The Use of a Digital Well-Being App (Stay Strong App) With Indigenous People in Prison: Randomized Controlled Trial

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BACKGROUND: Indigenous Australians in custody experience much greater rates of poor mental health and well-being than those of the general community, and these problems are not adequately addressed. Digital mental health strategies offer innovative opportunities to address the problems, but little is known about their feasibility in or impact on this population. OBJECTIVE: This study aims to conduct a pilot trial evaluating the impact of adding the Stay Strong app to mental health and well-being services for Indigenous women and men in custody. The trial compared immediate and 3-month delayed use of the app by the health service, assessing its effects on well-being, empowerment, and psychological distress at 3 and 6 months after the baseline. METHODS: Indigenous participants were recruited from 3 high-security Australian prisons from January 2017 to September 2019. The outcome measures assessed well-being (Warwick-Edinburgh Mental Wellbeing Scale), empowerment (Growth and Empowerment Measure [GEM]-giving total, 14-item Emotional Empowerment Scale, and 12 Scenarios scores), and psychological distress (Kessler Psychological Distress Scale). Intention-to-treat effects on these outcomes were analyzed using linear mixed models. RESULTS: Substantial challenges in obtaining ethical and institutional approval for the trial were encountered, as were difficulties in timely recruitment and retention due to staff shortages and the release of participants from prison before follow-up assessments and an inability to follow up with participants after release. A total of 132 prisoners (age: mean 33, SD 8 y) were randomized into either an immediate (n=82) or a delayed treatment (n=52) group. However, only 56 (42.4%) could be assessed at 3 months and 37 (28%) at 6 months, raising questions concerning the representativeness of the results. Linear improvements over time were seen in all outcomes (GEM total: Cohen d=0.99; GEM 14-item Emotional Empowerment Scale: Cohen d=0.94; GEM 12 Scenarios: Cohen d=0.87; Warwick-Edinburgh Mental Wellbeing Scale: Cohen d=0.76; Kessler Psychological Distress Scale: Cohen d=0.49), but no differential effects for group or the addition of the Stay Strong app were found. CONCLUSIONS: We believe this to be Australia's first evaluation of a digital mental health app in prison and the first among Indigenous people in custody. While the study demonstrated that the use of a well-being app within a prison was feasible, staff shortages led to delayed recruitment and a consequent low retention, and significant beneficial effects of the app's use within a forensic mental health service were not seen. Additional staff resources and a longer intervention may be needed to allow a demonstration of satisfactory retention and impact in future research. TRIAL REGISTRATION: ANZCTR ACTRN12624001261505; https://www.anzctr.org.au/ACTRN12624001261505.aspx.

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