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Depression is a major health issue among Māori indigenous adolescents, yet there has been little investigation into the relevance or effectiveness of psychological treatments for them. Further, consumer views are critical for engagement and adherence to therapy. However, there is little research regarding indigenous communities’ opinions about psychological interventions for depression.
The objective of this study was to conduct semistructured interviews with Māori (indigenous New Zealand) young people (taitamariki) and their families to find out their opinions of a prototype computerized cognitive behavioral therapy (cCBT) program called Smart, Positive, Active, Realistic, X-factor thoughts (SPARX), a free online computer game intended to help young persons with mild to moderate depression, feeling down, stress or anxiety. The program will teach them how to resolve their issues on their own using Cognitive Behavioural Therapy as psychotherapeutic approach.
There were seven focus groups on the subject of the design and cultural relevance of SPARX that were held, with a total of 26 participants (19 taitamarki, 7 parents/caregivers, all Māori). There were five of the groups that were with whānau (family groups) (n=14), one group was with Māori teenage mothers (n=4), and one group was with taitamariki (n=8). The general inductive approach was used to analyze focus group data.
SPARX computerized therapy has good face validity and is seen as potentially effective and appealing for Māori people. Cultural relevance was viewed as being important for the engagement of Māori young people with SPARX. Whānau are important for young peoples’ well-being. Participants generated ideas for improving SPARX for Māori and for the inclusion of whānau in its delivery.
SPARX computerized therapy had good face validity for indigenous young people and families. In general, Māori participants were positive about the SPARX prototype and considered it both appealing and applicable to them. The results of this study were used to refine SPARX prior to it being delivered to taitamariki and non-Māori young people.
The New Zealand Northern Y Regional Ethics Committee; http://ethics.health.govt.nz/home; NTY/09/003; (Archived by WebCite at http://www.webcitation/6VYgHXKaR).
Depression is a major concern globally and population-based studies internationally have indicated that 12-month prevalence rates are as high as 6.7% in adolescents [
The National Institute for Clinical Excellence in the United Kingdom recommends cognitive behavioral therapy (CBT) as a first line treatment for adolescents with mild to moderate depression [
However, indigenous minority adolescents rarely seek professional face-to-face help as a first treatment option for depression [
Ethnic minority populations are largely missing from the efficacy studies that make up the evidence base for psychological treatments. This is often due to the inclusion of small samples, which limit the accuracy of statistical inferences [
There are implications for those that design cCBT programs, in that the evidence base that they draw from to inform these therapies is fairly limited for ethnic minority groups, with a review of cCBT for adults highlighting that future research in the field needs to specifically assess the acceptability of cCBT among indigenous minority groups [
This study provides an opportunity to begin to understand some of these much needed “consumer opinions”. Not surprisingly, there has been little research published on psychological interventions for Māori [
In New Zealand, Smart, Positive, Active, Realistic, X-factor thoughts (SPARX), which is a form of cCBT, has been funded by the Prime Minister’s Youth Mental Health Project, and this form of cCBT has been made available free of charge to anyone wanting to access the program on a national level since April 2014.
SPARX (Smart, Positive, Active, Realistic, X-factor thoughts) is a free online computer program intended to help young persons with mild to moderate depression, feeling down, stress or anxiety. Through the game, the program teaches them how to resolve their issues on their own, using Cognitive Behavioural Therapy. Based in a 3D fantasy world, the game leads players through seven realms (each lasting between 30 and 40 minutes). In the beginning of SPARX, the user meets the Guide who explains what SPARX is and how it could help. Then the user customizes an avatar and starts to journey within the seven provinces in order to complete different quests. In the first level, gamers challenge GNATS (Gloomy Negative Automatic Thoughts). These GNATS fly towards the avatar and say negative things like, for example: “you're a loser”. Further in the game, the user meets different characters, solves puzzles and completes mini games. As soon as a quest is completed, the Guide explains how to use new skills in order to feel better, solve problems and enjoy real life. Players complete one or two levels in the game each week, during three to seven weeks.
