A Pilot Evaluation of a Smartphone Application for Muslims

with depressive symptoms.

Nawal Yousaf
Dr Ahmad Hankir
Abstract:
Interventions delivered via mobile apps show particular promise in tackling the burden of common mental
disorders. Appropriately targeting these interventions to at-risk populations is critical to their success. This
pilot study aims to assess the usability, feasibility, acceptability, and preliminary effects of an app-based
intervention designed to target depressive symptoms within a Muslim population. Fitra Health, a smartphone
app including a two-month long program of cognitive and behavioural therapeutic components, will be tested
in a pre-post pilot study with participants recruited via social media advertisements and collaborative
partnerships with clinical sites. Eligible participants for this study consist of individuals aged 18 or older,
identifying as Muslims, owning a smartphone, possessing adequate proficiency in either English or Arabic,
and self-reporting symptoms indicative of depression. The primary outcome under investigation is the
severity of depressive symptoms, quantified using the Patient Health Questionnaire-9 (PHQ-9). App usability
and engagement are assessed via a set of three questions adapted from the Mobile Application Rating Scale
(MARS). These inquiries focus on evaluating the ease of app utilization, user engagement, and interest in the
app's design and content. Additional questions examine the perceived utility of specific app features and
content, as well as reasons for discontinuing app usage if applicable. Feasibility and acceptability are
ascertained through questions adapted from the MARS, including the likelihood of recommending the app to
others and overall app rating. Further inquiries are included to measure participants' comprehension of app
content and whether the app contributes to an improvement in mental fitness. Participants also have the
opportunity to provide general feedback on the app through open-response questions. Intervention
adherence is quantified by collecting data on app usage, specifically recording the number of levels
successfully completed by each participant. Upon completion of this study, the gathered data will provide
valuable insights into the potential benefits, usability, and acceptability of the Fitra Health app as an
intervention for addressing depressive symptoms within the Muslim population. These preliminary findings
will lay a foundation for understanding its effectiveness in supporting mental health among Muslim
individuals. However, to establish its efficacy as an intervention for depression within this specific
demographic, a rigorous randomized controlled trial will be essential. Such a trial will offer a more
comprehensive assessment of the app's impact on mental well-being, further advancing our understanding of
its potential to address mental health challenges among Muslims.

1. Introduction:
Mental health among Muslims worldwide is a significant and growing issue, exacerbated by the COVID-19
pandemic. Mental ill-health among Muslim communities occurs at higher rates and for longer periods of time than
among other groups, yet 75% of those suffering from severe disorders never see a mental health professional1.
Effective care for disorders like depression and anxiety is limited by lack of easy to access and culturally appropriate
resources, large out-of-pocket costs for therapy, and stigma surrounding mental health2. Clinical research shows that
the Muslim population has unique mental health needs that dictate developmentally appropriate interventions. 3 As
Muslim patients are more likely to use religious coping techniques for their mental health than individuals from
most other religious groups,5 faith-based approaches are an important focus for culturally appropriate mental health
treatments. There is a need to develop digital mental health interventions that include faith-based approaches,
including culturally specific adaptations of existing treatments to improve their acceptability and relevance to
Muslim patients.

Within the GCC, it is estimated that approximately 15% of the population suffer from mental disorders in any given
year6 , however, data indicates that 75% of individuals with several mental health disorders do not seek any
treatment. With the average number of psychiatrists being only 2.58 per 100,000 of the population7 , there is an
insurmountable challenge to meet the demand for those in need of psychiatric services. Recent data from the Saudi
National Mental Health Survey published in 2021 indicates that 34% of Saudis meet the criteria for a mental health
condition sometime in their life. However, 80% of Saudis with several mental health disorders do not seek any
treatment8 . In the GCC, 37.5 million productive days are lost every year due to mental illness, equivalent to $3.5
billion.10 However, less than 2% of the health budget is spent on mental health.11 Studies have found that for every
$1 invested in scaled-up treatment for depression and anxiety, there is a $4 return in improved health and
productivity12. Therefore, there is a strong economic case for governments and businesses to invest more in
increasing access to mental health care for citizens in the GCC

One of the barriers to seeking care is stigma related to mental health in the Muslim community which can be
attributed to cultural beliefs and lack of education and awareness about mental health. There is a stigma and taboo
associated with the term "psychology" among some members of the Muslim community, which can be linked to the
perception of psychology being associated with "craziness" or "insanity." This stigma may be more prevalent among
the elderly or rural Arab population. Stigma remains a barrier to mental health awareness and help-seeking
behavior, with one Riyadh study revealing high levels of shame associated with seeking support for mental health.9
According to recent Google Trends data, Arabic online searches for "how to improve my mental health" have grown
by 1,100% in the past five years, and searches for the Arabic word for therapist reached a ten-year high in August
2020, indicating increased awareness and acceptance of mental health challenges.

