers (Ali et al., 2017, 2020), the inclusion of their perspectives is an important aspect to the development of appropriate and accessible interventions. Interestingly, the characteristics of the sample may be an indication that treatment barriers for historically marginalized individuals begin further upstream in the treatment process. For example, study recruitment largely relied on clinicians at treatment centres to disseminate promotional materials to individuals currently on waitlists for their services. As such, the lack of diversity in the sample may indicate that barriers to treatment may be impacting marginalized individuals’ capacity and engagement in treatment-seeking behaviours. Individuals may have a lack of knowledge regarding the identification of ED pathology and health literacy, particularly as historical models of eating pathology have focused exclusively on presentations in Caucasian and cis-gendered women (Schaumberg et al., 2017). Further, marginalized individuals face barriers preventing access to the broader healthcare system, such as a lack of health literacy, poverty, medical racism, disability, and houselessness (Marques et al., 2011). For example, immigrants from other countries face language barriers and citizenship challenges that limit their access to public healthcare (Thompson & Park, 2016). As such, additional research is needed to examine and address the upstream barriers that may be preventing marginalized individuals from accessing ED care. Additionally, the study sample reported a high degree of digital literacy. Though research has found an extremely high rate of global mobile device use, gaps in digital literacy remain, particularly for older individuals (Ellison et al., 2015). Given that older individuals with chronic and enduring EDs may also benefit from digital health interventions, additional research is needed to better investigate the appropriateness of MI-Coach: ED for their needs. Relatedly, a third limitation of the study pertains to the focus of the app on the needs of woman-identifying individuals. Historically conceived as a disorder uniquely affecting cisgendered women, a robust literature has emerged in recent years highlighting the prevalence of EDs and eating pathology in non-cisgendered individuals and men (Schaumberg et al., 57 2017). In order to address the heterogeneity of individuals with EDs while balancing the scope of the project, the present study was designed to be appropriate for a wide array of female identities (e.g., transgendered women, nonbinary individuals identifying as women). However, the lack of non-cisgendered participants in the study sample indicates that conclusions regarding the app’s acceptability and appropriateness for non-cisgendered women cannot be drawn at this time. Future research is required evaluating the acceptability of the app in gender diverse individuals and men and may require additional adaptations to better suit a broader array of user needs. Further, an additional limitation pertains to the experiences of participants that dropped out of the pilot test. Unfortunately, limited information could be gathered regarding their reasons for exiting the study. Given the associations between perceived ease of use and usefulness of digital platforms and their adoption, insights into treatment attrition may provide valuable insights into the feasibility and acceptability of the app. Though attempts were made to investigate reasons for drop-out, additional methods (e.g., providing additional incentives) may be considered to better understand the experiences of these individuals. Finally, given the design of the current study, conclusions regarding the efficacy of the app cannot be drawn. Though preliminary findings tentatively suggest that the app may be associated with changes in confidence and improvement in psychopathology, additional research using robust randomized control methods are needed to draw conclusions regarding the efficacy of MI-Coach: ED. Conclusion Providing app-based interventions to individuals who are waiting for ED treatment has the potential to improve treatment outcomes and represents a largely barrier-free, positive-approach method of addressing the growing problem of wait times for mental health care. The present study developed and assessed the feasibility and acceptability of MI-Coach: ED, a mobile app-based MI intervention for women on ED waitlists. The overall findings suggest that 58 the app is perceived as easy to use and useful to most participants and supports the acceptability and feasibility of the app. Importantly, the study highlighted the stark inaccessibility of ED treatments in BC and the urgency with which treatment barriers need to be addressed within the healthcare system. Preliminary investigations into the impact of the app on psychological functioning demonstrate the potential of the app to provide much-needed services to individuals while they wait for formal treatment. 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Supportive Care in Cancer, 26(2), 615–624. https://doi.org/10.1007/s00520-017-3875-5 73 Tables and Figures Table 1 Study Recruitment (n = 131) Variable N (%) Type Public Treatment Centre 58 (44%) Individual Clinician 34 (26%) Private Treatment Centre 28 (21%) Advocacy Organization 11 (8%) Outcome No response 75 (57%) Contact information inaccessible 42 (32%) Agreed to distribute study information 8 (6%) Declined to distribute study information 6 (5%) 74 Table 2 Participant Demographics (n = 11) Variable M (SD) N (%) Age (Years) 33.4 (7.7) - Body Mass Index 22.0 (3.8) - Age of Eating Disorder Onset (Years) 16.8 (8.4) - Duration of Eating Disorder (Years) 16.5 (7.3) - Time Spent on Treatment Waitlist (Weeks) 24.5 (29.9) - Comorbid Diagnoses Psychiatric Condition - 6 (55%) Physical Health Condition - 3 (27%) Ethnicity White/Caucasian - 11 (100%) Highest Degree Earned Some University/College Credit, No Degree - 3 (27%) Bachelor’s Degree - 5 (45%) Graduate Degree - 3 (27%) Average Yearly Income <$29,999 - 3 (27%) $30,000-$49,999 - 1 (9.1%) $50,000-$69,999 - 1 (9.1%) $70,000-$89,999 - 2 (18%) $100,000-$149,999 - 3 (27%) Prefer not to answer - 1 (9.1%) Technological Literacy eHEALS Score 3.5 (0.5) - MDPQ Score 39.1 (1.3) - Note. The eHealth Literacy Scale (eHEALS) ranges from 1-5; Mobile Device Proficiency Questionnaire (MDPQ) scale ranges from 8-40. 75 Table 3 Characteristics of App Use (n = 11) App Usage M (SD) Range Min. Max. Duration of Consistent Use (Days) 13.6 (9.8) 0 28 Frequency of Logins (Days) 4.7 (3.4) 0 11 Sessions Completeda 3.9 (2.4) 0 7 Exercises Completedb 11.2 (9.3) 0 34 uMARS Scores Engagement 3.6 (0.7) 2.8 4.8 Functionality 4.1 (0.6) 3.3 5 Aesthetics 4.3 (0.6) 3.3 5 Information 4.6 (0.4) 3.8 5 Overall App Quality 4.2 (0.5) 3.6 5 Adapted TAM Scores Ease of Use 5.9 (1.1) 3.8 6.7 Usefulness 5.2 (1.2) 2.7 7 Note. The User Version of the Mobile App Rating Scale (uMARS) ranges from 1-5, whereas the Technology Acceptance Model (TAM) Questionnaire ranges from 1-7. an of available sessions = 7. bn of available exercises = 38. 76 Table 4 uMARS Qualitative Responses (n = 5) Participant Additional Comments About the App 1 It would be helpful if each video in each session was paired specifically with the exercise it was related to. The videos were all grouped together in each session which led to confusion about which ones I had watched 2 There are some things that would have made it easier to use. One thing I was aware of was that my neurodivergence / executive functioning was challenged. I felt keeping track of the videos and completed sections was challenging to do and relied on my memory. I wish the app made it more clear what sections and videos had already been watched / completed rather than me having to keep track on my own. It also wasn’t that easy to switch between the video and exercises, so when the speaker directed me to an exercise it was not intuitive to stop the video and go to it. I wish that there were captions on the video because I do not always want to listen to sound and it helps me to take in information to also read (neurodivergence, and I thought of users with hearing loss as well). It also would be helpful to know how long a video will be before starting to watch it. When it came to setting goals, I found myself wishing for more examples or resources of examples. I think in the added resource section it would have been helpful to have materials that share some basics about behaviours that are good for eating disorder recovery, or directed to a specific resource, because it is hard to generate these ideas on your own when you have been in your own dysfunctional thinking for so long and may have never had healthy examples. It is hard to decipher what is “healthy” and unhealthy in our current cultural context because diet culture and eating disorder behaviour is so normalized, plus it is so hard to access eating disorder treatment to give you the “right” thing to do. It can also be difficult for someone to make the connection between a small change (adding something to your diet) having a bigger impact like lessening binge urges. I guess recovery literacy resources would be helpful. There was also something that happened when I typed in answers on my iPhone, where the text covered the question and it was a little glitchy, so that made it harder. 3 I really appreciated relevant having the information accessible when I felt like using it. I liked the graphics. I did not find listening to the recordings pleasant (would opt for reading the text / transcript). 4 The ability to do sections in small chunks was very helpful- could tailor sessions for how I was feeling. Helps build success to be able to complete as able. Doing at own pace was important. The combination of video, reading and exercises felt like a good way to take in the information. The content felt well researched and genuinely presented with care. Being able to move forward and back between the units was very helpful. This app is the first app I have tried that seem to fit for where I am at in my ED. Even though it has to be generic for multiple users, it felt specifically designed for my needs. 5 I didn’t like that you can only watch the videos (and listen to the text) and not have subtitles with it. Note. Qualitative responses are unedited. 77 Table 5 Changes in Readiness and Motivation Questionnaire Scores from Time 1 to Time 2 Measure Time 1 (M, SD) Time 2 (M, SD) Change p g Total (n = 11) Precontemplation 58.05 (21.56) 56.96 (15.74) -1.08 .654 -0.209 Action 44.84 (25.07) 42.3 (19.22) -2.54 .626 -0.228 Internal 66.62 (24.90) 67.95 (16.32) 2.19 .752 -0.148 Confidence 33.52 (17.95) 35.7 (15.98) 1.33 .932 -0.020 Cognitive (n = 11) Precontemplation 35.91 (23.49) 44.85 (17.66) 8.93 .520 0.270 Action 40.00 (24.22) 44.39 (27.87) 4.39 .896 0.056 Internal 79.39 (26.95) 78.18 (18.82) 9.85 .520 -0.266 Confidence 21.67 (20.45) 31.52 (21.83) -1.21 .412 0.321 Restriction (n = 10) Precontemplation 80.50 (20.34) 75.50 (18.17) -5.00 .208 -0.545 Action 29.50 (29.95) 28.50 (22.74) -1.00 .890 -0.074 Internal 49.00 (31.34) 46.50 (22.49) 2.50 .838 -0.094 Confidence 33.50 (21.35) 36.00 (20.25) -2.50 .990 0.049 Bingeing (n = 6) Precontemplation 31.67 (45.79) 46.67 (37.77) 15.00 .222 0.663 Action 85 (23.45) 68.33 (27.87) -16.67 .772 -0.236 Internal 95 (8.37) 85 (16.43) 10.00 .512 -0.397 Confidence 21.67 (20.41) 31.67 (29.94) -10.00 .884 -0.116 Compensatory (n = 11) Precontemplation 38.94 (21.07) 70 (23.18) 31.06 .032* 1.005 Action 49.24 (31.01) 46.82 (29.87) -2.42 .682 -0.172 Internal 60.76 (34.03) 68.64 (27.34) -1.97 .846 0.089 Confidence 41.21 (27.35) 39.24 (19.40) 7.88 .666 -0.177 Note. Participant n varies according to symptom domain. Effect sizes were calculated using Hedge’s g. Readiness and Motivation Questionnaire scales range from 0-100. *p < .05. **p < .01. ***p < .001. 