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Take a breath: the safety of a “mindful breathing” mobile application on acute anxiety in teenagers and young adults

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Take a breath: the safety of a “mindful breathing” mobile application on acute anxiety in teenagers and young adults

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Content UNIVERSITY OF SOUTHERN CALIFORNIA
Take a Breath: The safety
of a “mindful breathing”
mobile application on
acute anxiety in teenagers
and young adults
Lauren Lewis
Interactive Media and Games, M.F.A.
4/8/2015

1

Table of Contents
Take a Breath: The safety of a “mindful breathing” mobile application on acute anxiety in
teenagers and young adults ............................................................................................................. 2
Introduction ..................................................................................................................................... 2
Prior Work .................................................................................................................................. 5
Intervention ................................................................................................................................. 6
Project Status .............................................................................................................................. 7
Methods......................................................................................................................................... 11
Recruitment ............................................................................................................................... 11
Inclusion Criteria .................................................................................................................. 12
Exclusion Criteria ................................................................................................................. 13
Procedures ................................................................................................................................. 13
Schedule of Instruments ........................................................................................................ 13
Participant Burden ................................................................................................................ 14
Participant tracking ............................................................................................................... 14
Statistical Analysis .................................................................................................................... 14
RQ1. How will usage patterns change over time? ................................................................ 15
RQ2. Will application usage influence anxiety scores?........................................................ 15
H1. The majority of participants (75%) will not experience a clinically significant increase
in anxiety.w ........................................................................................................................... 15
Payment for Participation ......................................................................................................... 16
References ..................................................................................................................................... 16
Appendix A ............................................................................................................................... 20
Appendix B ............................................................................................................................... 23
Appendix C ............................................................................................................................... 25
Appendix D ............................................................................................................................... 26
Appendix E ............................................................................................................................... 28
Appendix F................................................................................................................................ 30
Appendix G ............................................................................................................................... 37
Appendix H ............................................................................................................................... 46

2

Take a Breath: The safety of a “mindful breathing” mobile
application on acute anxiety in teenagers and young adults

Introduction
Anxiety is a pervasive problem among teenagers and young adults in the United States. The
nationally representative National Comorbidity Survey Replication conducted between 2001 and
2003 places the lifetime prevalence estimate for anxiety disorders at 28.8%, with a median age of
onset of 11. Half of cases start by age 14, and three quarters of cases by age 24 (Kessler et al.
2005). For this reason, “[i]nterventions aimed at prevention or early treatment need to focus on
youth” (Kessler et al. 2005). Young people have unprecedented access and familiarity with
mobile devices, making the platform ideal for therapies which require access throughout the day
or in non-clinical settings (Matthews et al. 2008; Morris et al. 2010). The mobile platform is a
promising option for delivering mental health treatment “in a non-stigmatizing fashion to many
people who otherwise would not have access” (Morris et al. 2010).

While the potential benefits of the application of mobile technology to mental health treatment
have been researched, the majority of the applications studied mirror “pen-and-paper” techniques
used in existing therapies (for example, cognitive-behavioral therapy [CBT]), notably the
practice of mood tracking or charting (Matthews et al. 2008; Morris et al. 2010; Erhardt, Dorian
2013). The mobile platform is used primarily due to its ubiquity, and the convenience and
privacy it provides when compared to traditional methods of diary-keeping. This combination
results in higher levels of compliance (Matthews et al. 2008; Erhardt, Dorian 2013). The patient
in the single case study described by Erhardt and Dorian found that the change of platform was
integral to his engagement with his treatment: “He remarked that, in contrast to his prior
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experience with CBT, eliminating the need to both remember to do this self-monitoring
assignment and to carry the necessary forms with him made an enormous difference in his
adherence” (2013).

CBT is not the sole treatment option for sufferers of anxiety. Mindfulness-based therapy (MBT),
which can refer to both mindfulness-based cognitive therapy (MBCT; Segal et al. 2004) and
mindfulness-based stress reduction (MBSR; Kabat-Zinn 1982, 1994), is an alternate, and often
complementary, method of stress reduction and is predicated on the practice of “paying attention
in a particular way: on purpose, in the present moment, and non-judgmentally” (Kabat-Zinn
1994). The results of a meta-analytic review on the efficacy of mindfulness-based therapy
suggest that it is “a promising intervention for treating anxiety and mood problems in clinical
populations” (Hofmann et al. 2010). Specifically, “[e]ffect size estimates suggest that
mindfulness-based therapy was moderately effective for improving anxiety” (Hofmann et al.
2010). In a study on patients with Social Anxiety Disorder (SAD) in particular, those who
completed MBSR “showed improvement in anxiety and depression symptoms and self-esteem”
when compared with the baseline (Goldin, Gross 2010).

