3.2 Free-listing interviews (FLIs)
In FLIs we investigated access to communication technologies, as well as barriers and facilitators of use of e-mental health tools. 16 out of 22 participants experiencing unstable housing conditions had access to communication technologies, mobile telephones being the most frequently used (n = 14), followed by a computer/tablet (n = 2). Online applications most frequently used were YouTube, (n = 14/14) followed by Facebook (n = 10/14) and WhatsApp (n = 7/14). Twelve people reported that e-mental tools could be useful in terms of promoting good mental health (Table 1).
Table 1
Use of electronic devices and online applications among persons experiencing unstable housing conditions taking part in the qualitative RESPOND research study.
| Frequency | Example | Frequency |
Use of electronic devices | 14 | Phone | 13 |
| | Computer | 1 |
Online applications used | 39 | Youtube | 14 |
| | Facebook | 10 |
| | WhatsApp | 7 |
| | Google | 3 |
| | Instagram | 2 |
| | TikTok | 2 |
| | Microsoft Office | 1 |
Use of mobile applications to reduce mental distress and anxiety
KIs reported accessibility to be the most important facilitator for the use of mental health applications (44%), followed by potential benefits if used in parallel with stadard care (19%). However, most KIs also suggested that potentially lack of face-to-face interactions (40%) was a limitation. Further, some worried that there may be problems with text, image, and audio adaptations for migrants with low literacy levels (17%).
Almost all (86%) persons experiencing unstable housing conditions whom we interviewed felt that mobile apps might be useful to deal with stress and anxiety. Almost all interviewees experiencing unstable housing felt that smartphone apps could be helpful in dealing with stress and anxiety. Factors facilitating use of e-mental health tools listed by study participants were anonymity, mobility, a high level of confidentiality, equal access, ease of use, as well as reassurance regarding permanent availability. Participants generally considered that this type of tool would be more effective as an addition to standard mental health care rather than a stand-alone. Barriers to the use of e-mental health tools cited included: lack of confidentiality, individuals’ low literacy level (in any language), lack of access to the Internet, lack of confidence in the efficacy of DWM-OI, language barriers, and lack of face-to-face interactions. It is notable that, overall, participants experiencing unstable housing conditions reported more facilitating factors regarding the use of e-mental health tools, while social and healthcare workers more frequently expressed concern about barriers (Table 2)
Table 2
Barriers and facilitators of the use of e-health solutions as described by key informants of persons experiencing unstable housing conditions.
Applications for mental health – Key informants |
| Example | Frequency (%) | | Example | Frequency (17%) |
Possible Barriers | Lack of confidence | 17 | Possible Facilitators | Easy access | 18 |
| Literacy Level | 7 | | Addition to standard care | 8 |
| Lack of access | 6 | | Anonimity | 4 |
| Lack of efficacity | 5 | | Mobility | 4 |
| Language barrier | 4 | | Confidence | 3 |
| Lack of face-to-face interaction | 3 | | Equality | 1 |
| | | | Freedom | 1 |
| | | | Functioning | 1 |
| | | | Reassuring | 1 |
Focus groups interviews (FGI)
Acceptability of DWM-OI
DWM-OI generated interest among persons experiencing unstable housing conditions as well as among key informants and was generally considered acceptable.
“The procedure looks easy to me, and this is relaxing. I do not want too many troubles - when I am stressed - to log in on an app which is supposed to help me”. (Male, person with unstable housing, Focus group 2, Participant#3).
“My first impression is pretty positive. There are not too many things, the visuals are clear, rich and balanced” (Female, KI, Focus group 1, Participant#3).
Persons experiencing unstable housing conditions and key informants perceived the use of DWM-OI to be an addition to standard mental health care.
“The advantage of this application is that it is easily accessible, which can help us while waiting for our appointment with the psychologist (it takes a long time to get an appointment with a psychologist)”. (Male, literate person with unstable housing FGD-2, Participant#1).
“Then, being able to do it once a day (or even more), can keep them busy, particularly in expressing their feelings of anxiety”. (Female, KI, Focus group 1, Participant#2).
In terms of the app design, participants overwhelmingly complimented the use of the same colours throughout the app, and pointed out the diversity of cultures that were represented in the pictures used. Still, some suggestions were made. For example, a KI suggested:
“The images are good. Having said that, I think there are plenty of great examples (we [can] see families, economic issues, having access to schools…). But if we want the app to be effective, there should be images that persons can identify themselves with. We observe plenty of situations (having access to documents, unemployment, precarity…). They need to see that represented as well so they feel connected to them” (Female, KI FGD-1, Participant#2).
KIs also raised the issue of the lack of human interaction (or assistance beyond the application) and the need for trained-lay support staff to guide, accompany and provide support to persons experiencing unstable housing conditions, so that they could better use DWM-OI. Follow-up in person or via phone were considered as potentially helpful to better understand the app and maintain the user’s engagement (12).