78 Table 6 Changes in Clinical Characteristics from Time 1 to Time 2 (n = 11) Measure Time 1 (M, SD) Time 2 (M, SD) Change p g EDE-Q Restraint 2.68 (1.89) 2.75 (1.99) 0.07 .898 0.054 EDE-Q Eating 3.65 (0.913) 3.44 (1.15) -0.22 .460 -0.320 EDE-Q Shape 3.83 (1.93) 3.49 (1.30) -0.34 .640 -0.179 EDE-Q Weight 3.78 (1.80) 3.33 (1.42) -0.46 .664 -0.195 EDE-Q Global 3.49 (1.44) 3.25 (1.26) -0.24 .718 -0.148 PHQ-9 14.20 (6.87) 10.30 (6.07) -3.91 .576 -0.491 GAD-7 10.80 (6.54) 9.18 (5.38) -1.64 .248 -0.233 BSQ 108.0 (41.92) 107 (33.95) -1.00 .840 0.072 Note. Effect sizes calculated using Hedge’s g. Scale ranges are as follows: Eating Disorder Examination Questionnaire (EDE-Q) total and subscale range = 0-6; Body Shape Questionnaire (BSQ) scale range = 0-204; Patient Health Questionnaire 9-Item Questionnaire (PHQ-9) scale range = 0-27; Generalized Anxiety Disorder 7-Item Questionnaire (GAD-7) scale range = 0-21. *p < .05. **p < .01. ***p < .001. 79 Table 7 Time 1 Variable Correlations (n = 11) Variable 1 2 3 4 5 6 7 8 9 10 11 12 1. EDE-Q Restraint 1 2. EDE-Q Eating 0.344 1 3. EDE-Q Shape 0.827** 0.375 1 4. EDE-Q Weight 0.835** 0.244 0.969*** 1 5. EDE-Q Global 0.921*** 0.473 0.969*** 0.951*** 1 6. PHQ-9 0.322 0.352 0.161 0.146 0.261 1 7. GAD-7 0.132 0.146 0.002 -0.041 0.054 0.789** 1 8. BSQ 0.854*** 0.389 0.902*** 0.934*** 0.937*** 0.222 0.034 1 9. RMQ Precontemplation 0.328 0.518 0.660* 0.552 0.584 -0.046 -0.082 0.455 1 10. RMQ Action -0.042 -0.3 0.164 0.277 0.081 -0.237 -0.597 0.167 -0.075 1 11. RMQ Internal 0.052 -0.527 0.186 0.271 0.081 -0.661* -0.728* 0.208 -0.08 0.660* 1 12. RMQ Confidence -0.142 -0.159 0.137 0.214 0.041 -0.417 -0.657* -0.005 0.129 0.735* 0.395 1 Note. Eating Disorder Examination Questionnaire (EDE-Q); Patient Health Questionnaire 9-Item Questionnaire (PHQ-9); Generalized Anxiety Disorder 7-Item Questionnaire (GAD-7); Body Shape Questionnaire (BSQ); Readiness and Motivation Questionnaire (RMQ). *p < .05. **p < .01. ***p < .001. 80 Table 8 Time 2 Variable Correlations (n = 11) Variable 1 2 3 4 5 6 7 8 9 10 11 12 1. EDE-Q Restraint 1 2. EDE-Q Eating 0.383 1 3. EDE-Q Shape 0.720* 0.669* 1 4. EDE-Q Weight 0.702* 0.497 0.904*** 1 5. EDE-Q Global 0.866*** 0.692* 0.950*** 0.906*** 1 6. PHQ-9 -0.046 0.357 0.035 -0.018 0.067 1 7. GAD-7 -0.061 0.170 -0.068 0.010 0.000 0.896*** 1 8. BSQ 0.823** 0.524 0.892*** 0.783** 0.896*** 0.066 -0.059 1 9. RMQ Precontemplation 0.400 0.233 0.470 0.502 0.474 -0.02 0.169 0.271 1 10. RMQ Action -0.122 -0.375 0.133 0.185 -0.047 -0.048 -0.035 0.062 0.043 1 11. RMQ Internal -0.205 -0.294 -0.228 -0.250 -0.277 -0.515 -0.604* -0.051 -0.434 0.172 1 12. RMQ Confidence -0.101 -0.217 0.186 0.187 0.011 -0.308 -0.191 -0.030 0.324 0.784** -0.029 1 Note. Eating Disorder Examination Questionnaire (EDE-Q); Patient Health Questionnaire 9-Item Questionnaire (PHQ-9); Generalized Anxiety Disorder 7-Item Questionnaire (GAD-7); Body Shape Questionnaire (BSQ); Readiness and Motivation Questionnaire (RMQ). *p < .05. **p < .01. ***p < .001. 81 Table 9 Jacobson-Truax Clinical Significance by Variable Measure α n (%) Improved No Change Deteriorated RMQ Precontemplation (n = 11) 0.55 - 11 (100%) - RMQ Action (n = 11) 0.66 - 10 (91%) 1 (9%) RMQ Internal (n = 11) 0.80 1 (9%) 9 (82%) 1 (9%) RMQ Confidence (n = 11) 0.77 2 (18%) 8 (73%) 1 (9%) RMQ Cognitive Symptom Domain (n = 11) Precontemplation 0.55 - 10 (91%) 1 (9%) Action 0.66 2 (18%) 8 (73%) 1 (9%) Internal 0.80 2 (18%) 6 (55%) 3 (27%) Confidence 0.77 2 (18%) 9 (82%) - RMQ Restriction Symptom Domain (n = 10) Precontemplation 0.55 1 (10%) 8 (80%) 1 (10%) Action 0.66 - 9 (90%) 1 (10%) Internal 0.80 - 8 (80%) 2 (20%) Confidence 0.77 2 (20%) 7 (70%) 1 (10%) RMQ Bingeing Symptom Domain (n = 6) Precontemplation 0.55 - 6 (100%) - Action 0.66 - 4 (67%) 2 (33%) Internal 0.80 - 4 (67%) 2 (33%) Confidence 0.77 2 (33%) 3 (50%) 1 (17%) RMQ Compensatory Strategies Symptom Domain (n = 11) Precontemplation 0.55 4 (36%) 7 (63%) - Action 0.66 - 11 (100%) - Internal 0.80 - 11 (100%) - Confidence 0.77 - 9 (100%) - 82 Measure α n (%) Improved No Change Deteriorated EDE-Q Global (n = 11) 0.84 2 (17%) 8 (67%) 2 (17%) EDE-Q Restraint (n = 11) 0.84 - 11 (92%) 1 (8%) EDE-Q Eating Concern (n = 11) 0.85 2 (18%) 8 (73%) 1 (9%) EDE-Q Shape Concern (n = 11) 0.91 4 (33%) 5 (42%) 3 (25%) EDE-Q Weight Concern (n = 11) 0.84 3 (25%) 7 (58%) 2 (17%) BSQ (n = 11) 0.88 2 (18%) 6 (55%) 3 (27%) PHQ-9 (n = 11) 0.92 4 (33%) 6 (50%) 2 (17%) GAD-7 (n = 11) 0.89 4 (33%) 6 (50%) 2 (17%) Note. Readiness and Motivation Questionnaire (RMQ) Cronbach’s α calculated from Geller et al. (2013); Eating Disorder Examination Questionnaire (EDE-Q) Cronbach’s α calculated from Fairburn & Beglin (1994); Body Shape Questionnaire (BSQ) Cronbach’s α calculated from Cooper et al. (1987); Patient Health Questionnaire 9-Item Questionnaire (PHQ-9) Cronbach’s α calculated from Kroenke et al. (2001); Generalized Anxiety Disorder 7-Item Questionnaire (GAD-7) Cronbach’s α calculated from Spitzer et al. (2006). 83 Table 10 Qualitative Interview Participant Demographics (n = 8) Participant Age Ethnicity Highest Degree Previously Diagnosed with ED Z ED Duration (Years) Waitlist Duration (Weeks) Self-Reported Comorbid Diagnoses Psychiatric Physical P1 37 White Some University/ College Yes -0.11 19 52 Depression, Anxiety N/A P2 35 White Bachelors’ Degree Yes 1.07 17 4 PTSD, Anxiety Anemia P3 23 White Bachelor’s Degree Yes 0.23 13 22 Depression, Anxiety, PTSD N/A P4 29 White Some University/ College No -2.55 19 4 Anxiety, Depression Ehlers-Danlos syndrome P5 25 White Graduate Degree Yes -1.02 14 10 N/A N/A P6 39 White Bachelor’s Degree Yes 0.23 27 104 N/A N/A P7 30 White Bachelor’s Degree No 1.09 14 22 N/A N/A P8 47 White Graduate Degree Yes -1.69 7 4 OCD, Anxiety, Depression N/A Note. Z-scores were calculated by subtracting participant raw scores from the population mean, which were then divided by the population standard deviation. Population means and standard deviations were drawn from the scores reported by Fairburn and Beglin (1994). 84 Figure 1 MI-Coach: ED Adaptations Note. The home screen (A), session structure (B), article layout (C), videos (D), exercises (E), and article content (F) of the MI-Coach: ED mobile app. 85 Figure 2 Participant Flow 86 Figure 3 Adapted Technology Acceptance Model Ratings of MI-Coach: ED (n = 11) Note. Agreement with statements regarding MI-Coach: ED’s ease of use (A) and usefulness (B). 87 Figure 4 Correlogram of Time 1 and Time 2 Change Scores for All Variables (n = 11) Note. Change scores were calculated by subtracting Time 1 from Time 2 scores across all measures. The magnitude of correlation coefficients with p < .05 are represented graphically by the size and colour of circles, with non-significant correlation coefficients by blank squares. 88 Figure 5 Individual-Level Clinical Significance Change Scores by Variable (n = 11) Note. Each unique participant is represented graphically by a letter ranging from A-K. 89 Appendices Appendix A: MI-Coach: ED Session Outline Session Content Exercises Session 1: Introduction • Understanding behaviour change, the challenges faced when considering change, and the role of ambivalence • Introduction to Motivational Interviewing (MI) to work through challenges, explore and resolve ambivalence, and find the motivation to engage in behaviour change 1. Self-Reflection Exercise 2. Exploring Ambivalence: Eating Disorder Behaviours 3. Exploring Ambivalence: Importance and Confidence Session 2: Creating Safeness • Building a safe relationship with oneself and body • Learning to become one’s own partner in health, fostering self-acceptance and self-respect • Cultivating a compassionate motivation towards oneself • Introduction to the MI Spirit 1. Calming the body and mind 2. Accepting and Respecting Yourself Session 3: Let’s Focus • The importance of focus • Arriving at a specific focus for behaviour change • Creating a chart with circles to examine all the possible areas of change • Establish priorities • Arrive at a specific focus. 1. Preparing for a chart with circles 2. A chart with circles 3. Common behaviour changes people focus on Session 4: Exploring (Part 1) • Introduction to sustain talk (i.e., arguments against change) and change talk (i.e., arguments for change) • Bringing awareness to both sides of ambivalence 1. Responding to Dr Bossy with “Yes, but…” 2. What is your sustain talk? 3. Exploring arguments for change Session 5: Exploring (Part 2) • Further elaboration and deeper exploration of change talk 1. Desire change talk 2. Ability change talk 90 • Four dimensions of change talk: desire, ability, reason and need (DARN) • Preparing motivation to change using DARN 3. Reasons change talk 4. Need change talk Session 6: Commitment and Planning • Introduction to commitment language and how such commitments are predictive of actual change • The importance of strength of commitment and how commitment can be strengthened by building confidence and importance • Invitation to make a commitment to change 1. Exploring confidence 2. Getting started 3. Making change fun and rewarding 4. Reducing procrastination 5. Remembering to act 6. Confidence statements 7. Affirming personal strengths and qualities 8. Learning from the success of others 9. Always bring it back to the body 10. Exploring Importance 11. Exploring Discrepancies 12. What will you change? 13. Refining the Change goal 14. Developing the plan 15. Aligning with Values 16. Valued function replacement Session 7: Reflect and Review • Reflecting on behaviour change • Troubleshooting common challenges • Celebration of successes • Introduction to the concept of relapse and relapse management 1. Reviewing MI Coach: ED! 2. How did you go? 3. Troubleshooting challenges 4. Celebrating successes 5. Lapse versus Relapse 6. Defining risk situations 7. Risk and lapse management plan 91 Appendix B: Recruitment Flyer 92 Appendix C: Study Measures Demographics Questionnaire General Characteristics 1. In what country were you born? 2. What is your current age? 3. What is your gender identity? [Select one] a. Cisgender man b. Cisgender woman c. Transgendered man d. Transgendered woman e. Nonbinary person f. Prefer not to answer g. Other (please specify) 4. What are your preferred pronouns? 5. How would you describe your ethnic or racial background? [Select all that apply] a. Black/African American (e.g., African, Afro-Caribbean, African-Canadian, etc.) b. East Asian (e.g., Chinese, Korean, Japanese, Taiwanese, etc.) c. Latinx (e.g., Latin American, Hispanic, etc.) d. Middle Eastern (e.g., Arab, Persian, Afghan, Egyptian, Iranian, etc.) e. South Asian (e.g., East Indian, Pakistani, Sri Lankan, Indo-Caribbean, etc.) f. Southeast Asian (e.g., Filipino, Vietnamese, Cambodian, Thai, etc.) g. White (e.g., European descent) h. Indigenous (e.g., First Nations, Inuit, Métis, etc.) i. Oceania origins (e.g., Australian, New Zealander, Pacific Islander, etc.) j. Prefer not to answer k. Other (please specify) 6. What is your highest degree or level of school completed? [Select one] a. Less than grade 12 b. High school graduate, diploma or equivalent c. Trades/technical/vocational training d. Some university/college credit, no degree e. Bachelor's degree f. Graduate degree 7. What was your total household income before taxes last year? [Select one] a. 0 - $29,999 b. $30,000-$49,999 c. $50,000-$69,999 d. $70,000-$99,999 e. $100,000-$149,999 93 f. $150,000 or more g. Do not know h. Prefer not to answer Eating Disorder History 8. What is your current height? [Specify if feet/inches or meters/centimeters] 9. What is your current weight? [Specify if pounds or kilograms] 10. Have you ever been diagnosed with an eating disorder by a health care professional (e.g., psychologist, psychiatrist, counsellor, nurse, social worker, family doctor, etc.) a. Yes b. No 11. Around what age did you first start experiencing eating disorder symptoms? 