During the early era of psychiatry, religious beliefs were viewed as negative with the complete exclusion of faith
from the field of psychology and behavioral science. Sigmund Freud, who had an immense influence not only on
clinical psychology and psychotherapy, but on several domains of Western culture, famously stated that “religion
was a pathology that needed to be cured.” (Al-Karam, 2018). Many psychological theories have been
conceptualized from a Eurocentric framework, and their treatment utility designed for European Americans.
Psychologists are forced to adapt theories generated in Euro-American contexts s and transpose them to the
populations with which they are working. However, in reality, psychological theories are not easily adapted across
cultures. Adapting researched theories to a multicultural society requires an in-depth understanding of the
population, therefore there is a need to develop mental health interventions that include faith-based approaches
including culturally specific adaptations of existing treatments to improve their acceptability and relevance to
patients of different religious backgrounds.

In recent years, to disprove the notion that psychiatry was becoming blinded to the unique realities of patients within
different cultures and religions, the World Psychiatry Association published a position statement on spirituality and
religion in psychiatry urging the inclusion of spirituality and religion on clinical encounters and training with the
goal of providing a more holistic and comprehensive form of mental health care. (Moreira-Almeida et al., 2016).

According to clinical psychologists, promotion and prevention interventions for mental health are most impactful
when adapted to the local and cultural context16— leveraging the voices of those with experience of mental illness—
and targeting groups in the population that may be vulnerable. There is a need to incorporate spiritual values into
existing forms of therapies, to make them more suitable and acceptable and lift stigmas around counselling and
mental health in the Muslim population. There is increasing need to offer psychotherapeutic approaches that
accommodate religious and spiritual beliefs and acknowledge the potential for healing and growth offered by
religious frameworks. Over recent years, psychologists have sought to explore the role that religion and spirituality
might play in the psychotherapeutic encounter including the investigation of religion-related themes such as coping,
stress management, and even spiritual struggles. Since then, there have been a large number of books published on
this topic, many by the American Psychological Association itself, including its peer-reviewed journal Spirituality in
Clinical Practice, founded in 2014, that focuses on this explicitly.17

A recent Saudi study exploring the use of “traditional healers” in the capital city, Riyadh, reported that 42% of the
1,400 respondents had consulted a traditional healer at some point in their lifetime. This treatment approach is
widely known as al-ruqyah al-sharaaiya. The word ruqyah refers to healing and protective words used to treat people
suffering from an affliction, a ruqyah uses a combination of phrases taken from the Quran, or the sayings of the
Prophet.18

Based on the popularity of traditional approaches to psychological complaints, clinical psychologists recommend
working with these traditional methods considering their non-invasive nature to make mental health treatment more
culturally appropriate, improve engagement and reduce stigma. Various domains of Islam, including the Quran,
hadith, or Islamic law contain multiple references and notions to emotions, wellbeing, and general healing
approaches, In the UAE and the rest of the Muslim world, the most common and most gentle forms of traditional
interventions for mental health conditions center on the Quran and the prophetic traditions 19 (hadith). Islamically
Integrated Psychotherapy (IIP) is a modern approach or orientation to psychotherapy that integrates Islamic
teachings, principles, philosophies, and/or interventions with Western therapeutic approaches. IIP is also sometimes
referred to as Islamic counseling or Islamic psychotherapy.20 Islamic Psychotherapy is indigenous to the Islamic
tradition and known as “purification of the self” (tazkiyat al-nafs). Psychotherapy can be one way to obtain self-
knowledge, thereby potentially being an avenue through which one can change one’s condition and become closer to
God.21

Cognitive Behavioral Therapy (CBT) is demonstrably effective in reducing depressive symptoms and is a flexible
intervention in terms of format. Faith-based CBT or Religiously integrated CBT adheres to the same principles and
style of conventional CBT and uses many of the same tools. What is unique to religiously integrated CBT is the
explicit use of the client’s own religious tradition as a major foundation to identify and replace unhelpful thoughts
and behaviors to reduce depressive symptoms. A systemaic review on Islamically Modified Cognitive Behavioral
Therapy for Muslims With Mental Illness found that iCBT interventions incorporating religious aspects showed
potential benefits in reducing symptoms and improving functioning among religious individuals with mood and
anxiety disorders. iCBT is a therapeutic approach informed by Muslim clients’ own Islamic beliefs, practices, and
resources. It may help clients with mental health issues to develop thoughts and behaviors that enhance mental well-
being. Modifying CBT by adding religious/Islamic aspects may be suitable management for religious Muslims with
mental health issues.

Mobile/smartphone applications (mHealth) have emerged as an efficient avenue for delivering eHealth
interventions, offering the advantage of widespread distribution to maximize population outreach [6]. These apps
afford users flexibility in engagement, granting individuals the freedom to access interventions at their convenience
while enabling real-time monitoring of mood and behavior [7]. Moreover, the mobile technology landscape has
necessitated the development of new intervention formats characterized by frequent, brief exchanges. Multiple meta-
analyses of randomized controlled trials (RCTs) investigating smartphone-based mental health interventions have
consistently demonstrated significant, albeit moderate, effects in alleviating symptoms of anxiety and depression
when compared to control groups. These effects have been observed across a spectrum of populations,
encompassing both clinical and non-clinical contexts.