“I think it would be useful if some helper could be with them at the first session to show them how to use the app and how to get access” (Female, KI, Focus group 1, Participant#2).
“For me, who doesn't understand much, having someone explain how to use the application is a good idea”. (Male, person with unstable housing, Focus group 2, Participant#4).
Interestingly, none of the participants experiencing unstable housing expressed concerns about the lack of acceptability of the DWM-OI. However, KIs expressed concern regarding the confidentiality of the information persons share when using the DWM web application.
Feasibility of DWM-OI
Despite the positive feedback regarding DWM-OI, some issues raised could lead to improvements.
During FGDs, KIs emphasized different challenges in terms of literacy that apps like DWM-OI could present:
“We see people in our accommodation centre who do not read, nor write anything, and some of them even do not have a phone. I am concerned these applications will not help them because of these factors” (Female, KI FGD-1, Participant#2).
In contrast to KIs, persons experiencing housing instability did not report concerns with literacy.
“If we have simple images, not too many details and it is easy to understand, of course we will use these applications” (Male, illiterate person with unstable housing FGD-1, Participant#4).
“Indeed, as far as we can easily have access to the application, this could help while we are waiting to have a meeting with a doctor or with a psychologist. We can always ask for one of our roommates to give us a hand to understand if needed. But if it is in our language, we can manage that” (Male, literate person with unstable housing FGD-2, Participant#1).
“In our accommodation centre there are people who do not read, nor write anything, and some of them even do not have a phone. I am concerned these smartphone apps will not help them because of these factors” (Female, KI, Focus group 1, Participant#2).
However, it was suggested by persons with unstable housing conditions and specifically migrants that more audios should be provided to make DWM-OI easier to understand.
“For me, there's a lot of text, and I can't understand it all. understand it all. But maybe with audios, I'll be able to.” (Male, illiterate person with unstable housing FGD-2, Participant#3).
Interestingly, four KIs reported that, because of the lack of an accessible Internet connection, or because of users’ unstable situation, there was concern about their ability to access electronic devices and apps. However, the diversity of smartphone models, phone plans and particularly of types of Wi-Fi connexions in the accommodation centers were highlighted during the course of the study:
“The Internet connection is not good enough, and some of them even do not have a smartphone. For this kind of population, there is an important digital divide” (Female, KI, Focus group 2, Participant#1).
“What will participants do when they do not have connexion to the Internet? If there is not an off-line mode, there is a risk they will not complete any module” (Female, KI, Focus group 1, Participant#3).
Concerns about having correct translations of the content of DWM-OI were reported by persons with unstable housing conditions.
“The translation is not good enough, it looks like they used Google translate. Somebody who is competent enough should be in charge of that” (Male, person experiencing unstable housing, Focus group 1, Participant #4).
“One major point is being careful with the text translations for these kinds of topics. If it is translated literally, it could have a wrong meaning that could have an impact on us”. (Male, person experiencing unstable housing, Focus group 1, Participant#2).
Participants also expressed concerns about the cultural relevance of some terms used. For example, one Arabic-speaking healthcare worker/social work mentioned:
“Look at this ‘unhooking’ module, where they talk about ‘getting away from their values’. Maybe the images look simple, but these texts are… too complicated to explain. I do not find these sentences easy to explain. What does ‘an emotional storm’ mean?” (Female, health care/social worker, Focus group 2, Participant#3).
“Personally, I do find it too complex for our population. There are too many obstacles. The literacy level of our population is very low, so this application is indeed too complex for them” (Female, KI FGD-2, Participant#1).
The last topic covered in the focus groups covered different exercises aiming to help participants deal with stress. Both participants experiencing unstable housing and KIs considered the use of audios in the context of the DMW app appropriate for this purpose. In addition, they liked that every week a new module and new exercises were unlocked, and appreciated that they could repeat them as many times as needed. Nonetheless, there were some suggestions. One KI stated:
“The audios look good. But an eight-minute-long exercise… This is way too long. It could discourage people” (Female, health care/social worker, Focus group 1, Participant#3).
Likewise, a person experiencing unstable housing stated:
“The audios look great, but could we have some videos as well? They could show us how to act when we feel stressed” (Male, person with unstable housing, Focus group 1, Participant#2).
One of the aspects of DWM that seemed particularly appreciated were audio recordings, especially those related to exercises associated with relaxation techniques. Nevertheless, study participants generally deemed that it was necessary for support and accompany persons using DWM, to ensure appropriate use.
In our study, both persons experiencing unstable housing conditions and KIs indicated that the modules proposed were culturally well-suited.
“The images are good. They show us... how can I put it to say... they show what we are”. (Male, illiterate person experiencing unstable housing FGD-2, Participant#3).