12. Have you ever been treated for an eating disorder? a. Yes b. No If you answered ‘Yes’ to item 12, please answer items 13-15; if you answered ‘No’, please skip to item 16. 13. If yes to item 12: when was the last time that you received treatment? 14. If yes to item 12: in what type of treatment facility did you receive services? [Please select all that apply] a. Peer support services (i.e., seeing someone who is trained to provide support, but is not a health care professional, on a regular basis) b. Outpatient treatment (i.e., seeing a mental health professional, such as a psychologist, counsellor, or social worker, on a regular basis at a private practice, clinic, or hospital setting) c. Day treatment (i.e., staying at a hospital during the day for most days of the week) d. Inpatient treatment (i.e., staying at a hospital during the day and overnight, for most days of the week) e. Residential treatment (i.e., receiving overnight treatment at a setting other than a hospital, such as a private residence or clinic) f. Other (Specify) 15. If yes to item 12: please describe any other times that you received treatment for your eating disorder 16. Are you currently on a waitlist for eating disorder treatment? a. Yes b. No If you answered ‘Yes’ to item 16, please answer items 17-19; if you answered ‘No’, please skip to item 20. 94 17. If yes to item 16: how long have you been waiting for treatment? [Specify if days/weeks/months/years] 18. If yes to item 16: which of the following treatment centre waitlists are you currently on? [Select all that apply] a. Government-funded program (select from the following list):  Abbotsford Eating Disorders Services (Abbotsford, BC)  Adolescent Outpatient Services at St. Joseph’s Hospital (Comox, BC)  Adult Mental Health Substance Use Team in Nanaimo (Nanaimo, BC)  BC Children’s Kelty Mental Health Resource Centre (Vancouver, BC)  Campbell River North Island Eating Disorders Program (Campbell River, BC)  Central Island Child and Youth Eating Disorders Program (Nanaimo, BC)  Child & Youth Mental Health Eating Disorders Program (Duncan, BC)  Chilliwack Mental Health – Eating Disorders (Chilliwack, BC)  Comox Valley North Island Eating Disorders Program (Comox, BC)  Discovery Vista House (Vancouver, BC)  East Kootenay Eating Disorders Program (Cranbook, BC)  Eating Disorders Program – South Vancouver Island Region (Victoria, BC)  Eating Disorders Program run by NARSF (Nanaimo, BC)  Fraser South Eating Disorders Program (Delta, BC)  Jessie’s Legacy Eating Disorders Prevention and Awareness Program (North Vancouver, BC)  Kamloops Eating Disorders Program (Kamloops, BC)  Kelowna Eating Disorders Program (Kelowna, BC)  Kootenay Boundary Eating Disorder Clinic (Castlegar, BC)  Lions Gate Hospital Medical Stabilization (North Vancouver, BC)  North Fraser Eating Disorders Program (Port Moody, BC)  North Okanagan Eating Disorders Program (Vernon, BC)  Northern Regional Eating Disorders Clinic (Prince George, BC)  Outpatient Dietitian Services for Central Island (Nanaimo, BC)  Port Alberni Mental Health and Substance Use (Port Alberni, BC)  Provincial Specialized Eating Disorders Program for Adults (Vancouver, BC)  Richmond Eating Disorders Program (Richmond, BC)  TeleEating Disorders, Island Health (Victoria, BC)  The Looking Glass Foundation for Eating Disorders (Vancouver, BC)  The Looking Glass Residence (Vancouver, BC)  Vancouver Coastal Health Eating Disorders Program (Vancouver, BC) 95  Victoria General Hospital (Victoria, BC)  Williams Lake Eating Disorders Program (Williams Lake, BC) b. Private practice/clinician(s) (Specify names) c. Other (Specify) 19. If yes to item 16: please describe any additional information pertaining to your time waiting for eating disorder treatment Other Medical History 20. Have you ever been diagnosed with any other mental disorder by a health care professional (e.g., psychologist, psychiatrist, counsellor, nurse, social worker, family doctor, etc.) a. Yes (Specify) b. No 21. Have you ever been diagnosed with a schizophrenia-spectrum disorder (e.g., Schizophrenia, Schizotypal personality disorder), or experienced an episode of psychosis? a. Yes b. No 22. Have you experienced a traumatic brain injury (e.g., concussion) or other cognitive symptoms (e.g., stroke, loss of hearing or vision) in the past year? a. Yes b. No 23. Do you have any other physical health conditions? a. Yes (Specify) b. No 96 Eating Disorder Examination – Questionnaire The following questions are concerned with the past four weeks (28 days) only. Please read each question carefully. Please answer all the questions. Thank you. Questions 1 to 12: Please circle the appropriate number on the right. Remember that the questions only refer to the past four weeks (28 days) only. On how many of the past 28 days…. No days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Every day Have you been deliberately trying to limit the amount of food you eat to influence your shape or weight (whether or not you have succeeded)? 0 1 2 3 4 5 6 Have you gone for long periods of time (8 waking hours or more) without eating anything at all in order to influence your shape or weight? 0 1 2 3 4 5 6 Have you tried to exclude from your diet any foods that you like in order to influence your shape or weight (whether or not you have succeeded)? 0 1 2 3 4 5 6 Have you tried to follow definite rules regarding your eating (for example, a calorie limit) in order to influence your shape or weight (whether or not you have succeeded)? 0 1 2 3 4 5 6 Have you had a definite desire to have an empty stomach with the aim of influencing your shape or weight? 0 1 2 3 4 5 6 Have you had a definite desire to have a totally flat stomach? 0 1 2 3 4 5 6 Has thinking about food, eating, or calories made it very difficult to concentrate on things that you are interested in (for example, working, following a conversation, or reading)? 0 1 2 3 4 5 6 Has thinking about shape or weight made it very difficult to concentrate on things you are interested in (for example, working, following a conversation, or reading)? 0 1 2 3 4 5 6 97 Have you had a definite fear of losing control over eating? 0 1 2 3 4 5 6 Have you had a definite fear that you might gain weight? 0 1 2 3 4 5 6 Have you felt fat? 0 1 2 3 4 5 6 Have you had a strong desire to lose weight? 0 1 2 3 4 5 6 Questions 13 – 18: Please fill in the appropriate number in the boxes on the right. Remember that the questions only refer to the past four weeks (28 days). Over the past 28 days, how many times have you eaten what other people would regard as an unusually large amount of food (given the circumstances)? …. On how many of these times did you have a sense of having lost control over your eating (at the time that you were eating)? Over the past 28 days, on how many DAYS have such episodes of overeating occurred (i.e., you have eaten an usually large amount of food and have had a sense of loss of control at the time)? Over the past 28 days, how many times have you made yourself sick (vomit) as a means of controlling your shape or weight? Over the past 28 days, how many times have you taken laxatives as a means of controlling your shape or weight)? Over the past 28 days, how many times have you exercised in a “driven” or “compulsive” way as a means of controlling your weight, shape or amount of fat, or to burn off calories? Questions 19 to 21: Please circle the appropriate number. Please note that for these questions the term “binge eating” means eating what others would regard as an unusually large amount of food for the circumstances, accompanied by a sense of having lost control over eating. Over the past 28 days, on how many days have you eaten in secret (i.e., furtively)? …. Do not count episodes of binge eating. No days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Every day 0 1 2 3 4 5 6 On what proportion of the times that you have eaten have you felt guilty (felt that you’ve done wrong) because of its None of the times A few of the times Less than half Half of the times More than half Most of the time Every time 98 effect on your shape or weight? …. Do not count episodes of binge eating 0 1 2 3 4 5 6 Over the past 28 days, how concerned have you been about other people seeing you eat? …. Do not count episodes of binge eating Not at all Slightly Moderately Markedly 0 1 2 3 4 5 6 Questions 22 to 28: Please circle the appropriate number on the right. Remember that the questions only refer to the past four weeks (28 days). Over the past 28 days….. Not at all Slightly Moderately Markedly Has your weight influenced how you think about (judge) yourself as a person? 0 1 2 3 4 5 6 Has your shape influenced how you think about (judge) yourself as a person? 0 1 2 3 4 5 6 How much would it have upset you if you had been asked to weigh yourself once a week (no more, or less, often) for the next four weeks? 0 1 2 3 4 5 6 How dissatisfied have you been with your weight? 0 1 2 3 4 5 6 How dissatisfied have you been with your shape? 0 1 2 3 4 5 6 How uncomfortable have you felt seeing your body (for example, seeing your shape in the mirror, in a shop window reflection, while undressing or taking a bath or shower)? 0 1 2 3 4 5 6 How uncomfortable have you felt about others seeing your shape or figure (for example, in communal changing rooms, when swimming, or wearing tight clothes)? 0 1 2 3 4 5 6 99 Readiness and Motivation Questionnaire It's common for people to have mixed feelings about making changes to their eating and eating related thoughts and behaviours. We're interested in learning about your current and past experiences. 1. DIETARY RESTRAINT ON HOW MANY DAYS OUT OF THE PAST 28 DAYS have you consciously tried to restrict the amount of food you eat to influence shape or weight? (please circle one of the following) No days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Daily If you have never tried to restrict, please go to the next section. If you have ever restricted, please answer the following questions: IN THE PAST TWO WEEKS, how much of you has wanted to restrict your eating? (please circle one of the following percentages) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% IN THE PAST TWO WEEKS, how much of you has been actively working to eat more? (please circle one of the following percentages) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% If you were to reduce your restriction (i.e. eat more), how much of this would be for you (versus for others)? (please circle one of the following percentages) Not very much for me About half for me Mostly for me 0% 10 20 30 40 50 60 70 80 90 100% If you decided to reduce your restriction (i.e., eat more), how confident are you in your ability to do so? (please circle one of the following percentages) Not at all confident Extremely confident 0% 10 20 30 40 50 60 70 80 90 100% 2.1 MAINTAINING LOW WEIGHT (only answer if you are currently underweight) ON HOW MANY DAYS OUT OF THE PAST 28 DAYS have you tried to maintain a low weight? (please circle one of the following) No days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Daily If you have never tried to maintain a low weight, please go to the next section. If you have ever tried to maintain a low weight, please answer the following questions: 100 IN THE PAST TWO WEEKS, how much of you has wanted to maintain a low weight (please circle one of the following percentages) A small part of me About half of me Most of me 0% 10 20 30 40 0% 10 20 30 40 0% IN THE PAST TWO WEEKS, how much of you has been actively working to gain weight? (please circle one of the following percentages) A small part of me About half of me Most of me 0% 10 20 30 40 0% 10 20 30 40 0% If you were to gain weight, how much of this would be for you (versus for others)? (please circle one of the following percentages) Not very much for me About half for me Mostly for me 0% 10 20 30 40 0% 10 20 30 40 0% If you decided to gain weight, how confident are you in your ability to do so? (please circle one of the following percentages) Not at all confident Extremely confident 0% 10 20 30 40 0% 10 20 30 40 0% 2.2 WEIGHT LOSS (only answer if you responded “none” to the previous question ON HOW MANY DAYS OUT OF THE PAST 28 DAYS have you tried to lost weight? (please circle one of the following) No days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Daily If you have never tried to lose weight, please go to the next section. If you have ever tried to lose weight, please answer the following questions: IN THE PAST TWO WEEKS, how much of you has wanted to lose weight? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% IN THE PAST TWO WEEKS, how much of you has been actively working to stop your efforts to lose weight? (please circle one of the following percentages) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% If you were to stop your efforts to lose weight how much of this would be for you (versus for others)? (please circle one of the following percentages) Not very much for me About half for me Mostly for me 0% 10 20 30 40 50 60 70 80 90 100% If you decided to stop your efforts to lose weight, how confident are you in your ability to do so? (please circle one of the following percentages) Not at all confident Extremely confident 0% 10 20 30 40 50 60 70 80 90 100% 101 3. MENSTRUATION Are you on the birth control pill? Yes No Have you missed any periods in the past three months? Yes No If yes, how many periods have you missed? _____ If you answered no: Have you ever missed any periods due to weight loss? Yes No If you have never missed your period, please go to the next section. If you have ever missed your period due to weight loss, answer the following questions: IN THE PAST TWO WEEKS, how much of you has not wanted to have periods? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% IN THE PAST TWO WEEKS, how much of you has been actively working to get your periods back? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% If you were to try to get your periods back, how much of this would be for you (versus for others)? (please circle one of the following) Not very much for me About half for me Mostly for me 0% 10 20 30 40 50 60 70 80 90 100% If you decided to try to get your periods back, how confident are you in your ability to do so? (please circle one of the following) Not at all confident Extremely confident 0% 10 20 30 40 50 60 70 80 90 100% 4. EPISODES OF OVEREATING (I.e. Bingeing) ON HOW MANY DAYS OUT OF THE PAST 28 DAYS have you eaten an objectively large amount of food and most people would agree it was too much to have at one time, (i.e. bingeing) accompanied by a loss of control (i.e. you couldn't resist eating, or once you started you felt that you couldn't stop)? (please circle one of the following) No days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Daily If you have never binged, please go to the next section. If you have ever binged, please answer the following questions: 102 IN THE PAST TWO WEEKS, how much of you has wanted to binge? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% IN THE PAST TWO WEEKS, how much of you has been actively working to reduce your bingeing? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% If you were to reduce your bingeing, how much of this would be for you (versus for others)? (please circle one of the following) Not very much for me About half for me Mostly for me 0% 10 20 30 40 50 60 70 80 90 100% If you decided to reduce your bingeing, how confident are you in your ability to do so? (please circle one of the following) Not at all confident Extremely confident 0% 10 20 30 40 50 60 70 80 90 100% 5. DIETARY RESTRICTION OUTSIDE OF EPISODES OF OVEREATING (only answer this question is you answered yes to question 4) ON HOW MANY DAYS OUT OF THE PAST 28 DAYS have you restricted your eating (i.e. < 1200 calories/day) before or after binges in order to compensate for the binge? (please circle one of the following) No days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Daily If you have never tried to restrict to compensate for bingeing, go to the next section. If you have ever restricted to compensate for bingeing, answer the following questions: IN THE PAST TWO WEEKS, how much of you has wanted to restrict to compensate for binges? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% IN THE PAST TWO WEEKS, how much of you has been actively working to reduce your restriction before or after a binge? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% If you were to reduce your restriction before or after a binge, how much of this would be for you vs. others? (please circle one of the following) Not very much for me About half for me Mostly for me 0% 10 20 30 40 50 60 70 80 90 100% 103 If you decided to reduce your restriction before or after a binge, how confident are you in your ability to do so? (please circle one of the following) Not at all confident Extremely confident 0% 10 20 30 40 50 60 70 80 90 100% 6. SELF INDUCED VOMITTING ON HOW MANY DAYS OUT OF THE PAST 28 DAYS have you made yourself sick (vomit) as a means of controlling your shape or weight or to counteract the effects of eating (please circle one of the following) No days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Daily If you have never made yourself sick, please go to the next section. If you have ever made yourself sick, please answer the following questions: IN THE PAST TWO WEEKS, how much of you has wanted to make yourself sick? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% IN THE PAST TWO WEEKS, how much of you has been actively working to reduce the amount you make yourself sick? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% If you were to reduce the amount you make yourself sick, how much of this would be for you (versus for others)? (please circle one of the following) Not very much for me About half for me Mostly for me 0% 10 20 30 40 50 60 70 80 90 100% If you decided to reduce the amount you make yourself sick, how confident are you in your ability to do so? (please circle one of the following) Not at all confident Extremely confident 0% 10 20 30 40 50 60 70 80 90 100% 7. LAXATIVE MISUSE ON HOW MANY DAYS OUT OF THE PAST 28 DAYS have you taken laxatives to control your shape or weight or to counteract the effects of eating? (circle one of the following) No days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Daily 104 If you have never misused laxatives, please go to the next section. If you have ever misused laxatives, please answer the following questions: IN THE PAST TWO WEEKS, how much of you has wanted to use laxatives to control shape/weight? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% IN THE PAST TWO WEEKS, how much of you has been actively working to reduce your laxative use? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% If you were to reduce your laxative use, how much of this would be for you (versus for others)? (please circle one of the following) Not very much for me About half for me Mostly for me 0% 10 20 30 40 50 60 70 80 90 100% If you decided to reduce your laxative use, how confident are you in your ability to do so? (please circle one of the following) Not at all confident Extremely confident 0% 10 20 30 40 50 60 70 80 90 100% 8. DIURETIC MISUSE ON HOW MANY DAYS OUT OF THE PAST 28 DAYS have you taken diuretics (water tablets) as a means of controlling your shape or weight or to counteract the effects of eating (please circle one of the following) No days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Daily If you have never tried to maintain a low weight, please go to the next section. If you have ever tried to maintain a low weight, please answer the following questions: IN THE PAST TWO WEEKS, how much of you has wanted to use diuretics to control shape/weight? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% IN THE PAST TWO WEEKS, how much of you has been actively working to reduce your diuretic use? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% 105 If you were to reduce your diuretic use, how much of this would be for you (vs. others)? (circle one of the following) Not very much for me About half for me Mostly for me 0% 10 20 30 40 50 60 70 80 90 100% If you decided to reduce your diuretic use, how confident are you in your ability to do so? (please circle one of the following) Not at all confident Extremely confident 0% 10 20 30 40 50 60 70 80 90 100% 9. EXERCISE TO CONTROL SHAPE OR WEIGHT ON HOW MANY DAYS OUT OF THE PAST 28 DAYS have you vigorously exercised as a means of controlling your weight, altering your shape or amount of fat, or burning off calories (please circle one of the following) No days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Daily If you have never exercised to control shape or weight, please go to the next section. If you have ever exercised to control shape or weight, answer the following questions: IN THE PAST TWO WEEKS, how much of you has wanted to exercise? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% IN THE PAST TWO WEEKS, how much of you has been actively working to reduce your exercise? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% If you were to reduce your exercise, how much of this would be for you (versus for others)? (please circle one of the following) Not very much for me About half for me Mostly for me 0% 10 20 30 40 50 60 70 80 90 100% If you decided to reduce your exercise, how confident are you in your ability to do so? (please circle one of the following) Not at all confident Extremely confident 0% 10 20 30 40 50 60 70 80 90 100% 106 10. FEAR OF WEIGHT GAIN ON HOW MANY DAYS OUT OF THE PAST 28 DAYS have you had a definite fear that you might gain weight or become fat? (please circle one of the following) No days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Daily If you have never had a fear of weight gain, please go to the next section. If you have ever had a fear of weight gain, please answer the following questions: IN THE PAST TWO WEEKS, how much of you has wanted to hold on to your fear of weight gain? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% IN THE PAST TWO WEEKS, how much of you has been actively working to reduce your fear of weight gain? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% If you were to reduce your fear of weight gain, how much of this would be for you (versus for others)? (please circle one of the following) Not very much for me About half for me Mostly for me 0% 10 20 30 40 50 60 70 80 90 100% If you decided to reduce your fear of weight gain, how confident are you in your ability to do so? (please circle one of the following) Not at all confident Extremely confident 0% 10 20 30 40 50 60 70 80 90 100% 11. FEELINGS OF FATNESS ON HOW MANY DAYS OUT OF THE PAST 28 DAYS have you felt fat? (please circle one of the following) No days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Daily If you have never felt fat, please go to the next section. If you have ever felt fat, please answer the following questions: IN THE PAST TWO WEEKS, how much of you has wanted to hold on to your feelings of fatness? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% 107 IN THE PAST TWO WEEKS, how much of you has been actively working to reduce your feelings of fatness? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% If you were to reduce your feelings of fatness, how much of this would be for you (versus for others)? (please circle one of the following) Not very much for me About half for me Mostly for me 0% 10 20 30 40 50 60 70 80 90 100% If you decided to reduce your feelings of fatness, how confident are you in your ability to do so?