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SoAn: An interactive video to detect social anxiety in adolescents

Giovanna Gomez-Pacci, Carlos Orellano

School of Public Health and Administration, Universidad Peruana Cayetano Heredia, Lima, Peru
(Giovanna Gomez-Pacci MSc); School of Medicine, Universidad Peruana Cayetano Heredia, Lima,
Peru (Prof Carlos Orellano MD)

Correspondance to:
Giovanna Gomez-Pacci, School of Public Health and Administration, Universidad Peruana Cayetano
Heredia, Lima 15102, Peru
giovanna.gomez.p@upch.pe
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Summary—
Background: Social anxiety is a mental health problem present in the school adolescent population. Many times, this is
unknown to them. According to a study carried out in 2002, this prevalence is approximately 7% of the adolescent population in
Lima because of factors such as lack of interest, social stigma or difficulty of access to mental health services. The consequences
of social anxiety influence their adult life. On the other hand, nowadays teenagers are engaged with technology, such as
videogames or interactive programs. This study aimed to validate and evaluate the acceptability of an interactive video to detect
social anxiety in adolescents in a school.in adolescents of a school.
Methods: An interactive video was developed in Unity 3D through the high fidelity prototipate methodology and was meant
to be used in computers. The interactive videoIt was validated by obtaining sensitivity and specificity. The acceptability was
evaluated through the constructs Performed Income, Ease of Perceived Use and Behavioral Intention of the Technological
Acceptance Model (TAM), along with constructs Compatibility Perceived and Resistance to change.
Outcomes: The results showed a 50% of evaluated adolescents detected with social anxiety symptoms through the clinical
interview, considered as gold standard. The prototype had a sensibility and specifity of 63‧51 % and 72‧60%,
respectively, and an overall good acceptance.

Interpretation: An interactive video can be used to detect social anxiety in adolescents. However, it is necessary a software
refinery. Besides, the construct Resistance to Change must be labored to assure the software usefulness.

Funding: This study was founded by Concytec-Fondecyt Peru.

Index Terms—Adolescents, Acceptability Interactive video, Social Anxiety, Validation

Research in context

Evidence before this study

Up to date, there are some international publications about
using videogames, interactive videos or virtual reality tools
to treat some common mental disorders like depression and
anxiety, specially aimed at young population. However,
there are fewer publications about screening or diagnostic
tools.
In countries like Peru, although the idea of using these
technologies to break the social stigma of mental illnesses
is present, there are very few scientific reports on this kind
of screening approach. Regarding soxial anxiety, to our
knowledge there are no published research articles.
Added value of this study
We designed and evaluated an interactive video to detect
social anxiety. We also evaluated its acceptance using
TAM model. This implies that the created software can be
refined to assure a successful use of the screening test at the
aimed population.
Implications of all the available evidence
The project suggests that is possible to use interactive
videos to detect risk of anxiety in teenagers and do an
intervention to assure them a successful adult life, breaking
the social stigma at the same time.

I. INTRODUCTION
In childhood and adolescence, anxiety disorders are the most common worldwide 1, reaching a prevalence of 9 to 21%. Among
these disorders is social anxiety disorder, which affects 1% of adolescents. However, the actual prevalence rates are likely to be
higher. In clinical samples these figures amount to 14%. 2
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The prevalence of social phobia in adolescents in Lima was estimated at 7 ‧1% by the Specialized Institute of Mental Health
“Honorio Delgado-Hideyo Noguchi” in 2002. 3 However, another study in 2005 found a prevalence of social anxiety
symptoms of 40‧5% in a male college in Lima. 4
This subdiagnosis is an important issue to be treated. According to the World Health Organization (WHO), mental illnesses
constitute 16% of diseases and injuries in adolescents and most cases are not detected or treated. 5 The consequences can be
serious. Among them are poor academic performance and dropping out of school, the development of other anxiety and mood
disorders or the onset of alcohol or other intoxicating substances consumptionthe beginning of alcohol or other toxic substances.
If it is not resolved in time it also entails the consolidation and generalization of its effects on adult life. The individual can
finally develop a severe depressive condition and attempt suicide.
According to Baker et al 6, the symptoms of this disorder are manifested physically, emotionally, cognitively and behaviorally.
Physical symptoms include difficulty breathing, chest tightness, fast heartbeat, stomach upset, dizziness, tremor and numbness
or tingling. Emotional symptoms range from nervousness to terror and panic. Cognitive ones include worry, apprehension,
difficulty concentrating and negative thoughts regarding a possible threat. Behavioral anxiety symptoms generally aim to
decrease or prevent perceived threat or distress through avoidance, escape and safety behaviors; they often lead to a malfunction
in the home, work or social situations.
On the other hand, Mayer defines interactive videos as any system that allows users to send or receive data from other videotext
computers capable of displaying text and images 7 Monteagudo, Sánchez and Hernández made a documentary review of these
videos as a method of teaching, recommending to evolve towards more interactive forms. 8 Serrano informs that these videos can
be used to make interactive questionnaires, so that users can answer questions while watching the video. 9
When new technologies are incorporated, it is important to know if these will be accepted or not by the target audience. The
Technology Acceptance Model (TAM) proposes a way to measure the acceptability of a widely used and studied technology,
through constructs such as usability, ease of use, intention to use and attitude of use. 10
For all this, this study proposes proposed the validation and evaluation of the acceptability of an interactive video for the
detection of social anxiety disorder in adolescents.
.