When we developed SPARX, our aim was to design it to appeal to all young people in New Zealand, regardless of ethnicity [
Western research traditionally holds an individualistic approach to epistemology. However, the traditional Māori perspective has been to view the world in a collectivist way. Māori culture places an emphasis on the individual acting in a way that would seek to put the whānau (extended family) and iwi (tribe) needs before their own needs. This has implications for research from a Māori worldview, and this way of carrying out studies has come to be known as Kaupapa Māori research [
Kaupapa Māori research has emerged over the past two decades, alongside an increasing awareness and acknowledgement from academia of Māori epistemology, coupled with Māori ways (tikanga customs and protocols) of conducting research. Kaupapa Māori research encompasses an analytical approach that is about thinking critically, which includes critiquing Western definitions and constructions of Māori people and their worldview. It is also about valuing Māori self-determination and encouraging Māori participation in the research process [
Western psychological models such as CBT have tended to focus on an individual’s internal psychological state, for example, a change in one’s thoughts and feelings leads to improved mental health. In contrast, Māori culture emphases the importance of being connected to extended family (whānau), genealogy going back many generations (whakapapa), tribe (hapu and iwi), environment (land, rivers, seas, and mountains), and spiritual (wairua) and physical health [
It is important to also note that research that has been conducted in the past has often been detrimental to Māori communities [
The study was led by the first author, MS, who took a critical realist position, which posits that in order to understand the meaning of the data, it is essential to understand the context in which the phenomena takes place and the method by which the data are collected [
In total, seven focus groups were conducted, with a total of 26 Māori participants who were recruited through word of mouth (
Number and type of focus groups and participants.
Group | Group type | N | n (participants16-18 years) | n (participants parent/caregiver of adolescent) |
1 | Taitamariki (adolescents) | 8 | 8 | - |
2 | Taitamariki mothers | 4 | 4 | - |
3 | Whānau (family) | 4 | 2 | 2 |
4 | Whānau | 1 | - | 1 |
5 | Whānau | 3 | 2 | 1 |
6 | Whānau | 3 | 1 | 2 |
7 | Whānau | 3 | 2 | 1 |
All participants were shown the prototype of SPARX on a computer and asked for feedback during focus groups. A semistructured format was used. The sessions lasted between 30 and 60 minutes. Feedback was sought about the design and applicability of the content of the SPARX program. At the conclusion of the focus group, participants were invited to complete a questionnaire about their views of the session and the prototype SPARX program. The purpose of the questionnaire was to include rating scales so participants had the opportunity to quantify their views.
The questionnaire contained five questions, which consisted of four Likert scales (on a five point scale), four free-text spaces, and one closed question.
Focus group questionnaire.
Questions | Rating scale |
Q 1. How much were you able to express your opinions in the focus group? | 1= “Not at all” |
Q 2. Overall what did you think about the look and style of the game? | 1= “Didn’t like it at all” |
Q 3. Overall what did you think about the content (messages and information to help people) in the game? | 1= “Didn’t like it at all” |
Q 4. Overall what did you think about the cultural content in the game (Māori costume design and building/environment) designs? | 1= “Didn’t like it at all” |
Q 5. Would you like to make any other comments? | No rating needed |
Numerical data were analyzed using descriptive functions of the Statistical Package for the Social Sciences 15.0. The free-text comments were analyzed using a general inductive approach [
This qualitative research was conducted using a General Inductive Analysis (GIA) [
The qualitative method utilized for this research was thematic analysis [
Braun and Clarke’s [
The New Zealand Northern Y Regional Ethics Committee granted approval for this study (NTY/09/003). All participants provided their own written consent. No inducements were offered.
A number of themes were identified from the data, and these have been organized into four categories: (1) computerized therapy has good face validity and is seen as potentially effective and appealing, (2) cultural relevance was viewed as being important for the engagement of Māori young people with SPARX, (3) whānau are important for young peoples’ well-being, and (4) ideas for improvement of SPARX for Māori.
Taitamariki and whānau generally considered that SPARX could help young people with depression and considered that SPARX would be able to teach skills to help deal with depression.
SPARX is like a computer game that can help with depression
This game is more about helping you through it (depression) though I just realized it now (in response to MS asking what are your initial thoughts).
SPARX was able to teach skills. Most participants connected with the characters in SPARX and thought they could teach them skills. A skill that most participants understood and felt motivated to complete was the breathing/relaxation skill.