(please circle one of the following) Not at all confident Extremely confident 0% 10 20 30 40 50 60 70 80 90 100% 12. IMPORTANCE OF SHAPE AND WEIGHT ON HOW MANY DAYS OUT OF THE PAST 28 DAYS, has your weight and/or shape influenced how you think about (judge) yourself as a person? (please circle one of the following) No days 1-5 days 6-12 days 13-15 days 16-22 days 23-27 days Daily If shape or weight has never influenced how you judge yourself, please go to the next section. If shape or weight has ever influenced how you judge yourself, answer the following questions: IN THE PAST TWO WEEKS, how much of you has wanted your shape or weight to matter? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% IN THE PAST TWO WEEKS, how much of you has been actively working to make shape or weight matter less? (please circle one of the following) A small part of me About half of me Most of me 0% 10 20 30 40 50 60 70 80 90 100% If you were to try to make shape or weight matter less, how much of this would be for you (versus for others)? (please circle one of the following) Not very much for me About half for me Mostly for me 0% 10 20 30 40 50 60 70 80 90 100% If you decided to make shape and weight matter less, how confident are you in your ability to do so? (please circle one of the following) Not at all confident Extremely confident 0% 10 20 30 40 50 60 70 80 90 100% 108 Patient Health Questionnaire (PHQ-9) Over the last 2 weeks, how often have you been bothered by any of the following problems? Not at all Several days More than half the days Nearly every day 1. Little interest or pleasure in doing things ☐ 0 ☐ 1 ☐ 2 ☐ 3 2. Feeling down, depressed, or hopeless ☐ 0 ☐ 1 ☐ 2 ☐ 3 3. Trouble falling or staying asleep, or sleeping too much ☐ 0 ☐ 1 ☐ 2 ☐ 3 4. Feeling tired or having little energy ☐ 0 ☐ 1 ☐ 2 ☐ 3 5. Poor appetite or overeating ☐ 0 ☐ 1 ☐ 2 ☐ 3 6. Feeling bad about yourself – or that you are a failure or have let yourself or your family down ☐ 0 ☐ 1 ☐ 2 ☐ 3 7. Trouble concentrating on things, such as reading the newspaper or watching television ☐ 0 ☐ 1 ☐ 2 ☐ 3 8. Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual ☐ 0 ☐ 1 ☐ 2 ☐ 3 9. Thoughts that you would be better off dead or of hurting yourself in some way ☐ 0 ☐ 1 ☐ 2 ☐ 3 If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? ☐ Not difficult at all ☐ Somewhat difficult ☐ Very difficult ☐ Extremely difficult 109 General Anxiety Disorder (GAD-7) 1. Over the last 2 weeks, how often have you been bothered by the following problems? Not at all Several days More than half the days Nearly every day Feeling nervous, anxious, or on edge ☐ 0 ☐ 1 ☐ 2 ☐ 3 Not being able to stop or control worrying ☐ 0 ☐ 1 ☐ 2 ☐ 3 Worrying too much about different things ☐ 0 ☐ 1 ☐ 2 ☐ 3 Trouble relaxing ☐ 0 ☐ 1 ☐ 2 ☐ 3 Being so restless that it's hard to sit still ☐ 0 ☐ 1 ☐ 2 ☐ 3 Becoming easily annoyed or Irritable ☐ 0 ☐ 1 ☐ 2 ☐ 3 Feeling afraid as if something awful might happen ☐ 0 ☐ 1 ☐ 2 ☐ 3 2. If you checked off any problem on this questionnaire so far, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? ☐ Not difficult at all ☐ Somewhat difficult ☐ Very difficult ☐ Extremely difficult 110 Body Shape Questionnaire (BSQ-34) We should like to know how you have been feeling about your appearance over the PAST FOUR WEEKS. Please read each question and circle the appropriate number to the right. Please answer all the questions. OVER THE PAST FOUR WEEKS: Never Rarely Some-times Often Very Often Always 1. Has feeling bored made you brood about your shape? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 2. Have you been so worried about your shape that you have been feeling you ought to diet? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 3. Have you thought that your thighs, hips, or bottom are too large for the rest of you? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 4. Have you been afraid that you might become fat (or fatter)? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 5. Have you worried about your flesh being not firm enough? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 6. Has feeling full (e.g., after eating a large meal) made you feel fat? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 7. Have you felt so bad about your shape that you have cried? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 8. Have you avoided running because your flesh might wobble? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 9. Has being with thin women made you feel self-conscious about your shape? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 10. Have you worried about your thighs spreading out when sitting down? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 11. Has eating even a small amount of food made you feel fat? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 111 12. Have you noticed the shape of other women and felt that your own shape compared unfavourably? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 13. Has thinking about your shape interfered with your ability to concentrate (e.g., while watching television, reading, listening to conversations)? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 14. Has being naked, such as when taking a bath, made you feel fat? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 15. Have you avoided wearing clothes which make you particularly aware of the shape of your body? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 16. Have you imagined cutting off fleshy areas of your body? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 17. Has eating sweets, cakes, or other high calorie food made you feel fat? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 18. Have you not gone out to social occasions (e.g., parties) because you have felt bad about your shape? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 19. Have you felt excessively large and rounded? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 20. Have you felt ashamed of your body? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 21. Has worry about your shape made you diet? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 22. Have you felt happiest about your shape when your stomach has been empty (e.g., in the morning)? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 23. Have you thought that you are in the shape you are because you lack self-control? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 112 24. Have you worried about other people seeing rolls of fat around your waist or stomach? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 25. Have you felt that it is not fair that other women are thinner than you? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 26. Have you vomited in order to feel thinner? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 27. When in company have your worried about taking up too much room (e.g., sitting on a sofa, or a bus seat)? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 28. Have you worried about your flesh being dimply? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 29. Has seeing your reflection (e.g., in a mirror or shop window) made you feel bad about your shape? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 30. Have you pinched areas of your body to see how much fat there is? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 31. Have you avoided situations where people could see your body (e.g., communal changing rooms or swimming baths)? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 32. Have you taken laxatives in order to feel thinner? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 33. Have you been particularly self-conscious about your shape when in the company of other people? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 34. Has worry about your shape made you feel you ought to exercise? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 ☐ 6 113 eHEALS Literacy Scale I would like to ask you for your opinion and about your experience using the Internet for health information. For each statement, tell me which response best reflects your opinion and experience right now. 1. How useful do you feel the Internet is in helping you in making decisions about your health? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 Not useful at all Not useful Unsure Useful Very useful 2. How important is it for you to be able to access health resources on the Internet? ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 Not useful at all Not useful Unsure Useful Very useful 3. I know what health resources are available on the Internet a. Strongly Disagree b. Disagree c. Undecided d. Agree e. Strongly Agree 4. I know where to find helpful health resources on the Internet a. Strongly Disagree b. Disagree c. Undecided d. Agree e. Strongly Agree 5. I know how to find helpful health resources on the Internet a. Strongly Disagree b. Disagree c. Undecided d. Agree e. Strongly Agree 6. I know how to use the Internet to answer my questions about health a. Strongly Disagree b. Disagree c. Undecided d. Agree e. Strongly Agree 7. I know how to use the health information I find on the Internet to help me a. Strongly Disagree b. Disagree c. Undecided d. Agree e. Strongly Agree 114 8. I have the skills I need to evaluate the health resources I find on the Internet a. Strongly Disagree b. Disagree c. Undecided d. Agree e. Strongly Agree 9. I can tell high quality health resources from low quality health resources on the Internet a. Strongly Disagree b. Disagree c. Undecided d. Agree e. Strongly Agree 10. I feel confident in using information from the Internet to make health decisions a. Strongly Disagree b. Disagree c. Undecided d. Agree e. Strongly Agree 115 Mobile Device Proficiency Questionnaire (MDPQ) About the MDPQ This questionnaire asks about your ability to perform a number of tasks with a mobile device. What is a Mobile Device? A mobile device is a device that allows you to perform many of the same tasks as a standard computer but without the use of a physical keyboard and mouse. Instead, these devices use a touchscreen as their interface between the user and computer programs (called Apps—short for applications). Mobile devices come in many sizes. Depicted above are two different sized tablets, as well as a smartphone. These are the types of devices we are interested in. Instructions Please answer each question by placing an X in the box that is most appropriate. If you have not tried to perform a task with a mobile device or do not know what a task is, please mark “NEVER TRIED,” regardless of whether or not you think you may be able to perform the task. Remember, you are rating your ability to perform each of these tasks specifically using a mobile device (tablet or smartphone). 