Included under the umbrella term MBT is the basic meditation exercise “mindful breathing,”
which involves the specific application of mindful attention to the physical sensations associated
with breathing (Feldman, Greeson, Senville 2010). Feldman, Greeson, and Senville conducted a
study to test the effects of mindful breathing (along with progressive muscle relaxation and
loving-kindness meditation) on decentering, a possible mechanism of mindful interventions, and
negative reactions to repetitive thoughts. Those patients who were directed to do mindful
4

breathing reported more decentering than those directed to use the other methods, and had a
weaker association between the amount of repetitive thinking and negative reactions to thoughts
than with the other two methods, “suggesting that mindful breathing may help to reduce
reactivity to repetitive thoughts,” a symptom associated with anxiety (Feldman, Greeson,
Senville 2010). In the same vein, patients in the aforementioned SAD study showed “decreased
negative emotion experience” during the mindful breathing task (Goldin, Gross 2010). This
technique is convenient in that it can be used at any time and in nonclinical environments,
making it an ideal technique to adapt a mobile context. While commercial mobile applications
which claim to be designed around MBT are available, some including elements relating to
mindful breathing, as of yet no research has been done on the efficacy of these applications.

The application being tested in this study, Take a Breath, is an interactive mindful breathing
application for teenagers and young adults with anxiety. The initial target demographic,
teenagers and young adults aged 18-24, was selected based on the onset statistics discussed
above. Because it is developed for a mobile platform, Take a Breath could be used almost
anywhere at any time, without interrupting the user’s day or calling unwanted attention to the
user’s distress. The user drags on the screen in time with their breathing, and a circle grows,
shrinks, and gradually changes color in response.

This preliminary study is intended to determine the safety of the application for use by teenagers
and young adults. The application is considered “safe” if it does not cause an increase in anxiety
from a pre-test anxiety inventory to a post-test anxiety inventory. Study participants’ anxiety
levels will be evaluated through inventories conducted through Qualtrics online, and within the
5

application itself. Depending on the findings of this study, future research will be done to
determine the efficacy of the intervention.

Research Questions & Hypothesis:
RQ1. How will usage patterns change over time?
RQ2. Will application usage influence anxiety scores?
H1. The majority of participants (75%) will not experience a clinically significant increase in
anxiety.
Prior Work
While attention to or control over breathing is a component of a number of existing mental health
mobile applications, few focus on breathing as a primary intervention. The application created
and studied by Morris et al., MoodKit, had a breathing visualization similar to the Take a Breath
application as part of its suite of “mobile therapies,” however the “blue circle that expanded and
contracted slowly to encourage deliberate and slower breathing” changed size automatically,
rather than in response to the patient’s input (2010). Additionally, the efficacy and frequency of
use of this specific component were not described within the study. The Department of Defense's
National Center of Telehealth and Technology has a created a number of mobile applications
intended to serve as tools for military sufferers of severe mental health disorders such as PTSD
(Shore et al. 2014), some of which are solely based on the principle of mindful breathing
(Breathe2Relax, Tactical Breather). While similar, these applications are tailored for use by
adults within a military context, and may not be effective in addressing the needs of teenaged
and young adult civilians with intermittent, less-severe anxiety.
6

Intervention
Take a Breath is a mobile application available on devices running Apple’s iOS operating system.
The user can interactively track their breathing by dragging on the screen. For the purposes of
our study, the user is prompted to answer a four-question anxiety inventory periodically, so that
change in anxiety level can be measured. Intermittent sampling is being used to gather data
during the testing period because of its longer duration.

The participants are presented with the inventory within the application itself in order to raise the
chances of compliance. A study conducted by Bush et al., compared the psychometric properties
(i.e., internal consistency and test-retest reliability) of behavioral screening measures taken on
paper, on a computer, and using an iPhone: “The results showed the internal consistencies of the
smartphone-delivered measures to be equivalent and very high across all three modalities and the
test-retest reliability of the iPhone measures also to be very high. Furthermore, completion of the
behavioral screening measures by the iPhone was highly preferred over the other modalities and
was reported to be easy and convenient” (Bush et al. 2013).

The application reports the inventory responses and usage analytics to a cloud backend as they
are collected. When participants are provided with the application they will be assigned a unique
alphanumeric code via email which is needed to activate the application upon initial launch. Data
collected by the application will be tied to this code. The primary investigator will be able to
connect codes with personal information.
7

Project Status
This project stemmed from my desire to create something that could help young people
struggling with anxiety. Initially, I wanted this application to be tested among a younger
population; in the process of revising the study protocol, it became clear that gaining IRB
approval would be significantly less likely if we included minors in study, and so the population
age range was changed.

I have had anxiety and panic issues since I was in middle school. I wish there had been more
tools available for me, particularly ones that had a very low barrier to entry: options that were
free, private, and easily obtainable. We live in an amazing time technologically, and the only
thing more wondrous than the constant innovations that come into our lives is how utterly
mundane they become to us so soon after their inception. Interactive media has an unparalleled
capability to reach people under the age of 25 because it has been reaching us our entire lives.
We own this technology, we use this technology, and we love this technology. I wanted to make
something with a wide reach, and there is no better medium suited to this demographic than the
interactive.

When I initially pitched this concept in Thesis Prep, it was a prototype with 4 mini experiences,
all based on my understanding of mindful and grounding principles, and what worked for me
when I was anxious (simple and easily accomplished tasks). In addition to the breath tracker that
became my final project, there was an exercise which asked you to input sensory impressions
about your body, a task that required you to type the alphabet backwards, and a color matching
game where you had to tap on blocks until they were all the same color.
8

Figure 1: Prototype launch screen and menu.