How everything in there we knew and everything that gets you thinking, especially when they said to breathe. It makes you want to breathe with it and it is only a video game (comment during spontaneous discussion).
The main thing was probably breathe in, breathe out. It is a good exercise.
It is good to breathe when you get angry.
It calms you down (in response to MS asking about what messages did you take away).
Most of the participants valued the Māori designs on the characters and there was a range of opinions about whether participants found them relevant. Participants were also interested in the whakapapa (genealogy) of the characters in SPARX. Participants acknowledged that the characters were able to teach skills and wondered whether the Guide character could be a role model for taitamariki.
Māori designs within the SPARX environment were relevant for Māori. Most participants noticed the Māori designs and thought that the inclusion of the designs helped to enhance the engagement and gaming experience of SPARX.
Hey, that is cool...Yes, it snuck up to me. And poutama’s (Māori art design, symbolizing a climb up toward a goal) got a good meaning too. That is really cool. That is like telling them to get happier. So it makes you feel like you have got to try.
Yes, I was feeling that too (in response to discussion led by MS asking for feedback about the graphic designs in SPARX).
The participants spoke of the value of Māori designs in SPARX. Most participants in the focus groups thought that the Māori designs on the outfits of the main SPARX characters were a good idea. Most recognized the hybrid nature of the design of the characters (see
I reckon he looks mean as. He looks like a medieval Māori (in response to MS asking for opinions about the Guide).
There were some differing views. A small number of participants, both taitamariki and parents/caregivers, did not understand the hybrid concept of the designs (see
It looks like a couple of people from the medieval time that have nothing to do with anything Māori, they don’t really look Māori (spontaneous discussion about what is seen as applicable for Māori).
It is important that SPARX characters include their whakapapa (genealogy)
Because you could say which tribe you are from and then pick your tribe and stuff and different tribes have a different dude or something (comment during discussion about what is seen as culturally applicable).
The Guide could be a role model for taitamariki. Participants acknowledged the Guide could be utilized as a role model for taitamariki.
Actually one of my mates has stopped himself from being depressed and one of the reasons why he killed himself was his family was too hard to get to and there was nothing to help him on his journey. I think some young people find it hard to talk to their parents...If we had a role model, we would go straight to them. But some young people don’t really have role models in terms of what they want to do. But not many people have people to look up to, to help them on the way and maybe the video game (SPARX) would be something to help them along. And maybe at the end of the game you could guide them to actually go and talk to their parents or wherever they are living and talk to them. Get them to sit down and help them do what they want (a spontaneous response nearing the end of the focus group from a young person that had been listening, but not saying much throughout the group).
Whānau expressed a range of opinions about when they needed to be informed that their taitamariki were using SPARX. Whānau thought that they would benefit from having resources to support them while their taitamariki were using SPARX. There were also differing opinions about where whānau would want their taitamariki to be using SPARX.
Some feelings from parents about the inclusion of whānau in the process varied. Some parents expressed that they wanted to know more about SPARX before their taitamariki used the program, while other whānau preferred to be informed when their taitamariki were either using SPARX or had completed it. Some parents were comfortable with not being informed, as long as their taitamariki could talk to someone about their depression and get the support they needed, such as from extended whānau or a clinician.
I am very much a traditionalist, and if it was my child, I would like to know before they got onto the computer that they were going through this type of depression...I would prefer some kind of means of being able to identify that there is a problem and actually being with them, right beside them, as they work through it. So if they get an opportunity to sit on the computer on their own then I am aware of that, but I wouldn’t want them to spill their feelings to a computer first. I would be very hurt if that was my child (comment during spontaneous discussion about how whānau can support their youth).
The resources that could be used for whānau to help them understand about depression were discussed. There was a range of opinions about how SPARX could be used with whānau members. However, most participants in the focus groups agreed that it was important to think about extra resources that whānau could use to support them while their taitamariki completed the SPARX program. This could include having an extra module within SPARX that was applicable to whānau members. Alternatively, a booklet could be developed that provided psychological education to whānau about depression.
I think you should have another disc (SPARX) for the parents... something anyway just so then they can help the child through that (in response to MS asking about what resources are needed for the treatment of depression).