116 1. Mobile Device Basics Using a mobile device I can: Never tried Not at all Not very easily Somewhat easily Very easily a. Turn the device on and off ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 b. Charge the device when the battery is low ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 c. Navigate onscreen menus using the touchscreen ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 d. Use the onscreen keyboard to type ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 e. Copy and paste text using the touchscreen ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 f. Adjust the volume of the device ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 g. Adjust the screen brightness ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 h. Adjust text size ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 i. Connect to a WiFi network ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 2. Communication Using a mobile device I can: Never tried Not at all Not very easily Somewhat easily Very easily a. Open emails ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 b. Send emails ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 c. Send the same email to multiple people at the same time ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 d. Store email addresses in an email address book or contact list ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 e. View pictures sent by email ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 f. Send pictures by email ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 g. Post messages to Social Media Networks (e.g., Facebook, Twitter, Instagram, Google Plus) ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 117 Using a mobile device I can: Never tried Not at all Not very easily Somewhat easily Very easily h. Use instant-messaging (e.g., AIM, Yahoo Messenger, MSN Messenger) ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 i. Use video-messaging (e.g., Skype, Google Hangout, FaceTime) ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 3. Data and File Storage Using a mobile device I can: Never tried Not at all Not very easily Somewhat easily Very easily a. Transfer information (files such as music, pictures, documents) on my mobile device to my computer ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 b. Transfer information (files such as music, pictures, documents) on my computer to my mobile device ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 c. Store information with a service that lets me view my files from anywhere (e.g., Dropbox, Google Drive, Microsoft Onedrive) ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 4. Internet Using a mobile device I can: Never tried Not at all Not very easily Somewhat easily Very easily a. Use search engines (e.g., Google, Bing) ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 b. Find information about local community resources on the Internet ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 c. Find information about my hobbies and interests on the Internet ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 d. Find health information on the Internet ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 118 Using a mobile device I can: Never tried Not at all Not very easily Somewhat easily Very easily e. Read the news on the Internet ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 f. Make purchases on the Internet ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 g. Bookmark websites to find them again later (make favorites) ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 h. Save text and images I find on the Internet ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 5. Calendar Using a mobile device I can: Never tried Not at all Not very easily Somewhat easily Very easily a. Enter events and appointments into a calendar ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 b. Check the date and time of upcoming and prior appointments ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 c. Set up alerts to remind me of events and appointments ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 6. Entertainment Using a mobile device I can: Never tried Not at all Not very easily Somewhat easily Very easily a. Use the device’s online “store” to find games and other forms of entertainment (e.g., using Apple App Store or Google Play Store) ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 b. Watch movies and videos ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 c. Listen to music ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 d. Read a book ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 e. Take pictures and video ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 119 7. Privacy Using a mobile device I can: Never tried Not at all Not very easily Somewhat easily Very easily a. Set up a password to lock/ unlock the device ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 b. Erase pictures and videos stored on the device ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 c. Erase all Internet browsing history and temporary files ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 d. Reset the device to factory settings, erasing all account information ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 8. Troubleshooting and Software Management Using a mobile device I can: Never tried Not at all Not very easily Somewhat easily Very easily a. Restart the device when it is frozen or not working right ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 b. Update games and other applications ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 c. Close games and other applications ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 d. Delete games and other applications ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 e. Upgrade device software ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 120 Adapted Technology Acceptance Model Questionnaire Perceived Usefulness 1. Using MI-Coach: ED allowed me to access mental health services more quickly. a. Extremely likely b. Quite likely c. Slightly likely d. Neither likely nor unlikely e. Slightly unlikely f. Quite unlikely g. Extremely unlikely 2. Using MI-Coach: ED improved my eating disorder symptoms. a. Extremely likely b. Quite likely c. Slightly likely d. Neither likely nor unlikely e. Slightly unlikely f. Quite unlikely g. Extremely unlikely 3. Using MI-Coach: ED increased my motivation to recover from my eating disorder. a. Extremely likely b. Quite likely c. Slightly likely d. Neither likely nor unlikely e. Slightly unlikely f. Quite unlikely g. Extremely unlikely 4. Using MI-Coach: ED enhanced my ability to stay on my treatment waitlist. a. Extremely likely b. Quite likely c. Slightly likely d. Neither likely nor unlikely e. Slightly unlikely f. Quite unlikely g. Extremely unlikely 5. Using MI-Coach: ED made it easier to start my eating disorder recovery. a. Extremely likely b. Quite likely c. Slightly likely d. Neither likely nor unlikely 121 e. Slightly unlikely f. Quite unlikely g. Extremely unlikely 6. I found MI-Coach: ED to be useful in my eating disorder recovery. a. Extremely likely b. Quite likely c. Slightly likely d. Neither likely nor unlikely e. Slightly unlikely f. Quite unlikely g. Extremely unlikely Perceived Ease of Use 7. Learning to use MI-Coach: ED was easy for me. a. Extremely likely b. Quite likely c. Slightly likely d. Neither likely nor unlikely e. Slightly unlikely f. Quite unlikely g. Extremely unlikely 8. I found it easy to do what I wanted to do on MI-Coach: ED a. Extremely likely b. Quite likely c. Slightly likely d. Neither likely nor unlikely e. Slightly unlikely f. Quite unlikely g. Extremely unlikely 9. Using MI-Coach: ED was clear and understandable a. Extremely likely b. Quite likely c. Slightly likely d. Neither likely nor unlikely e. Slightly unlikely f. Quite unlikely g. Extremely unlikely 122 10. I found MI-Coach: ED to be flexible to interact with. a. Extremely likely b. Quite likely c. Slightly likely d. Neither likely nor unlikely e. Slightly unlikely f. Quite unlikely g. Extremely unlikely 11. It was easy for me to become skillful at using MI-Coach: ED. a. Extremely likely b. Quite likely c. Slightly likely d. Neither likely nor unlikely e. Slightly unlikely f. Quite unlikely g. Extremely unlikely 12. I found MI-Coach: ED easy to use. a. Extremely likely b. Quite likely c. Slightly likely d. Neither likely nor unlikely e. Slightly unlikely f. Quite unlikely g. Extremely unlikely 123 Mobile Application Rating Scale: User Version (uMARS) Circle the number that most accurately represents the quality of the app you are rating. All items are rated on a 5-point scale from 1. Inadequate to 5. Excellent. Select N/A if the app component is irrelevant. App Quality Ratings SECTION A Engagement – fun, interesting, customisable, interactive, has prompts (e.g., sends alerts, messages, reminders, feedback, enables sharing) 1. Entertainment: Is the app fun/entertaining to use? Does it have components that make it more fun than other similar apps? 1 Dull, not fun or entertaining at all 2 Mostly boring 3 OK, fun enough to entertain user for a brief time (< 5 minutes) 4 Moderately fun and entertaining, would entertain user for some time (5-10 minutes total) 5 Highly entertaining and fun, would stimulate repeat use 2. Interest: Is the app interesting to use? Does it present its information in an interesting way compared to other similar apps? 1 Not interesting at all 2 Mostly uninteresting 3 OK, neither interesting nor uninteresting; would engage user for a brief time (< 5 minutes) 4 Moderately interesting; would engage user for some time (5-10 minutes total) 5 Very interesting, would engage user in repeat use 3. Customisation: Does it allow you to customise the settings and preferences that you would like to (e.g., sound, content, and notifications)? 1 Does not allow any customisation or requires setting to be input every time 2 Allows little customisation and that limits app’s functions 3 Basic customisation to function adequately 4 Allows numerous options for customisation 5 Allows complete tailoring the user’s characteristics/preferences, remembers all settings 124 4. Interactivity: Does it allow user input, provide feedback, contain prompts (reminders, sharing options, notifications, etc.)? 1 No interactive features and/or no response to user input 2 Some, but not enough interactive features which limits app’s functions 3 Basic interactive features to function adequately 4 Offers a variety of interactive features, feedback and user input options 5 Very high level of responsiveness through interactive features, feedback and user input options 5. Target group: Is the app content (visuals, language, design) appropriate for the target audience? 1 Completely inappropriate, unclear or confusing 2 Mostly inappropriate, unclear or confusing 3 Acceptable but not specifically designed for the target audience. May be inappropriate/unclear/confusing at times 4 Designed for the target audience, with minor issues 5 Designed specifically for the target audience, no issues found SECTION B Functionality – app functioning, easy to learn, navigation, flow logic, and gestural design of app 6. Performance: How accurately/fast do the app features (functions) and components (buttons/menus) work? 1 App is broken; no/insufficient/inaccurate response (e.g. crashes/bugs/broken features, etc.) 2 Some functions work, but lagging or contains major technical problems 3 App works overall. Some technical problems need fixing, or is slow at times 4 Mostly functional with minor/negligible problems 5 Perfect/timely response; no technical bugs found, or contains a ‘loading time left’ indicator (if relevant) 7. Ease of use: How easy is it to learn how to use the app; how clear are the menu labels, icons, and instructions? 1 No/limited instructions; menu labels, icons are confusing; complicated 2 Takes a lot of time or effort 3 Takes some time or effort 4 Easy to learn (or has clear instructions) 5 Able to use app immediately; intuitive; simple (no instructions needed) 125 8. Navigation: Does moving between screens make sense; Does app have all necessary links between screens? 1 No logical connection between screens at all /navigation is difficult 2 Understandable after a lot of time/effort 3 Understandable after some time/effort 4 Easy to understand/navigate 5 Perfectly logical, easy, clear and intuitive screen flow throughout, and/or has shortcuts 9. Gestural design: Do taps/swipes/pinches/scrolls make sense? Are they consistent across all components/screens? 1 Completely inconsistent/confusing 2 Often inconsistent/confusing 3 OK with some inconsistencies/confusing elements 4 Mostly consistent/intuitive with negligible problems 5 Perfectly consistent and intuitive SECTION C Aesthetics – graphic design, overall visual appeal, colour scheme, and stylistic consistency 10. Layout: Is arrangement and size of buttons, icons, menus, and content on the screen appropriate? 1 Very bad design, cluttered, some options impossible to select, locate, see or read 2 Bad design, random, unclear, some options difficult to select/locate/see/read 3 Satisfactory, few problems with selecting/locating/seeing/reading items 4 Mostly clear, able to select/locate/see/read items 5 Professional, simple, clear, orderly, logically organised 11. Graphics: How high is the quality/resolution of graphics used for buttons, icons, menus, and content? 