Figure 2: Interactive breathing tracker.
9

Figure 3: Sensory grounding exercise.

Figure 4: Typing the alphabet backward.
10

Figure 5: Color matching blocks.

The breathing exercise got the most positive, and personally satisfying, feedback, and so that was
the one I decided to go with for my final thesis. In order to design and run the study, I needed to
make my application as small as possible, so that I could accurately test whether this specific
intervention worked without additional variables muddying up my conclusions.

This was my first time doing real, quantitative research, and it’s been a challenging at times. The
process of writing the study protocol and having to make countless decisions on minutiae I didn’t
fully understand was petrifying. It never felt like I had enough information, and I was worried
that every step I took violated some sacred research social norms and sensibilities that I just
didn’t know. (In reality, that was only the case some of the time.) I am incredibly grateful to my
committee for helping me when I needed it. I am also grateful that they continually pushed me,
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and told me when things needed to improve. As with many of my experiences in this program, it
was a (controlled, ultimately safe, yet terrifying) sink or swim situation, where I just had to hit
the ground running and figure it out as I went. I am most productive when I am so busy that I
have no time to worry that I might fail. Working on my thesis has been fantastic challenge, and a
really valuable learning opportunity for me as I look toward more scientific work in the future.

As of this writing, the Take a Breath application is in final development, for approximately the
third time; the prototype version above has been used up until this point. Development needed to
be finished weeks ago, but the developers I try to hire have continuously missed deadlines and
I’m technically incapable of developing for iOS on a PC, so here we are. The IRB has approved
our study protocol, and recruitment is underway.

Methods
Recruitment
Recruitment is being conducted largely via the internet to maximize our potential reach and
appeal to our target demographic: tech-savvy teenagers and young adults. Because this study
does not require physical proximity, social media and email are ideal channels for recruitment.
Facebook, Twitter, Tumblr, Craigslist, school affiliated email lists, and physical posters on the
USC campus will be used to find participant.

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The target population for this study is 100 participants between the ages of 18 and 24, half of
whom show elevated signs of anxiety and half whom do not. A quota system will be used to
ensure both the control and experimental groups have no more than 50 individuals.

Recruiting 160 volunteers will ideally result in over 50 participants with elevated levels of
anxiety and 50 non-anxious participants.

Participants will be classified as showing elevated signs of anxiety based on the cut-off scores
for the Anxiety subscale of the Depression Anxiety Stress Scales (DASS; Lovibond, Lovibond
1995). The DASS is a well-validated scale with cut-off scores based on the means and standard
deviations from scales derived from a nationally representative sample of adults aged 17 to 69
years old. The scale includes 14 items that can be scored from 0 to 3 (NEVER to ALMOST
ALWAYS). A score of a 10 or above on the Anxiety scale corresponds to scoring more than 1
standard deviation above the mean; this is classified as experiencing moderate anxiety. A score
of 20 or above on the Anxiety scale corresponds to scoring more than 3 standard deviations
above the mean; this is classified as experiencing extremely severe anxiety. Thus, participants
scoring in the range of 10 up to and including 19 on the Anxiety sub-scale of the DASS will be
classified as participants showing elevated signs of anxiety.

Inclusion Criteria
In order to be eligible to participate in this study, subjects must be aged 18-24, fluent in English,
and must own and be comfortable using a mobile device running the iOS operating system.

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Exclusion Criteria
Participant shows signs of currently having an anxiety disorder. This will be based on two
criteria: 1) exceeding the 320 point cut-off score on the Visual-Analogue Scale of Anxiety
(Baron VAS-Anxiety; Jordan-Marsh et al. 2013); 2) exceeding the 19 point cut-off score on the
Anxiety sub-scale of the DASS. Meeting either of these two exclusion criteria is sufficient for
participants to be excluded from this study.

Procedures
An online screening questionnaire will be used to determine eligibility. If the applicant is
qualified, willing to participate, and participant quotas have not yet been met, they will be
provided with an information sheet, asked to consent online, and given the baseline questions. If
they agree, they will be enrolled in the study and provided with access to the application. The
software application server will collect data on anxiety responses and usage data (ex. frequency
of use, duration of use) during the study as participants use the software on their smartphone.
After two weeks, or sooner if participants no longer wish to use the software, some participants
will be sent the post-test survey on Qualtrics and some will be asked to participate in an in-
person or web-based interview.

Schedule of Instruments

Screening Baseline Pre-Test Post-Test
Screening
Questionnaire

Baseline Survey
(identifiers,

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demographics)
Tech Habits 
Brief COPE  
Baron VAS-Anxiety   
DASS (Anxiety
subscale)
 
Intrinsic Motivation
Inventory
(Interest/Enjoyment,
Value/Usefulness)


Participant Burden
The screening questionnaire is designed to take less than five minutes to complete. If the
participant passes the screening process, they will be prompted to complete the baseline survey,
which should take less than 30 minutes. Once enrolled, the participants will be provided the
application to use for up to two weeks. The exit interviews will be held on a case-by-case basis
and will not exceed 30 minutes in length. The total length of subject participation from screening
to exit interview will be approximately three weeks.