The range of location sites for use of SPARX by taitamariki is noted. Whānau were open to a range of different localities where their taitamariki could be using SPARX. This varied from SPARX being used at a high school, a library, a health service, or in the whānau home.
If they want to get dropped off at the library that is fine, if they want to do it in their room and close the door, that’s fine. If they want me out of the house, that’s fine (in response to MS asking about what resources are needed for the treatment of depression).
Participants suggested that SPARX needed more activities for Māori males, and that the puzzles and challenges needed to be more difficult. SPARX also needed to include language that reflected taitamariki understandings about depression.
SPARX needs activities that appeal to male adolescents. These added activities would need to direct male adolescents to participate in physical challenges such as fishing, skate boarding, kapa haka, or mau rākau (traditional Māori martial arts). The reasons given were that SPARX contains a lot of text, and male adolescents may not want to sit down at a computer and read a lot of text.
I think it (SPARX) is pretty good, but I would probably get lost on the computer because I don’t know if many Māori boys or the other kids like using computers because I definitely don’t and I get lost straight away and I just think I would just sit there. I don’t want to just sit there and watch and listen to video games or something. Maybe SPARX needs relaxing things like fishing or something or more activities to do in the game (in response to MS asking what would be good about using a program like SPARX for young people with low mood).
The use of language in SPARX for adolescents may not be adequate. Participants thought that adolescents do not always have the necessary language to be able to identify that they may be experiencing depression. Adolescents may need education about what terms to use to describe how they are feeling. Conversely, it was thought that mental health professionals needed to listen more carefully to the colloquialisms of adolescents and then use these in their clinical practice.
You know what you were talking about with regard to the language, how you need to teach young people a whole new language, maybe it is the other way round. Maybe it is them teaching us the language and then us interpreting it (spontaneous discussion about what else SPARX may need to be maximally useful for young people).
SPARX has too much text to read for some participants. A majority of participants indicated that the text needed to be shortened so that it was more manageable to read.
Does it read alright the text?
Yes, it does. It is just a lot of words. And it could probably be shortened or you could get straight to the point and maybe the facts are at a different stage or before something.
Developers should include the Māori language within SPARX. Even though SPARX was designed as a program for all ethnicities, some of the participants stated that it was important to incorporate Māori language in the text as a way to help taitamariki to connect and have ownership of the SPARX program.
It might just give it a little bit of ownership back to those young people (to have Māori terms in the text), this is my language...It is not an American thing; it is actually a Māori thing or a New Zealand thing (in response to MS asking would it be helpful if there were Māori words in SPARX).
Developers should increase the use of audio rather than text. The audio clips were thought to help support those taitamariki who struggled with the amount of text or who simply do not like to read.
What if you had a voice over instead of the writing?
Yes, that is another good point. We are going to do that.
Not many people our age like to read.
I don’t like reading (spontaneous discussion about how there was too much text in the prototype of SPARX).
Picture of the poutama (staircase) design.
Picture of character from SPARX.
Nineteen of the 26 participants completed a questionnaire. These results demonstrated that; most participants were able to express their opinions in the group; most people liked the graphic style of SPARX; the majority liked the content of SPARX; and most liked the cultural content of SPARX. In
Results of focus group questionnaire.
Number of participants | Questions | Mean |
SD |
n=19 | How much were you able to express your opinions in the focus group? | 3.95 | 1.17 |
n=19 | Overall what did you think about the look and style of the game? | 4.2 |
0.8 |
n=19 | Overall what did you think about the content (messages and information to help people) in the game? | 4.00 |
0.88 |
n=19 | Overall what did you think about the cultural content in the game (Māori costume design and building/environment) designs? | 4.2 |
0.6 |
This is a unique study, as it is the first, to our knowledge, to gather the opinions of ethnic minority indigenous people about their experiences of a computerized therapy program and to do so using a research methodology developed by Māori people to ensure good outcomes for Māori people participating in research. Participants were positive about the prototype version of SPARX, and their views were used to refine and improve on the final version of SPARX. Cultural relevance was viewed as being important for the engagement with SPARX among Māori young people. The incorporation of Māori symbols and the use of a Māori actor to provide the voice over for the character of the Guide all led to acceptance of SPARX by Māori, and their inclusion was seen as key in the dissemination of the SPARX program. Participants’ highlighted specific opportunities to improve SPARX for Māori, and the ideas from these focus groups were incorporated into the final design of SPARX. Participants also highlighted specific opportunities to improve SPARX for Māori.