1 Graphics appear amateur, very poor visual design - disproportionate, stylistically inconsistent 2 Low quality/low resolution graphics; low quality visual design – disproportionate 3 Moderate quality graphics and visual design (generally consistent in style) 4 High quality/resolution graphics and visual design – mostly proportionate, consistent in style 5 Very high quality/resolution graphics and visual design - proportionate, consistent in style 126 12. Visual appeal: How good does the app look? 1 Ugly, unpleasant to look at, poorly designed, clashing, mismatched colours 2 Bad – poorly designed, bad use of colour, visually boring 3 OK – average, neither pleasant, nor unpleasant 4 Pleasant – seamless graphics – consistent and professionally designed 5 Beautiful – very attractive, memorable, stands out; use of colour enhances app features/menus SECTION D Information – Contains high quality information (e.g., text, feedback, measures, references) from a credible source 13. Quality of information: Is app content correct, well written, and relevant to the goal/topic of the app? N/A There is no information within the app 1 Irrelevant/inappropriate/incoherent/incorrect 2 Poor. Barely relevant/appropriate/coherent/may be incorrect 3 Moderately relevant/appropriate/coherent/and appears correct 4 Relevant/appropriate/coherent/correct 5 Highly relevant, appropriate, coherent, and correct 14. Quantity of information: Is the information within the app comprehensive but concise? N/A There is no information within the app 1 Minimal or overwhelming 2 Insufficient or possibly overwhelming 3 OK but not comprehensive or concise 4 Offers a broad range of information, has some gaps or unnecessary detail; or has no links to more information and resources 5 Comprehensive and concise; contains links to more information and resources 15. Visual information: Is visual explanation of concepts – through charts/graphs/ images/videos, etc. – clear, logical, correct? N/A There is no visual information within the app (e.g., it only contains audio, or text) 1 Completely unclear/confusing/wrong or necessary but missing 2 Mostly unclear/confusing/wrong 3 OK but often unclear/confusing/wrong 4 Mostly clear/logical/correct with negligible issues 5 Perfectly clear/logical/correct 127 16. Credibility of source: does the information within the app seem to come from a credible source? N/A N/A There is no information within the app 1 Suspicious source 2 Lacks credibility 3 Not suspicious but legitimacy of source is unclear 4 Possibly comes from a legitimate source 5 Definitely comes from a legitimate/specialised source App Subjective Quality SECTION E 17. Would you recommend this app to people who might benefit from it? 1 Not at all I would not recommend this app to anyone 2 There are very few people I would recommend this app to 3 Maybe There are several people I would recommend this app to 4 There are many people I would recommend this app to 5 Definitely I would recommend this app to everyone 18. How many times do you think you would use this app in the next 12 months if it was relevant to you? 1 None 2 1-2 3 3-10 4 10-50 5 >50 19. Would you pay for this app? 1 Definitely not 2 3 4 5 Definitely yes 128 20. What is your overall (star) rating of the app? 1 ★ One of the worst apps I’ve used 2 ★★ 3 ★★★ Average 4 ★★★★ 5 ★★★★★ One of the best apps I've used Perceived Impact SECTION F 1. Awareness – This app has increased my awareness of the importance of addressing the health behaviour Strongly Disagree Strongly Agree ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 2. Knowledge – This app has increased my knowledge/ understanding of the health behaviour ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 3. Attitudes – The app has changed my attitudes toward improving this health behaviour ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 4. Intention to change – The app has increased my intentions/motivation to address this health behaviour ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 5. Help seeking – This app would encourage me to seek further help to address the health behaviour (if I needed it) ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 6. Behaviour change – Use of this app will increase/decrease the health behaviour ☐ 1 ☐ 2 ☐ 3 ☐ 4 ☐ 5 Do you have any further comments about the app? 129 Appendix D: Time 1 Consent Form Mobile App-Delivered Motivational Interviewing for Individuals on Eating Disorder Clinic Waitlists: Pilot and Feasibility Study Principal Investigators: Maya Libben, Ph.D., Department of Psychology, UBC Irving K. Barber School of Arts and Social Sciences, ASC 284 University of British Columbia Okanagan Email: plan.lab@ubc.ca Work: 250-807-9026 Co-Investigator: Amané Halicki-Asakawa, B.A., The PLAN Lab, UBC Invitation We would like to invite you to take part in a research study for adult women on waitlists for eating disorder treatment. This consent form describes the study and the details of the research project. Please take time to read the following information carefully and contemplate whether you would like to participate in the study. If you do wish to participate in this study, you will be asked to sign this form. Background of the study Many women with eating disorders face significant barriers to accessing treatment, due to both external (e.g., long waitlists) and internal (e.g., low motivation) factors. As treatment delays are associated with worsening symptoms, there is a strong need to explore other ways of delivering treatments to women with eating disorders. Mobile apps have been suggested as an accessible, cost-effective, and enjoyable way to deliver such services. This study will pilot test a mobile-app based intervention, MI-Coach: ED, that is designed to increase motivation to recover from an eating disorder in adult women aged 18 and above. What is the purpose of the study? The goal of this study is to gather information on whether the MI-Coach: ED app is an acceptable and feasible way to improve motivation to recover from an eating disorder. This study aims to do this by asking adult women on eating disorder waitlists to use the mobile app for a one-month duration, and to provide their feedback on their experience. This study will help us understand the strengths and weaknesses of the mobile app, and to assess if it is well-suited to women with eating disorders and their needs. The results will be used to improve the mobile app, and to develop future studies that will further evaluate MI-Coach: ED. Who is conducting the study? The Principal Investigator, Dr. Maya Libben, and the Co-Investigator, Amané Halicki-Asakawa, are researchers from the University of British Columbia in the Okanagan. The researchers specialize in studying eating disorders. This study is part of Amané Halicki-Asakawa’s Master’s thesis, which is a public document that will be available on the Internet through UBC cIRcle. 130 Who can participate in this study? You can participate in this study if you identify as a woman between the ages of 18-60 experiencing eating disorder symptoms, currently on a waitlist to receive eating disorder treatment in British-Columbia. It is also important that you are comfortable communicating in English. Who should not participate in the study? Individuals who have a history of psychosis or diagnosis of a schizophrenia-spectrum disorder, or have experienced a recent traumatic brain injury or other cognitive impairment should not participate in the study, as these aforementioned conditions may impact their ability to use the MI-Coach: ED app. What does the study involve? This study will take approximately 5 – 14 hours in total. In the study, you will be asked to complete a series of questionnaires that could take up to 1 hour, online. Then, you will meet with the researcher or research assistant on Zoom (https://zoom.us), a secure teleconferencing platform, and will be oriented to the MI-Coach: ED app (estimated to take 45 min in total), and given access to the app for a 1-month duration. You may use the app as much as you wish during this time. Following this, you will be asked to complete another series of online questionnaires, which may take up to 1 hour. Finally, you will participate in a Zoom interview, during which you will be asked about your experience using the MI-Coach: ED app. The interview may be up to 1 hour. Please be advised that the Zoom interview will be recorded. In order to better understand your use of the MI-Coach: ED app, we will track information such as the number of sessions you complete, the videos that you choose to watch, and the ways in which you complete the exercises. Your participation is voluntary Your participation in this study is entirely voluntary. If you do not wish to take part, there will be no disadvantage of any kind to you and we thank you for considering our request. What are the possible harms and discomforts? If you participate in this study, there are risks no greater than what you would experience in your daily life. Some of the questions or topics in the study may make you uncomfortable. You may choose not to answer those questions or participate in those mobile-app sessions. You may also withdraw from this study at any time without penalty by closing your browser to exit the survey, leaving the Zoom meeting, or discontinuing app use. If you choose to withdraw, your data will be deleted and omitted from analysis. What are the potential benefits of participating? This research study will provide important scientific information and our findings can help find ways to improve service access for women with eating disorders in the future. In addition, you may experience improvements in your motivation to recover from your eating disorder. 131 Will I be paid for participating in the study? You will be offered $10 CAD for each study component completed (i.e., orientation, two sets of questionnaires, interview), resulting in a total of $40 CAD compensation via online gift card for full participation. In addition, you will be provided with 1-year access to the MI-Coach © app (valued at $122 CAD). How will my taking part in this study be kept confidential? Your confidentiality will be respected. All information collected from this study will be kept completely confidential. All documents will be identified only by code number and stored electronically. You will not be identified by name in any reports or presentations of the completed study. The online questionnaires will be administered by the UBC-hosted version of Qualtrics. All data will be stored and backed up in Canada. Once the data has been downloaded to a confidential and password-protected laboratory computer, they will be permanently deleted from the Qualtrics servers. The Zoom orientation and interview will be conducted using a UBC licensed version of Zoom, which uses servers located in Canada. The Zoom interview will be recorded and then transcribed, after which the recording will be permanently deleted. All identifying information will be deleted from the interview transcripts. All data entered into the mobile app will be protected and kept confidential according to Resiliens Inc.’s privacy policy (https://resiliens.com/privacy), the developers of the MI-Coach: ED app. All data security practices are in line with the US’ Health Insurance Portability and Accountability Act (“HIPAA”). Resiliens Inc.’s data is stored through the Amazon Web Services platform on secure servers located in North Virginia, USA, and will be permanently deleted once the data is securely transferred to project researchers. The data on which the results of the project depend upon will be retained in secure storage for 5 years after the research has been published. After