Participant tracking
When participants are provided with the software application they will be assigned a unique
alphanumeric code via email which is needed to activate the application upon initial launch. Data
collected by the application will be tied to this code. Research personnel will be able to connect
codes with personal information.
Statistical Analysis
For medical devices, the most current review validates the FDA’s indication that a sample
composed of 15 participants per major group (or a minimum of 25 users) should be “enough to
15

identify 90–97% of the usability problems” (Borsci, et al., 2014, p. 513) with measured cost-
effectiveness.
RQ1. How will usage patterns change over time?
We will plot frequency of usage day by day for each user in order to address RQ1.
RQ2. Will application usage influence anxiety scores?
For each participant change scores will be computed for the Depression Anxiety Stress scales
(DASS). The change scores will be computed by subtracting the DASS scores obtained on the
posttest from the DASS scores obtained on the baseline. A linear and quadratic regression will be
computed using the change scores as the dependent variable and the frequency of usage of the
software as the independent variable. The change scores will also be plotted (ordinate) against
usage of software (abscissa) to visualize this relationship. We will visualize Baron VAS-Anxiety
scores over time. We will compare usage scores with Brief COPE scores to determine whether
usage profiles emerge based on participant coping profiles.
H1. The majority of participants (75%) will not experience a clinically
significant increase in anxiety.
The National Institute of Mental Health criterion (Anderson et al. 1988) for a clinically
significant change on anxiety is a shift of 30% (increase or decrease). We will compute the
difference between pre and post DASS scores and then will rank order these differences and
compare the results to the cutoff described above.

16

Not all participants will be interviewed upon exit. For the participants who complete the full
duration of the study (2 weeks) a subset will be selected based on their frequency of usage of the
software. From the each quartile of usage 3 participants will be randomly selected to be
interviewed at the conclusion of the study. In addition participants who leave the study before the
end of the study will be interviewed.

Interviews will be coded in terms of their reaction to the software.
Payment for Participation
Participants will be eligible to win a $25 Amazon gift card which will be distributed digitally at
the end of the study. Participants are not required to complete the study to be eligible to win.
There will be three gift cards, and the winners will be determined via a random number generator
to ensure fairness.

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(November 2013): 991–95. doi:10.1097/NMD.0000000000000039.
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Carver, Charles S. “You Want to Measure Coping but Your Protocol’s Too Long: Consider the
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Appendix A: Tech Habits Instrument

21

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Appendix B: Brief COPE
These items deal with ways you've been coping with the stress in your life. There are many ways
to try to deal with problems. Each item says something about a particular way of coping. Don't
answer on the basis of whether it seems to be working or not—just whether or not you're doing
it. Try to rate each item separately in your mind from the others. Make your answers as true for
you as you can.
1 = I haven't been doing this at all
2 = I've been doing this a little bit
3 = I've been doing this a medium amount
4 = I've been doing this a lot
1. I turn to work or other activities to take my mind off things.
2. I concentrate my efforts on doing something about the situation I'm in.
3. I say to myself "this isn't real."
4. I get emotional support from others.
5. I give up trying to deal with it.
6. I take action to try to make the situation better.
7. I refuse to believe that it has happened.
8. I say things to let my unpleasant feelings escape.
9. I get help and advice from other people.
10. I try to see it in a different light, to make it seem more positive.
11. I criticize myself.
12. I try to come up with a strategy about what to do.
24

13. I get comfort and understanding from someone.
14. I give up the attempt to cope.
15. I look for something good in what is happening.
16. I make jokes about it.
17. I do something to think about it less, such as going to movies, watching TV, reading,
daydreaming, sleeping, or shopping.
18. I accept the reality of the fact that it has happened.
19. I express my negative feelings.
20. I try to find comfort in my religion or spiritual beliefs.
21. I try to get advice or help from other people about what to do.
22. I learn to live with it.
23. I think hard about what steps to take.
24. I blame myself for things that happened.
25. I pray or meditate.
26. I make fun of the situation.

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Appendix C: Baron VAS-Anxiety

26

Appendix D: DASS-Anxiety
This is the final portion of this questionnaire. Please read each statement of the 14 statements and
select a number 0, 1, 2 or 3 which indicates how much the statement applied to you over the past
week. There are no right or wrong answers.

Do not spend too much time on any statement.

The rating scale is as follows:
0 Did not apply to me at all
1 Applied to me to some degree, or some of the time
2 Applied to me to a considerable degree, or a good part of time
3 Applied to me very much, or most of the time

I was aware of dryness of my mouth.
I experienced breathing difficulty (e.g., excessively rapid breathing, breathlessness in the
absence of physical exertion).
I had a feeling of shakiness (e.g., legs going to give way).
I found myself in situations that made me so anxious I was most relieved when they ended.
I had a feeling of faintness.
I perspired noticeably (e.g., hands sweaty) in the absence of high temperatures or physical
exertion.
I felt scared without any good reason.
I had difficulty in swallowing.
27

I was aware of the action of my heart in the absence of physical exertion (e.g., sense of heart rate
increase, heart missing a beat).
I felt I was close to panic.
I feared that I would be "thrown" by some trivial but unfamiliar task.
I felt terrified.
I was worried about situations in which I might panic and make a fool of myself.
I experienced trembling (e.g., in the hands).