II.METHODS

A. Study design

This project had an observational design, corresponding to the validation of a diagnostic test. Sensitivity and specificity were
found by comparing the test with the gold standard, the clinical interview done by the clinical psychologist.

This study followed a quantitative method, through the application of surveys. The acceptability survey was created from the
TAM, plus the compatibility and resistance to change constructs. Figure 1 shows the phases of the study.

B. Participants
The target population of this study are were the adolescents enrolled in a secondary school of Lima, Peru. The number of
secondary school students was approximately 870. The sample was taken as indicated below, ordering by phases:

Phase II Pilot Test

It was considered a two-phase pilot test. Each phase used 5Five teenagers were randomly selected in each phase for the
formative stage of the software. They, who were asked about the functionality of the software and possible suggestions they
have.

In order to know what modifications had to be made, the following method was proposed. 11
If less than 60% of users answer a question positively, this concept will be modified.
If between 60 and 80% of users answer a question positively, this concept will be reviewed.
If more than 80% of users answer a question positively, the concept will remain unchanged.

Phase IV: Screening with SPAI-B

The study evaluated all the adolescents of the school who wanted to participate with the SPAI-B paper questionnaire. The
screening was conducted room by room, from the sections of First from secondary to Fifth of Secondary. The classrooms of the
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morning shift were screened first and then those of the evening shift.

Phase IV: Prototype test and acceptability survey

Through the OpenEpi software, for a minimum sensitivity and specificity of 80%, a minimum quantity of 76 people with and
without social anxiety disorder was needed, with an accuracy of 9% and 95% confidence intervals.

Phase V: Psychological evaluation

The psychological evaluation of all students who agreed to participate, both negative and positive, was done.

C.Procedures
Phase I: Creation of the interactive video prototype

The high fidelity software prototyping methodology was followed.

1) Requirement collection and refinement

The requirements are summarized in tables I and II, based on the concepts presented by Sommerville. 12

Functional software requirements

1. The user, optionally, must be able to create a user (unique ID) with his email, where he will enter his name, his age and
his sex (female, male).
[2.] The interactive video will be presented according to the user's sex to your gender. The user will select their answers
through buttons displayed on the screen. The system will automatically save your the user’s responses over the internet.
[3.] The user will be presented with Aa final message is presented to the user about whether or not he was detected with
social anxiety, which will also be sent to his registered email.

The user will be detected at risk of suffering from social anxiety disorder if his final score is greater than or equal to 23 and had a
score greater than or equal to 4 in item 3, as expressed by García et al in his study on the SPAI -B.

2) Modeling, fast design

The prototype of the interactive video was created using the MarvelApp programsoftwares to create prototypes and Krita, for
digital painting.

Background drawings and visual novel style characters were used. A visual novel is a digital book in which the events that are
narrated are represented graphically. The components of a visual novel are the following: Background image, Sprites, Music,
CG’s / Videos, Text and Elections. 13

Figure 2 shows an example of a scene made in the Krita software. In figure 3 it is seen a screenshot of the Project in MarvelApp.
3) Prototype Construction
Each scene to be included in the interactive video was built to be included in the interactive video using the Unity platform. An
asset called Online Account System was used for user registration 14, which the user can optionally use.

