Design and Development of an mHealth Application for Depression and Anxiety Self-Care in Ethiopia

Background: Depression and anxiety are the most common mental health disorders, affecting people across all ages, genders, and socioeconomic groups. These conditions contribute significantly to the global burden of disease, often leading to impaired functioning, reduced quality of life, and increased healthcare utilization. While mental health challenges are widespread, their impact is especially pronounced in low-resource settings, where structural inequities and limited access to care exacerbate the burden. In such contexts, individuals may face compounded challenges, including limited availability of linguistically appropriate interventions and high levels of unmet need due to geographic, financial, or systemic barriers. Given these persistent gaps in access and linguistically appropriate care, innovative solutions such as mobile health applications have emerged as promising tools to bridge inequalities and extend mental health support to underserved populations. Mobile health applications reduce barriers to care by offering 24/7 support. Despite this, there are few applications developed for low-income countries such as Ethiopia, and none tailored to the cultural context, language, or user preferences, which limits adoption and effectiveness.Aims: This doctoral thesis aims to design, develop, and evaluate a ‘Mobile Mental Health Solution App’ tailored for linguistically diverse individuals experiencing depression and anxiety in Ethiopia. The aim is achieved through six research objectives: 1) To assess smartphone application use patterns among individuals with mental health disorders, 2) To develop and validate tools to measure smartphone use patterns, interest, attitudes, and feature preferences toward smartphone app use, 3) To assess mobile mental health application use, and app feature preferences among patients with mental disorders, 4) To explore healthcare providers' attitudes, preferences, and suggestions regarding the use of smartphone apps for mental health self-management by patients, 5) To design and develop a ‘Mobile Mental Health Solution App’ prototype for individuals with depression and anxiety, and 6) To assess usability of a “Mobile Mental Health Solution App” developed for depression and anxiety self-care in Ethiopia.Methods: The Design Science Research Method (DSRM) approach was chosen to design, develop, and evaluate the ‘Mobile Mental Health Solution App’. The rationale for DSRM in developing the mental health app involved problem identification, solution definition, design, development, demonstration, evaluation, and dissemination. DSRM integrates theory and practice, creating innovative, context-applicable solutions that address real-world challenges and opportunities. It emphasizes the importance of understanding the context in which solutions are applied. A systematic literature review and meta-analysis were conducted for objective one. To achieve objective two, a Modified Delphi study was conducted. In the Modified Delphi study, 21 experts in Round 1 and 16 in Round 2 rated the questionnaire for relevance, clarity, and importance. Consensus was evaluated using the Content Validity Index, Universal Agreement, and Content Validity Ratio. A pilot survey was also conducted with 400 individuals with mental illness at Amanuel Mental Specialized Hospital. A cross-sectional survey was conducted to achieve objective three. A cross-sectional study was conducted among 419 outpatients with mental health disorders at Amanuel Mental Specialized Hospital, Ethiopia, using convenience sampling methods. Data on patients’ self-reported mental health app use, interests, attitudes, and preferred features were collected. A qualitative study was undertaken to address objective four. Two focus group discussions were held with 14 mental healthcare professionals at Amanuel Mental Specialized Hospital in Ethiopia. Audio recordings were transcribed, coded, and analyzed using NVivo 14. For objective five, to develop the ‘Mobile Mental Health Solution App’, evidence from objective three and four was used; furthermore, experts' feedback and an iterative test were conducted. A Cognitive Walkthrough (CW) was conducted with six experts to evaluate the app's features. Subsequently, 20 volunteers participated in closed app testing after using the app for 14 days. A usability test and user experience assessment were conducted to address objective six. A convergent mixed‑methods design was used to assess the usability and user experience of the ‘Mobile Mental Health Solution App’ in Ethiopia. The study was conducted at Tibebe Ghion Specialized Hospital and Amanuel Mental Specialized Hospital. The study included a cross‑sectional survey of 370 participants with depression and anxiety, and 20 in‑depth interviews.Results: A summary of the results is presented based on the phases of the DSRM: 1) Problem identification and evidence generation: A systematic literature review and meta-analysis of smartphone app use among individuals with mental disorders found high ownership (88 %) but low app usage (23 %), despite high perceived usefulness (73 %) and future interest (79 %). A modified Delphi study was conducted to validate a 46‑item patient survey questionnaire; the finding showed high validity and reliability. The survey of 419 individuals with mental health conditions in Ethiopia revealed that 94.7% showed interest in using Mobile Mental Health applications (MHAs), but only 21.2% were currently using such apps. Psychoeducational content, symptom tracking, self-care content, and reminders were among the features to be included in the applications. Focus groups with 14 mental health professionals highlighted perceived potential benefits of MHAs in improving mental health awareness and well-being and reducing workload. Psychoeducational content, self-monitoring, multimedia, self-care, and a helpline during emergencies were commonly recommended application design requirements. However, participants raised concerns about the application's usability in linguistically diverse individuals experiencing depression and anxiety.2) Solution definition, design and development: The findings from the survey and focus groups informed the app’s design, emphasizing key app design requirements like psychoeducational content, self-assessment (DASS-21), tracking, medication reminders, appointment, and profile. Persuasive System Design (PSD) features like tailoring, reminders, trustworthiness, and self‑monitoring are mapped to app design requirements. As a result, a ‘Mobile Mental Health Solution App’ prototype was created in Figma and refined through clinicians' and experts' Cognitive Walkthroughs (CW). The CW results showed that study participants liked and agreed with most of the app interface design requirements. Of feedback, amendments were made to the text alignment, interface design, and text size. Amendments were made by consolidating similar content into a single screen. 3) Evaluation and usability assessment: After developing and releasing the Mobile Mental Health Solution App, a mixed-methods usability evaluation was conducted with 370 patients who used the app for two weeks, along with 20 in-depth interviews. The results from the usability test showed that participants found the app easy to use, were highly satisfied with the app interface, and found it useful. App features such as mood tracking, reminders and progress reports were rated as highly valued for inclusion in the app. Qualitative results were positive about the app’s relevance and accessibility, while recommending future improvements such as screen reader support and additional language options.In summary, the results highlighted the potential of a tailored MHA to improve mental health support in Ethiopia, where the burden and prevalence of mental health conditions are high. The ‘Mobile Mental Health Solution App’ was designed and developed through a three-phase process: problem identification, solution design, and usability evaluation. The application integrates psychoeducational content, symptom tracking, self-care, and reminders in two languages: Amharic and English. Usability testing with 370 patients and qualitative interviews confirmed high satisfaction, ease of use, and relevance, underscoring the importance of locally adapted digital tools in low-Income Countries like Ethiopia. This thesis advances the field of digital mental health by demonstrating how linguistically diverse tailored MHAs can be developed, with a view to enhancing engagement and usability among underserved populations in Ethiopia. The findings contribute actionable insights for policymakers, application developers, and mental health practitioners seeking inclusive, context-sensitive digital solutions. However, this thesis is limited by the absence of randomized controlled trials to assess clinical efficacy, uneven digital access in rural areas, and limited generalizability beyond smartphone users. It is important to note that the design and development of the Mobile Mental Health Solution App was limited to depression and anxiety; it is not comprehensive enough to address other mental health conditions.