this time, they will be destroyed. Your rights to privacy are legally protected by federal and provincial laws that require safeguards to ensure that your privacy is respected. Further details about these laws are available on request to your study Investigator. Who do I contact if I have questions about the study during my participation? Please feel free to contact us at any time with questions and concerns you may have about participating in this research study. You are also welcome to contact Dr. Libben to request the results of the study. Who do I contact if I have any questions or concerns about my rights as a participant? If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the University of British Columbia Office of Research Ethics by e-mail at RSIL@ors.ubc.ca or by phone at 604-822-8598 (Toll Free: 1-877-822-8598). Please reference the study number H22-02046 when calling so the Complaint Line staff can better assist you. 132 CONSENT FORM Mobile App-Delivered Motivational Interviewing for Individuals on Eating Disorder Clinic Waitlists: Pilot and Feasibility Study Participant Consent Signatures By signing the section below, you acknowledge that all of your questions pertaining to the current study have been answered, and consent to participate is given. Your participation in this study is entirely voluntary and you may withdraw from the study at any time. ☐ I consent to participate in this study. ☐ I consent to the recording of the Zoom interview. My Name Signature Date 133 Appendix E: Brief Consent Form Mobile App-Delivered Motivational Interviewing for Individuals on Eating Disorder Clinic Waitlists: Pilot and Feasibility Study Principal Investigators: Maya Libben, Ph.D., Department of Psychology, UBC Irving K. Barber School of Arts and Social Sciences, ASC 284 University of British Columbia Okanagan Email: plan.lab@ubc.ca Work: 250-807-9026 Co-Investigator: Amané Halicki-Asakawa, B.A., The PLAN Lab, UBC Invitation We would like to invite you again to take part of a research study for adult women on waitlists for eating disorder treatment. Given the duration of time that has passed since the initial consent form was signed, the purpose of this form is to revisit whether you would like to continue to take part in the study. This consent form describes the details of the research project, as well as the previous activities to which you consented. Please take time to read the following information carefully and contemplate whether you would like to continue participation. If you do wish to participate in this study, you will be asked to sign this form. Purpose of the study This study will pilot test a mobile-app based intervention, MI-Coach: ED, that is designed to increase motivation to recover from an eating disorder in adult women aged 18 and above. The goal is to determine if the app is an acceptable and feasible way to improve motivation to recover from an eating disorder. This study aims to do this by asking adult women on eating disorder waitlists to use the mobile app for a one-month duration, and to provide their feedback on their experience. The results will be used to improve the mobile app, and to develop future studies that will further evaluate MI-Coach: ED. Who is conducting the study? The Principal Investigator, Dr. Maya Libben, and the Co-Investigator, Amané Halicki-Asakawa, are researchers from the University of British Columbia in the Okanagan. This study is part of Amané Halicki-Asakawa’s Master’s thesis, which is a public document that will be available on the Internet through UBC cIRcle. What did I consent to previously? During the previous consent process, you agreed to take part in the following study components (estimated to take 5-14 hours in total): the completion of two sets of questionnaires (taking up to 1 hour each, online), an orientation to the MI-Coach: ED app (taking approximately 45 minutes), use of the app month for a 1-month duration, and a 1-hour recorded Zoom interview asking about your experiences using the app. This consent form revisits whether you would like to continue with the completion of the second set of questionnaires and the Zoom interview and will take approximately 2 hours in total. 134 Your participation is voluntary Your participation in this study is entirely voluntary. If you do not wish to take part, there will be no disadvantage of any kind to you and we thank you for considering our request. What are the possible harms and discomforts? If you participate in this study, there are risks no greater than what you would experience in your daily life. Some of the questions or topics in the study may make you uncomfortable. You may choose not to answer those questions. You may also withdraw from this study by closing your browser to exit the survey or leaving the Zoom meeting. If you choose to withdraw, all of your data, including from the first portion of the study, will be deleted and omitted from analysis. What are the potential benefits of participating? This research study will provide important scientific information and our findings can help find ways to improve service access for women with eating disorders in the future. Will I be paid for participating in the study? You will be offered $10 CAD for each study component completed (i.e., orientation, two sets of questionnaires, interview), resulting in a total of $40 CAD compensation via online gift card for full participation. In addition, you will be provided with 1-year access to the MI-Coach © app (valued at $122 CAD). How will my taking part in this study be kept confidential? Your confidentiality will be respected. All information collected from this study will be kept completely confidential. All documents will be identified only by code number and stored electronically. You will not be identified by name in any reports or presentations of the completed study. The online questionnaires will be administered by the UBC-hosted version of Qualtrics. All data will be stored and backed up in Canada. Once the data has been downloaded to a confidential and password-protected laboratory computer, they will be permanently deleted from the Qualtrics servers. Zoom interviews will be conducted using a UBC licensed version of Zoom, which uses servers located in Canada. The Zoom interview will be recorded and then transcribed, after which the recording will be permanently deleted. All identifying information will be deleted from the interview transcripts. All data entered into the mobile app will be protected and kept confidential according to Resiliens Inc.’s privacy policy (https://resiliens.com/privacy), the developers of the MI-Coach: ED app. All data security practices are in line with the US’ Health Insurance Portability and Accountability Act (“HIPAA”). Resiliens Inc.’s data is stored through the Amazon Web Services platform on secure servers located in North Virginia, USA, and will be permanently deleted once the data is securely transferred to project researchers. The data on which the results of the project depend upon will be retained in secure storage for 5 years after the research has been published. After this time, they will be destroyed. Your rights to privacy are legally protected by federal and provincial laws that require safeguards to ensure that your privacy is respected. Further details about these laws are available on request to your study Investigator. 135 Who do I contact if I have questions about the study during my participation? Please feel free to contact us at any time with questions and concerns you may have about participating in this research study. You are also welcome to contact Dr. Libben to request the results of the study. Who do I contact if I have any questions or concerns about my rights as a participant? If you have any concerns or complaints about your rights as a research participant and/or your experiences while participating in this study, contact the Research Participant Complaint Line in the University of British Columbia Office of Research Ethics by e-mail at RSIL@ors.ubc.ca or by phone at 604-822-8598 (Toll Free: 1-877-822-8598). Please reference the study number H22-02046 when calling so the Complaint Line staff can better assist you. 136 BRIEF CONSENT FORM Mobile App-Delivered Motivational Interviewing for Individuals on Eating Disorder Clinic Waitlists: Pilot and Feasibility Study Participant Consent Signatures By signing the section below, you acknowledge that all of your questions pertaining to the current study have been answered, and consent to participate is given. Your participation in this study is entirely voluntary and you may withdraw from the study at any time. ☐ I consent to participate in this study. ☐ I consent to the recording of the Zoom interview. My Name Signature Date 137 Appendix F: Qualitative Interview Guide General Questions 1. How are you doing today? a. Follow up: How are you doing in regard to your eating disorder recovery? 2. What has your experience been so far in terms of being on a waitlist for eating disorder treatment? a. Follow up: How many treatment sites have you been waitlisted for? b. Follow up: How long have you been waiting for services? c. Follow up: Have you been able to access any services in the interim (e.g., self-help books, websites, peer support groups, etc.) 3. What experience do you have in regard to internet- and mobile-app based mental health services, aside from MI-Coach: ED? a. If applicable: Of those that you have accessed, how many have been specific to eating disorder recovery? Expectations 4. Recall your experience prior to starting the program: what were your expectations and hopes for MI-Coach: ED? a. Follow up: How did you think this mobile app would work for you? b. Follow up: Was there anything that you looked forward to? That you didn’t look forward to? 5. What has or has not met your expectations? 6. How has your view of the program changed since you started using MI-Coach: ED? 7. How has your experience been different from previous interventions you accessed for your eating disorder (e.g., face-to-face treatment, self-help programs, online, etc.)? Acceptability 8. What were your first thoughts when you first started using MI-Coach: ED? 9. How often did you find yourself using the mobile app on a daily/weekly basis? a. Follow up: How many sessions did you get through? b. Follow up: How many exercises did you complete? 10. What was your favourite part of the app? What was your least-favourite part? 138 Content 11. What changes (for the better/the worse), if any, have you noticed in yourself through using the MI-Coach: ED app (e.g., eating disorder behaviours, motivation to recover, outlook on staying on treatment waitlists, feelings about future, relationship with others)? 12. How has the mobile-app helped/not helped you prepare for treatment? 13. Which aspect of the MI-Coach: ED app was the most/least helpful to you? a. Video sessions b. Exercises c. Articles 14. Which session of MI-Coach: ED did you find most helpful? 15. Is there any aspect of the mobile app that you feel should be changed? d. Follow up: Is there anything that you feel was missed? Barriers/Facilitators 16. What was easy/difficult for you in trying to integrate MI-Coach: ED into your daily routine? a. Follow up: Any technology-related factors? (e.g., interface, notifications, user experience) b. Follow up: Any personal factors? 17. Is there any other way that you feel that MI-Coach: ED can be improved? (e.g., how it looks, session content, layout, etc.) 18. Is there anything else about your experience with MI-Coach: ED that you wished to share?
Thesis/Dissertation
eng
Psychology
Vancouver : University of British Columbia Library
Attribution-NonCommercial-NoDerivatives 4.0 International
Graduate
Libben, Maya
Mobile app-delivered motivational interviewing for women on eating disorder treatment waitlists : pilot and feasibility study
Text