Participants’ thought that learning a simple relaxation exercise was particularly beneficial, thus indicating that some skills can be learned without the aid of a therapist. This finding is in keeping with the literature [
Although SPARX was designed to appeal to more than one cultural group, SPARX does contain: Māori specific artwork; Māori-based characters; some Māori language; and the Guide character (who is the virtual therapist and main character, after the user’s avatar) has a distinct Māori-English accent. Feedback from the focus groups confirmed the importance of the cultural relevance of the design. Most of the participants noticed the Māori designs within the SPARX environment and thought the designs enhanced the engagement with the program. Culturally adapted mental health interventions, targeted to a specific cultural group, are thought to be approximately four times more effective than interventions provided to groups from a variety of cultural backgrounds [
Māori, like other ethnic groups, are not homogeneous. The SPARX prototype was not, and perhaps cannot be, applicable to all Māori. Durie [
The graphic designs in SPARX represented a “leap forward” in terms of contemporary tikanga (Māori protocols) employed within modern game design, and this process has provided some much needed information about the process of adapting nonindigenous interventions for use by indigenous people, about the efficacy of these interventions for indigenous people, and, more pointedly, for Māori [
Whānau are important for the well-being of young people [
Indigenous minority adolescents often do not access help for depression [
In this study, we gathered views from young people and their families from an indigenous ethnic minority group, a group frequently neglected in trials of therapeutic interventions. In New Zealand, there has been an attempt to develop a social policy about whānau ora (healthy families) [
Based on the results of this study, we were able to improve SPARX for Māori; for example, we included audio files for the text wherever possible as a direct result of the feedback obtained from participants in this study.
This is a small study, limited to focus groups and one individual interview. The views, therefore, are not reflective of all Māori. Conducting individual interviews may have provided a greater range of in-depth opinions; however, focus groups allowed for richness in interaction between participants, which individual interviews would not have provided. The findings of this study were not based on a clinical population. We thought that within this minority indigenous population depression is common and help seeking is low.
Therefore, we did not want to create a barrier to Māori peoples’ participation in this study.
It is important for researchers to consult with indigenous groups when developing programs for these young people. These processes can then lead to greater engagement with the specific program. Once a program has been developed, it is essential that support be provided to indigenous families to help families encourage and support their young people with depression when using cCBT. Traditional Māori (and other indigenous) families will want to be a part of how their young person engages with a cCBT self-help resource, and they will want to know when and where their young people are using it. Hence, family resources need to be developed alongside a cCBT program so that information is provided to the family about what program their young person is using. This collectivist approach to cCBT and its delivery contrasts considerably with the often individualistic focus of cCBT delivery to date.
In general, taitamariki and whānau supported the contemporary tikanga approach to the graphic designs that were used for the characters and environment within SPARX. These findings are important, as a resource like SPARX, which has sought to engage indigenous youth in its creation (and subsequent formal evaluation), has never been developed previously. This study provided information that was utilized in the further refinement and development of SPARX to help ensure maximal applicability to taitamariki and provides a potential model for other cCBT interventions.
cognitive behavioral therapy
computerized CBT
General Inductive Analysis
Reynolds Adolescent Depression Scale-Short Form
Smart, Positive, Active, Realistic, X-factor thought
The development and evaluation of SPARX was funded by the New Zealand Ministry of Health and was supported by the Rotary Club of Downtown Auckland. MS was paid to work part-time on the development of SPARX and was also funded by a Henry Rongomau Bennett scholarship from Te Rau Matatini. Maru Nihoniho and her team from Metia Interactive assisted in the creation of SPARX. We would like to thank the young people who participated in this research and our Kaumātua Rawiri Wharemate for his wisdom and guidance.
The Intellectual Property for SPARX is owned by Uniservices at the University of Auckland. MS, TF, ML, KS, SM are co-developers of SPARX and can benefit from any profits generated from SPARX.