Prototype validation by an expert

In order to validate the content of the vignettes, the opinion of an expert in psychiatry was requested, which compared that
content with the SPAI-B test. This process was carried out twice, in which the pertinent modifications were made.

Phase II: Pilot test

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4) Evaluation of the prototype by the client

5 Five participants were selected by simple random sampling among those who agreed to participate. Then they used the
interactive video prototype. They were subsequently asked about the prototype in development through semi-structured personal
interviews. The prototype was refined according to the feedback provided by users. This step was performed twice.
Refinement of the prototype: The scenes were refined according to the feedback provided by the adolescents.

Interview questions:
1. Could you use the prototype to know if you are at risk of social anxiety or not?
2. Did you detect any failure in the prototype? If so, describe it.
3. From 1 to 5, how interested were you in the prototype?
4. Did you understand the instructions of the prototype?
5. Tell me a suggestion about the prototype, if any.

The responses of this phase were summarized in table III. All the students indicated that they could use the prototype to know if
they are at risk or not, that is, they obtained the final message. They indicated that they did not detect failures and that they
understood the instructions of the prototype. On the other hand, in suggestions one student pointed out that he would not greet
his classmates and another student that the letters should be faster. In general, the prototype had a score of 3 ‧8 out of 5 of
interest. As for each question more than 80% of users responded positively the concept remained unchanged.

The responses of second phase were summarized in table IV. All the students indicated that they could use the prototype to know
if they are at risk or not, that is, they obtained the final message. They indicated that they did not detect failures and that they
understood the instructions of the prototype. On the other hand, in suggestions one student pointed out that more specific
questions could be asked, another student who could show some more images and another student that the letters should be
faster. In general, the prototype had a score of 3 ‧4 out of 5 of interest. As for each question more than 80% of users responded
positively the concept remained unchanged.

5) Engineering Product: The finished prototype.

Phase III: Screening with SPAI-B

The study screened all adolescents in the school with the SPAI-B paper questionnaire that agreed to be part of the study. They
were asked to put their name, age and sex on that questionnaire.

Phase IV: Prototype test and acceptability survey

All those adolescents who agreed to participate were invited to use the interactive video prototype completed in the school's
computer rooms as all the study took place inside the school.
For validation, students' responses were collected in the prototype and in the clinical interview (Gold Standard).
The concepts of sensitivity and specificity have been used. To find these values, the OpenEpi software available on the Internet
has beenwas used. The results obtained in the SPAI-B test, the prototype and the individual clinical interview of each student,
used as the standard Gold, have beenwere contrasted.
Subsequently, an anonymous individual survey was taken in the KoboToolbox software to assess its acceptability. Table V
groups the sentences according to construct.
It is based on Davis's TAM model, which includes the constructs: Pperceived Eease of Uuse, Pperceived Uutility and
Bbehavioral Iintent. In addition, the constructs Compatibility perceived, of the proposal of the proposal of Moore and Benbasat
and Resistance to the change, of the proposal of Bhattacherjee and Hikmet and Guo et al.
An instrument was prepared to collect the responses of adolescents from the survey created by Sánchez-Prieto, Olmos-
Migueláñez and García-Peñalvo, adapting it for the present context. It was anonymous to encourage teenagers to respond
honestly.

Phase V: Psychological evaluation

A clinical psychologist went to the school to evaluate those participants. Each participant was evaluated psychologically by the
clinical psychologist, and previous screening by the SPAI-B was confirmed or rejected.
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[III.] OUTCOMESRESULTS

1) Population characteristics

A total of 147 adolescents between 12 and 17 years of age were evaluated using the SPAI-B, the prototype and the interview.
There were 62% females and 38% males. The median age was 13 years. Figure 4 shows the quantity of teenagers evaluated by
age.

Figure 5 shows the number of adolescents detected by the Gold Standard (Clinical Interview). The average age of those detected
was 14‧30.

Table VI shows the average age of adolescents detected and not detected, as well as the standard deviation. According to Fisher's
exact test calculated by R, with a significance level of 0 ‧05, p was 0 ‧4808, which means that there is no statistically
significant difference between the ages of those detected.