This pilot study aims to assess the usability, feasibility, acceptability, and preliminary effects of an app-based
intervention designed to reduce depression and improve mental health within a Muslim population. The primary
objective of this study is to test the impact of the Fitra Health app on depressive symptoms among Muslim
individuals. This study also aims to assess participant engagement and level of satisfaction with the app.

2. Materials and Methods

2.1. Study Design

This pilot study will take place from November to December 2023. Muslim adults will be recruited via social media
and clinical sites to test the usability, feasibility, acceptability, and preliminary effects of the app via pre- and post-
intervention questionnaires.
2.2. Participants

Eligible participants are Muslim individuals, aged over 18, who own a smartphone, have adequate English or Arabic
comprehension, and self-reported symptoms of depression. All participants will provide informed consent
electronically, and no identifiable information will be included in the study data. The study will be conducted in
accordance with the Declaration of Helsinki
2.3. Intervention/App

Fitra Health was developed by researchers from King’s College London Institute of Psychiatry, Psychology and
Neuroscience and the London Institute of Healthcare Engineering. For this study's purpose, modifications to the app
content and design were made through consultation with users, clinical psychologists, psychiatrists, medical device
experts and design and user experience specialists. The main component of the Fitra Health app is a 2-month long
intervention structured into eight weekly sessions, each consisting of a video tutorial and a series of customized
activities tailored to address individual requirements. To bolster cultural resonance, the program incorporates
activities related to Islamic faith, practiced by psychiatrists and psychologists with Muslim patients. As participants
progress through the program, they gain access to new app features, facilitating progress tracking and the sustained
management of their symptoms. The central framework of the program is based on well-established treatment
protocols, encompassing fundamental elements of Cognitive Behavioral Therapy (CBT) and behavioral activation.
Moreover, faith-based therapeutic strategies have been seamlessly integrated to ensure cultural appropriateness for
Muslim individuals.

2.4. Procedure:

Participants will be recruited via targeted social media advertisements calling for Muslims experiencing symptoms
of depression to test a new mental health app. Individuals who click on the link in the advertisements will be
directed to the study website which will include information about study procedures and inclusion criteria. Interested
individuals will then directed to read the online participant information statement and consent form on the study
website.After providing informed consent electronically, participants will be required to complete a checklist to
confirm that they met the inclusion criteria. Those who fail to meet the inclusion criteria or were not experiencing
symptoms of depression will be ineligible for the study and excluded. These individuals will be provided with a list
of mental health support services and were encouraged to contact the research team if they required any referral
advice. Those eligible for the study will be asked to complete the baseline questionnaire immediately after
screening. Upon completion of baseline assessment, participants will be provided with links to download the Fitra
Health app to their smartphone from either the App Store (for iPhone users) or the Google Play Store (for Android
phone users). Participants will be required to enter their mobile number and password the first time they access the
app, to link their in-app data and questionnaire responses. Account details will be securely encrypted and will not be
stored with participant data. Participants will be encouraged to access the application daily for a period of 2 months.
Participants will receive a text message invitation to complete online post-intervention assessment 2 weeks after
completing baseline (with up to two reminder emails for non-completers).

2.4. Measures

The primary outcome is depressive symptoms, measured using the Patient Health Questionnaire-9 (PHQ-9) [26].
The PHQ-9 is a reliable and valid 9-item measure of depression severity over the previous two weeks and is
sensitive to change [27,28]. The PHQ-9 can be used either as a diagnostic algorithm to make a probable diagnosis of
major depressive disorder (MDD) or as a continuous measure with scores ranging from 0 to 27 and cutoff points of
5, 10, 15, and 20 representing mild, moderate, moderately severe, and severe levels of depressive symptoms. At
post-intervention, app usability and engagement will be measured using three questions adapted from the Mobile
Application Rating Scale (MARS) [35], assessing ease of use and engagement/interest in the app design and content,
along with questions regarding the usefulness of specific app features/content and the reasons for stopping app usage
(if applicable). Feasibility and acceptability will be assessed via questions adapted from the MARS (likelihood of
recommending the app to others, and overall rating of app), as well as further questions to measure understanding of
app content, and whether the app helped improve mental fitness. Participants will also provide general app feedback
via open response questions. Intervention adherence will be measured via collection of app usage data, which
recorded the number of challenge days completed.

2.6. Statistical Analysis

3. Results

3.1. Recruitment and Retention

3.2. Sample Characteristics
3.3. Symptom Change
3.4. App Usage
3.5. Usability and Engagement
3.6. Feasibility and Acceptability
3.7. App Feedback
4. Discussion
5. Conclusions
Acknowledgments

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