28

Appendix E: Intrinisic Motivation Inventory
The sub-scales are used as headers. Underlined text is text inserted by this study’s Principal
Investigator, as prescribed by the scale’s design.

For each of the following statements, please indicate how true it is for you, using the following
scale:
1 2 3 4 5 6 7
not at
all true
somewhat
true
very true

Interest/Enjoyment
I enjoyed doing this activity/using this app very much.
This activity/using this app was fun.
I thought using this app/ I thought this was a boring activity. (Reverse scored)
This activity/using this app did not hold my attention at all. (Reverse scored)
I would describe this activity/using this app as very interesting.
I thought this activity/using this app was quite enjoyable.
While I was doing this activity/using this app, I was thinking about how much I enjoyed it.

Value/Usefulness
I believe this activity/using this app could be of some value to me.
I think that doing this activity/using this app is useful for people trying to learn how to deal with
stress.
I think this app/activity important to do because it can teach people how to calm themselves
down.
29

I would be willing to do this again because it has some value to me.
I think doing this activity/using this app could help me to better handle stressful situations in my
everyday life.
I believe doing this activity/using this app could be beneficial to me.
I think this is an important activity/app.

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Appendix F: Information Sheet

University of Southern California
School of Cinematic Arts – 900 W 34
th
St, Los Angeles, CA 90007

INFORMATION SHEET FOR NON-MEDICAL RESEARCH

Take a Breath: The safety of a "mindful breathing" mobile application on
acute anxiety in teenagers and young adults

PRINCIPAL INVESTIGATOR: Lauren Lewis, BSc, MFA Candidate

You are invited to participate in a research study conducted by Lauren Lewis, BSc, under the
direction of Marientina Gotsis, MFA, at the University of Southern California, because you are
between the ages of 18 to 24 years old, proficient in English, someone who owns a mobile Apple
iOS device with a touchscreen, and someone who is comfortable navigating applications on a
mobile device using a touchscreen. Your participation is voluntary. You should read the
information below, and ask questions about anything you do not understand, before deciding
whether to participate. Please take as much time as you need to read the consent form. You may
also decide to discuss participation with your family or friends. If you decide to participate, you
will be asked to sign this form. You will be given a copy of this form.

PURPOSE OF THE STUDY
This study is about mobile applications and mental health. We hope to determine if the "mindful
31

breathing" mobile application Take a Breath is safe for use by anxious teenagers and young
adults.

STUDY PROCEDURES
If you volunteer to participate in this study, you will be asked to complete an online screening
survey, anticipated to take less than 5 minutes to complete. This survey asks very basic
demographic questions and questions about your ability to use mobile applications.

Depending on your answers to the survey, you may be invited to complete another set of
questionnaires about how you tend to deal with stress and anxiety in your day to day life. We
expect this to take no more than 10 to 15 minutes.

You may then be invited to test the Take a Breath mobile application. You will be provided with
the application for you to use for up to 2 weeks. You may use the application as often or as little
as you would like; there are no restrictions on your use of the application during the testing
period. During this period, the application will occasionally prompt you to answer 4 short
questions about how you are feeling at that time. You may choose not to answer these questions
without penalty. The application will send your responses and application usage statistics (such
as the time and date when the application was used, and the duration of use) to us over the
internet. This data will be sent automatically. The application will not access any private data
(such as passwords or browser activity) on your mobile device.
At the end of your participation, you may be asked to take part in an exit interview, either via an
online video chat service or in person at the USC University Park campus; the interview is
32

anticipated to last no more than 30 minutes and will be audio recorded. If you do not wish to be
recorded, you cannot participate in the interview.

POTENTIAL RISKS AND DISCOMFORTS
There are no anticipated risks to participating in this research study. Some of the questions may
make you feel uneasy or embarrassed. You may find answering the questionnaires annoying,
boring, or repetitive. If this happens, please know that you can take a break or skip a question.
You have the right to refuse to answer any question(s) you don’t want to. (Please note, however,
that skipping particular questions in the screening questionnaire (the first part questionnaire) may
result in the system automatically classifying you as ineligible for the rest of the study.)

There are possible risks associated with using the Take a Breath application during this study.
This application is designed to allow you to focus on your own breathing in stressful situations.
There is a small risk that paying attention to your breathing in this way might increase, rather
than decrease, your feelings of stress or anxiety. The application may make your frustrated if you
do not understand how to use it, or if you do not find it relaxing to use. If you find yourself
experiencing any of these emotions more intensely than you are comfortable with, you are free to
take a break or stop using the application at any time.