Regarding sex, a greater number of women with social anxiety was found. (See table VII). Regarding age, a greater number of
16-years-old adolescents was detected (See figure 5). The relationship between women and men is greater in the group of 13
years old students.

Regarding sex and quantity of detected and undetected teenagers, the p-value is 0‧0618 with a significance level of 0‧
05 according to Fisher's exact test. There is no statistically significant difference regarding the sex of the participant.
Table VIII groups the detected and undetected teenagers by age and sex.

A. Validation

SPAI-B validation

The teenagers' responses The results of the adolescents in the paper test and in the clinical interview have been compared. A
sensitivity of 68% and a specificity of 100% were obtained by the Wilson points method.

Prototype validation

Similarly, the results of the contrast between the prototype and the standard Gold are presented, also by the Wilson points
method. A sensibility of 63‧51% and an especifity of 72‧60% were obtained.

B. Acceptance

Table IX shows the scores for each statement. In general there is a positive appreciation of the prototype.

Table X shows the scores for each sex. There are statistically significant differences between female and male sex in statements
3, 5 and 11. Likewise, it is observed that the medians in all constructs were 4 and 5, which correspond to More or less agree and
Agree.

D.Data analysis
The analysis was done using the EpiInfoTM, OpenEpi, R and Microsoft Excel programsSoftware. Two databases were built in
xls format. The graphics were made with Microsoft Excel Ssoftware.
For the sensitivity and specificity analysis, the OpenEpi software was used to evaluate diagnostic tests.
An univariate analysis by construct of the acceptability survey was presented.
For the univariate analysis of the qualitative variables, absolute frequencies and percentages were used. The graphs were pie
charts and bar charts. For the quantitative variables, arithmetic means, medians, standard deviation and interquartile range were
used.

E. Ethical considerations
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First, the approval of the Ethics Committee of the Peruvian University Cayetano Heredia was obtained. The participation of
each teenager was voluntary. A format of consent was given to adolescents. Informed consent was given to the parents, which
was filled out. A report was made for the school with the list of students detected with symptoms of anxiety, so they can see a
specialist from the Center for Community Mental Health "Nancy Reyes Bahamonde", located near the school. They were also
given business cards to give to each parent or tutor. A small gift was given to teenagers for their participation.

F. Role of the funding source

The funding source had no role in this research.

[IV.] DISCUSSION

In the present research, a high percentage (50‧34%) of adolescents with symptoms of social anxiety has beenwas found.
This constrasts the results of the 2002 Noguchi Institute of Mental Health report on the prevalence of social anxiety 3 and
of the 2007 report 15 which indicates an even lower prevalence of 3‧4%. Aditionally, a study conducted in Arequipa
indicated a prevalence of 10% of the disorder, ranging in age from 14 to 19 years.16 This can be explained because the
symptoms must remain at least six months to be considered a disorder 17 and that teenagers tend to be insecure and seek
external validation.

On the other hand, the result coincides with that of the study by Lindo et al, which reported a prevalence of 40 ‧5% according to
the SPIN and 22‧6% according to the LSAS of male adolescents with symptoms of social anxiety. 4 As the objective of the
present study was not to find the prevalence, the prevalence found could be higher than the real one due to the greater
participation by adolescents which considered could have the condition.
In relation to sex, a higher prevalence of social anxiety symptoms was found in women (56 ‧52%) but which was not
statistically significant. Other studies in literature, like the study by Huamán-Mamani 16 say that "Women of reproductive age are
more vulnerable to developing anxiety disorders than men, approximately 2 to 3 times more ... possibly due to differences in
brain anatomy, neurochemistry and patterns of activation and response to environmental stimuli". 18
Likewise, we found an average age of those detected of 14 ‧30 years and a higher percentage of those detected of 13 years
(51‧72%), which is consistent with what was stated by Olivares-Rodríguez et al, 19 which mentions that the age of the onset is
usually between 13 and 15 years and found an average of 15 ‧03 years in his study. It also agrees with the statements made by
Ramírez and Reyes, 20 who say that the average age of onset of social phobia is half of adolescence. Ramírez and Reyes
highlighted that adolescents usually present an increasement in evaluative social anxiety, since young people when they go
from childhood to adolescence give greater relevance to the perceptions of their peers, friends and adults and their social
relationships when they go from childhood to adolescence. In other words, transient episodes of anxiety in social situations are
frequent and are part of their development.