The application will report question responses and usage statistics to us during the testing period.
The application will not access any private information stored on your mobile device; it will only
send us data relating to your use of the application. You may feel uncomfortable that this data is
sent to us automatically, or that you cannot see what data is being sent by the application. You
33

have the right to uninstall the application or withdraw your participation at any time if you are
concerned about the information security of your mobile device.

If you are experiencing anxiety, you should either talk to your physician (primary care or mental
health specialist) or you can utilize a low cost clinic. You will be responsible for any costs
incurred as a result of the visits. The following are phone numbers to various hotlines:

County Crisis Line: 1-800-854-7771
Didi Hirsch: 1-877-727-4747
Trevor Project (LGBTQ) 1-866-488-7386
National Suicide Prevention Lifeline: 1-800-273-8255

POTENTIAL BENEFITS TO PARTICIPANTS AND/OR TO SOCIETY
You may not directly benefit from your participation in this study.

This study seeks to determine whether this specific mobile application is safe for use among our
intended audience of teenagers and young adults. In this context, “safe” means that this
application does not increase your anxiety during use. Ultimately, we want to explore whether
interactive technology and mobile technology can be used as a tool in mental health treatment.
This is a very new frontier for the fields of psychology and interactive/game design; this study
may therefore help researchers learn whether “mindful breathing” is an anti-anxiety technique
which can effectively be translated into a mobile application. The data you provide may help
propel this field forward with important knowledge. Less globally, your data and feedback will
34

likely help the application used in this study to ultimately reach its full potential.

PAYMENT/COMPENSATION FOR PARTICIPATION
You will not be compensated for your participation in the screening portion of this study.

If you are enrolled in the study after the screening process, you will be eligible to win one of
three $25 Amazon gift cards. The winners will be selected using a random-number generator to
ensure fairness. You do not have to complete the study in order to win, and your chances to win
are not affected by the duration or quality of your participation.

If you are selected for an exit interview and decide to participate in person, you will be
reimbursed for parking expenses incurred at the University of Southern California University
Park campus.

POTENTIAL CONFLICTS OF INTEREST OF THE INVESTIGATOR
The principal investigator owns the intellectual property rights of the mobile application Take a
Breath. The application is free, and no profits have been made from the sale of the application.
There are no current plans to profit from sale of the application in the future. If this application is
ever further developed and made available commercially, you will not receive any money
resulting from the sale of the application.

CONFIDENTIALITY
We will keep your records for this study confidential as far as permitted by law. However, if we
35

are required to do so by law, we will disclose confidential information about you. The members
of the research team and the University of Southern California’s Human Subjects Protection
Program (HSPP) may access the data. The HSPP reviews and monitors research studies to
protect the rights and welfare of research subjects.

All data gathered during your participation will be labeled with a numerical code. Identifiable
information will be stored separately from data collected during the study. The audio recording
will be destroyed after transcription.

All data will be kept in a locked drawer inside a locked office and/or on password protected
computers. All identifiable information will be destroyed once the study is completed. The
remaining data will be maintained indefinitely and may be used in future research studies or for
educational purposes. If you do not want your data used in future research studies or for
educational purposes, you should not participate in this study.

When the results of the research are published or discussed in conferences, no identifiable
information will be used.

PARTICIPATION AND WITHDRAWAL
Your participation is voluntary. Your refusal to participate will involve no penalty or loss of
benefits to which you are otherwise entitled. You may withdraw your consent at any time and
discontinue participation without penalty. You are not waiving any legal claims, rights or
remedies because of your participation in this research study.
36

ALTERNATIVES TO PARTICIPATION
You do not have to participate in this study if you don’t want to. Your relationship with USC
will not be affected, whether or not you participate in this study.

INVESTIGATOR’S CONTACT INFORMATION
If you have any questions or concerns about the research, please feel free to contact the principal
investigator, Lauren Lewis. Daytime phone: (818) 527-6278. Email: laurenfl@usc.edu.

RIGHTS OF RESEARCH PARTICIPANT – IRB CONTACT INFORMATION
If you have questions, concerns, or complaints about your rights as a research participant or the
research in general and are unable to contact the research team, or if you want to talk to someone
independent of the research team, please contact the University Park Institutional Review Board
(UPIRB), 3720 South Flower Street #301, Los Angeles, CA 90089-0702, (213) 821-5272
or upirb@usc.edu

37

Appendix G: Recruitment Materials
1) Facebook Advertisement
Research volunteers: try a new app for anxiety!

2) Facebook Page
Short Description (2-3 sentences, limited by Facebook):
Do you own an iPhone? Do you experience anxiety? We need volunteers to try a new
mobile application for our research study!

Long Description:
Welcome! This page is an informational hub for anyone interested in participating in a
University of Southern California research study relating to mobile technology and
anxiety.

Do you or someone you love experience anxiety? Do you or your loved one own an
Apple mobile device with a touchscreen (examples: iPhone, iPod Touch)? We are
looking for 18-24 year olds to participate in a study on a new mobile application, Take a
Breath, intended to help with occasional or episodic anxiety. Take a Breath is designed
around the stress-relief technique “mindful breathing.” The application allows you to
interactively track your breathing, encouraging mindful breathing in times of anxiety.

Participation in this study involves a screening questionnaire to check your eligibility
(approximately 5 minutes), brief surveys after enrollment (15 minutes), a testing period
38

(up to 2 weeks), and a potential exit interview (30 minutes). Your participation is
voluntary and you may decide to withdraw from the study at any time without any
penalties. Regardless of how long you choose to participate, all participants will be
entered to win three $25 Amazon gift cards at the end of the study.

If you agree to participate in the study, you will be asked to complete a short online
survey. Depending on your answers to the survey, you may be invited to test the Take a
Breath application. You will be provided with the application for you to use as desired for
up to two weeks. At the end of your participation, you may be asked to take part in a
voluntary exit interview, either via an online video/audio chat service or in person at the
USC University Park campus. You are not obligated to complete the exit interview, and
you may decline to interview without consequence.

If you are interested in participating in this study, please click here (insert link) for more
information!

3) Facebook Group Post
Hello!

My name is Lauren Lewis and I am a Master’s candidate in Interactive Media at the
University of Southern California.

39

We are looking for 18-24 year olds to participate in a study on a new mobile application,
Take a Breath, intended to help with occasional or episodic anxiety. Take a Breath is
designed around the stress-relief technique “mindful breathing.” The application allows
you to interactively track your breathing, encouraging mindful breathing in times of
anxiety.

If you agree to participate in the study, you will be asked to complete a short online
survey. Depending on your answers to the survey, you may be invited to test the Take a
Breath application. You will be provided with the application for you to use as desired for
up to two weeks. At the end of your participation, you may be asked to take part in a
voluntary exit interview, either via an online video/audio chat service or in person at the
USC University Park campus. Regardless of how long you choose to participate, all
participants will be entered to win three $25 Amazon gift cards at the end of the study.

Participation in this study is voluntary and you are free to withdraw at any time for any
reason. If you are interested in participating in this study, please click here (insert link)
for more information!

4) Twitter Account
Short description (max 160 characters, limited by Twitter):
USC study on mobile application for anxiety seeks volunteers! Requirements: aged 18-24,
own iPhone/iPod Touch, comfortable using apps. See link for more info!

40

5) Tweets
Interested in participating in a USC research study on anxiety? Aged 18-24? Test our new
“mindful breathing” app! (insert link)

Looking for volunteers for a USC study on an app for anxiety sufferers aged 18-24!
Interested in participating? (insert link)

Looking for a more discreet and convenient way to address anxiety? Take part in our
USC research study! (insert link)

6) Tumblr
Short description:
USC study on mobile application for anxiety seeks volunteers! Requirements: aged 18-24,
own iPhone/iPod Touch, comfortable using apps.

7) Tumblr Post
Do you or someone you love experience anxiety? Do you or your loved one own an
Apple mobile device with a touchscreen (examples: iPhone, iPod Touch)? We are
looking for 18-24 year olds to participate in a study on a new mobile application, Take a
Breath, intended to help with occasional or episodic anxiety. Take a Breath is designed
around the stress-relief technique “mindful breathing.” The application allows you to
interactively track your breathing, encouraging mindful breathing in times of anxiety.

41

Participation in this study involves a screening questionnaire to check your eligibility
(approximately 5 minutes), brief surveys after enrollment (15 minutes), a testing period
(up to 2 weeks), and a potential exit interview (30 minutes). Your participation is
voluntary and you may decide to withdraw from the study at any time without any
penalties. Regardless of how long you choose to participate, all participants will be
entered to win three $25 Amazon gift cards at the end of the study.

If you agree to participate in the study, you will be asked to complete a short online
survey. Depending on your answers to the survey, you may be invited to test the Take a
Breath application. You will be provided with the application for you to use as desired for
up to two weeks. At the end of your participation, you may be asked to take part in a
voluntary exit interview, either via an online video/audio chat service or in person at the
USC University Park campus. You are not obligated to complete the exit interview, and
you may decline to interview without consequence.

If you are interested in participating in this study, please click here (insert link) for more
information!

8) Email Recruitment (USC)
Hello!

My name is Lauren Lewis and I am a Master’s candidate in Interactive Media here at
USC. I am conducting a study and I want to invite you to participate if you are between
42

the ages of 16 and 21, experience anxiety, and you’re comfortable using apps on your
mobile iOS device (examples: iPhone, iPod Touch).

We are studying a new application, Take a Breath, intended to help with occasional or
episodic anxiety. Take a Breath is designed around the stress-relief technique “mindful
breathing.” The application allows you to interactively track your breathing, encouraging
mindful breathing in times of anxiety.

If you agree to participate in the study, you will be asked to complete a short online
survey. Depending on your answers to the survey, you may be invited to test the Take a
Breath application. You will be provided with the application for you to use as desired for
up to two weeks. At the end of your participation, you may be asked to take part in a
voluntary exit interview, either via an online video/audio chat service or in person at the
USC University Park campus. Regardless of how long you choose to participate, all
participants will be entered to win three $25 Amazon gift cards at the end of the study.

Participation in this study is voluntary and you are free to withdraw at any time for any
reason. If you are a USC student, your grades will not be affected by your participation.