Regarding the validation of the prototype to detect social anxiety, García-López and Vera-Villarroel made a review of all the
instruments to detect it. They indicated that the SPAI is a reliable tool to measure anxiety in both adults and adolescents. A
sensitivity of 68% and a specificity of 100% were found, which is consistent with what Garcia expressed in his study. In this
research he mentions a greater specificity of SPAI-B, although in general it is a good tool to detect social anxiety.
The reliability or accuracy of a test is its ability to produce the same results each time it is applied under similar conditions. The
accuracy of the SPAI-B in this study was 0‧84, corresponding to a good test, unlike the Garcia-López study 21, where it is 0‧
94. This may be due to the differences between the Spanish population and the Peruvian population and the difference in the
sample size (1034 versus 147) and the different prevalence of the disorder. Quintero 22 mentions that a study conducted in 1997
in Spain found a prevalence of. 8%, although the results may be lower than the real ones due to participation bias. At higher
prevalence, sensitivity decreases. 23
The interactive video prototype showed an accuracy of 0 ‧68, which is an accuracy of a regular test. The sensitivity could be
lower due to a response bias, in which the participants did not honestly answer the questions in the video. It could also be
improved by including more scenes that represent social situations that generate social anxiety in the participant.

The SPAI-B has a diagnostic accuracy of 84‧35%, which means that it will adequately detect 84 ‧35% of cases. The prototype
has an accuracy of 68‧03%. The SPAI-B has a negative likelihood ratio of 0.3108, that is, those with negative results are 0 ‧
3108 more likely to suffer from the disorder. The prototype has a positive likelihood ratio of 2 ‧318 and a negative of 0 ‧5025,
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those who have positive results are 2‧318 more likely to suffer from the disorder and those who have negative results are 0 ‧
5025 more likely to suffer from it.
On the other hand, the survey of acceptability of the prototype generally showed a positive appreciation by the adolescents.
Within the constructs Perceived utility, Perceived Ease of Use, Behavioral Intention of Use and Compatibility, more than 34% of
adolescents responded that they agreed with the statements. The same happened with the Resistance to Change construct, which
indicates that it must be intervened to ensure full acceptance of the test. Regarding the differences about the sex of the
participant, all the statements had a minimum median of 4, which is consistent with the study conducted by Sánchez-Prieto.
Statistically significant differences were found in the some statements. The statements “The Use of the prototype can make it
easier to detect social anxiety”, “Learning to use the prototype would be easy for me” and “Using the prototype would be
compatible with me” have a better appreciation by women. Then it could be said that women are more predisposed to use
interactive video to detect anxiety. One possible explanation is that the majority of visual novels are for female audiences,
which will attract their attention more.
With respect to age, no significant differences were found in any statement, which means that adolescents aged 12 to 17 are
equally predisposed to use the software programtool. The minimum medians were 3‧5 and 3 in the statement “I do not want the
prototype to change the therapist-patient interaction” of adolescents aged 14 and 16, which indicates that they are more likely to
assume such change.

In conclusion, the results show that the prototype can be used to detect the risk of suffering social anxiety. It has an accuracy of
0‧68, which means it is an average test that can be refined to obtain more sensibility and especifity. TAM theory proposed by
Davis is a valid tool to obtain acceptance. In general, there was a good acceptance and compatibility, but there was resistance to
change. This would be a variable to intervene to assure the successful use of this kind of tools.

III.[V.] CONTRIBUTORS
GGP had the main idea of the study and draw a draft of the methodology and CO refined them. GGP did the literature research
and CO supervised the project. GGP wrote he original article draft and CO reviewed and gave feedback. GGP did the
recruitment, data adquisition, coordination with the school and other authorities and CO adviced in each of these steps. GGP did
the analysis and CO contributed reviewing it. Both authors had access to the data and had the responsibility to submit for the
decision to submit for publication.

IV.[VI.] DECLARATIONS OF INTERESTS

We declare no competing interests.

V.[VII.] DATA SHARING

No data is available for sharing.

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