If you are interested in participating in this study, please click here (insert link) for more
information!

Sincerely,
43

Lauren Lewis
Interactive Media, MFA Candidate
University of Southern California

9) Email Recruitment (General)
Hello!
My name is Lauren Lewis and I am a Master’s candidate in Interactive Media at the
University of Southern California. I am looking for volunteers for a study I am
conducting on anxiety and mobile applications.
Do you or someone you love experience anxiety? Do you or your loved one own an
Apple mobile device with a touchscreen (examples: iPhone, iPod Touch)? We are
looking for 18-24 year olds to participate in a study on a new mobile application, Take a
Breath, intended to help with occasional or episodic anxiety. Take a Breath is designed
around the stress-relief technique “mindful breathing.” The application allows you to
interactively track your breathing, encouraging mindful breathing in times of anxiety.
If you agree to participate in the study, you will be asked to complete a short online
survey. Depending on your answers to the survey, you may be invited to test the Take a
Breath application. You will be provided with the application for you to use as desired for
up to two weeks. At the end of your participation, you may be asked to take part in a
voluntary exit interview, either via an online video/audio chat service or in person at the
USC University Park campus. Regardless of how long you choose to participate, all
participants will be entered to win three $25 Amazon gift cards at the end of the study.
44

Participation in this study is voluntary and you are free to withdraw at any time for any
reason. If you are interested in participating in this study, please click here (insert link)
for more information!
Sincerely,
Lauren Lewis
Interactive Media, MFA Candidate
University of Southern California

10) Craigslist
Do you or someone you love experience anxiety? Do you or your loved one own an
Apple mobile device with a touchscreen (examples: iPhone, iPod Touch)? We are a team
of researchers from the University of Southern California looking for 18-24 year olds to
participate in a study on a new mobile application, Take a Breath, intended to help with
occasional or episodic anxiety. Take a Breath is designed around the stress-relief
technique “mindful breathing.” The application allows you to interactively track your
breathing, encouraging mindful breathing in times of anxiety.

Participation in this study involves a screening questionnaire to check your eligibility
(approximately 5 minutes), brief surveys after enrollment (15 minutes), a testing period
(up to 2 weeks), and a potential exit interview (30 minutes). Your participation is
voluntary and you may decide to withdraw from the study at any time without any
penalties. Regardless of how long you choose to participate, all participants will be
entered to win three $25 Amazon gift cards at the end of the study.
45

If you are interested in participating in this study, please click here (insert link) for more
information!

46

Appendix H: Poster Advertisement

Abstract (if available)

Abstract This study explores whether the ""mindful breathing"" mobile application Take a Breath is safe for use during episodes of acute anxiety in teenagers and young adults. Similar applications have been developed and used in the treatment of post‐traumatic stress disorder in military service members. Commercially‐developed alternatives have not been assessed scientifically. No application of this type is designed specifically for the needs of teenagers and young adults with anxiety. Eligible participants will be asked to use ""Take a Breath,"" a mobile application available on smartphones running iOS, over a 2‐week period. The user can interactively track their breathing by dragging on the screen. The study population is teenagers and young adults aged 18 to 24, half of whom self‐identify as anxious and half of whom do not. Volunteers with signs of extremely severe anxiety will not be eligible for participation. We are collecting anxiety inventory responses and usage analytics over the internet during the test period (facilitated by the application). We will also conduct exit interviews with selected participants either on campus or via an online video chat service. The quantitative data collected via the application and qualitative data collected via exit interviews will be analyzed to determine whether the intervention is safe. The application will be characterized as 'safe' if it does not result in an increase in anxiety.

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Asset Metadata

Creator Lewis, Lauren (author)

Core Title Take a breath: the safety of a “mindful breathing” mobile application on acute anxiety in teenagers and young adults

School School of Cinematic Arts

Degree Master of Fine Arts

Degree Program Interactive Media

Publication Date 04/23/2015

Defense Date 04/08/2015

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag anxiety,breathing,iOS,Mental Health,mindfulness,OAI-PMH Harvest,smartphones

Format application/pdf (imt)

Language English

Contributor Electronically uploaded by the author (provenance)

Advisor Gotsis, Marientina (committee chair), Granic, Isabela (committee member), Wixon, Dennis (committee member)

Creator Email laurenfl@usc.edu,laurenflewis@gmail.com

Permanent Link (DOI) https://doi.org/10.25549/usctheses-c3-558920

Unique identifier UC11298822

Identifier etd-LewisLaure-3383.pdf (filename),usctheses-c3-558920 (legacy record id)

Legacy Identifier etd-LewisLaure-3383.pdf

Dmrecord 558920

Document Type Thesis

Format application/pdf (imt)

Rights Lewis, Lauren

Type texts

Source University of Southern California (contributing entity), University of Southern California Dissertations and Theses (collection)

Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the a...

Repository Name University of Southern California Digital Library

Repository Location USC Digital Library, University of Southern California, University Park Campus MC 2810, 3434 South Grand Avenue, 2nd Floor, Los Angeles, California 90089-2810, USA