Adolescence is characterized by intense cognitive, emotional, social, and physiological growth; increased vulnerability [1,2]; and deficits in emotion regulation capability [3-6]. Young people (under the age of 25 years) experience high levels of mental disorders [1,7] and increased exposure to risk factors [8,9]. In recent years, however, there has been a shift of focus in psychology from mental illness and pathologizing ill health toward positive psychology approaches, well-being, recovery-oriented approaches, and resilience- and strength-based frameworks, which is exemplified in research on well-being.

Commonly described as the experience of positive emotions about one’s life, such as happiness, life satisfaction, and positive functioning, well-being is illustrated by a sense of fulfilment and engagement in life [10]. In 1998, Keyes [11] proposed the dual-continua mental health model which posits that mental illness and mental well-being lie on two separate but related continua, such that mental well-being cannot be merely defined as the absence of mental illness. Further research suggested that mental illness and well-being represent two distinct subcomponents of an overarching construct of mental health [12]. Well-being recovery models describe the transcendence of symptoms into a renewed sense of meaningful life, despite the limitations of mental illness [13]. Greater well-being is associated with fewer symptoms of mental illness and reduced incidences of behavioral issues such as criminality, substance use [14,15], and physical illness [16]. Thus, recent approaches to mental health propose a shift from the treatment and prevention of mental illness toward the enhancement of well-being [17].

Keyes [18] defines flourishing as the presence of emotional, psychological, and social well-being. The lack of well-being, defined as languishing, is characterized by low levels of these characteristics. Young Australians consistently report lower levels of well-being than adults [9,19-22]. According to these definitions, lower youth well-being levels reflect emotional, psychological, social, and help-seeking–related factors. (1) Emotional—Young adulthood is a developmental period frequently associated with an increased exposure to risk factors including increased emotional imbalance, developing emotion regulation skills, and the stressful period of transition to adulthood, placing demands on coping resources [8,9]. Young people experience increasing emotional unrest and have low capacity to effectively regulate emotions [4,5]. (2) Psychological—Most mental illness emerges before the age of 25 years [7]. In Australia, mental disorders commonly affect children and adolescents (aged 4 to 17 years), with 13.9% reporting a mental disorder in the past 12 months [23]. The 2019 National Health Survey in Australia [24] revealed that young people aged 15 to 24 years experience the highest levels of mental or behavioral conditions compared to all other age groups. (3) Social—Relationships play a central role in the well-being of young people [25]. The most common reason for individuals aged 12 to 25 years contacting major Australian youth counseling services such as Headspace or Kids Helpline was “relationship problems,” which includes family, partner, or peer relationships [26,27]. (4) Help Seeking—It is concerning that only one-third of young people with mental disorders seek help. This is due to barriers such as stigma, confidentiality issues, lack of accessibility, self-reliance, lack of knowledge about mental health services, and fear or stress about the act of help seeking or the help source itself [28-31]. Alarmingly, even those who seek help may struggle to receive it. For example, Kids Helpline, Australia’s largest telephone and web-counseling service, is unable to meet demand, with continuously decreasing yearly response rates of approximately 50% [32,33]. Highly effective, innovative, accessible, and engaging support solutions that promote well-being are urgently needed [29].

The ubiquity and increasing functionality of modern mobile health (mHealth) technology offers promise for filling the gap by addressing barriers, such as stigma, confidentiality concerns, or difficulty of accessing support, to help seeking [34]. Young people are among the highest adopters of innovative technologies [34]. This presents an excellent opportunity for the development of novel, accessible mHealth interventions that offer reliable information and support.

Quality mHealth interventions are engaging, functional, professionally designed, and contain reliable information [35,36]. Several factors are essential to increase an intervention's potential for uptake, use and efficacy. This includes involving stakeholders in co-design, through participatory design workshops; conducting in-depth research of the phenomena which the mHealth intervention is designed to address [12,37,38]; involving researchers and design experts to interpret and translate participatory design workshop data into the design of the intervention; and involving health experts to assess its alignment with established theoretical models [39].

The purpose of this project was to qualitatively explore how young people conceptualize and construct individual recovery journeys, from being unwell toward experiencing greater levels of well-being. The findings were used to inform the conceptual design of a youth-led information-, resource-, and support-focused mHealth intervention for the largest support service for young people in Australia (Kids Helpline).

Ethics approval from Queensland University of Technology was granted for all stages of this project (Human Research Ethics Approval Number 1600000956). Recruitment was done via Facebook and researcher networks within Brisbane, Australia. Young people were invited to attend a series of workshops with the aim of co-designing a new digital tool for youth well-being. Quota sampling was applied and included age (12-25 years) and English language as participation criteria. Information sheets were sent to 35 young people who contacted the team. We grouped participants by age (3 separate age groups were formed—12-15 years; 16-19 years, and 20-25 years) to ensure variability of age-specific experiences and to reduce age-related peer pressure within each group. Consent (including parental consent for the youngest cohort) was obtained before participation. A series of participatory design workshops (3 per age group) were conducted between February and March 2017; each workshop lasted approximately 2 hours each. Participants were offered $30 (approximately US $23.25) or a movie voucher for their time.

The participatory design workshops [38,40,41] combined visual and linguistic data collection methods—photo elicitation [42,43] and journey mapping—drawn from user experience design [44,45], to ensure a rich variety of concepts. The use of linguistic methods alone creates limitations, especially for younger participants [42,46-48]; therefore, the young people were provided with multiple communication modalities to explore individual experiences and understanding [45,49,50] of well-being, being unwell, the recovery journey between, and potential technological solutions. 

Analysis was largely informed by a social constructionist perspective [51], which assumes that people construct their own meaning of reality through interactions with others within a social space. This theoretical framework also allows for the interpretation of both linguistic and visual methods [49]. Hence, we viewed the data as forms of self-accounting in which participants were attentive to the expectations associated with the production and reception of identities, both in immediate and broad social contexts.

Verbal data were transcribed verbatim and COREQ (Consolidated Criteria for Reporting Qualitative Research) [52] guidelines were followed. Codes were organized into thematic groups following inductive thematic analysis [53]. One team member with 7 years of experience conducting qualitative psychological research coded the transcripts in 3 iterative steps. After each coding step, a discussion was held with 2 additional team members, who were also experienced in qualitative research, to reach agreement on the codes, themes, and theme names. Visual data were interpreted using photo elicitation analysis [42] and image clustering patterns were mapped over the verbal elaborations of the thematic analysis [53]. Comprehensive notes (on both verbal and visual data) were taken during the iterative process and incorporated in the final analysis.

Aggregate technological solutions data were used to develop the concept design, storyboard, and functions of the mHealth tool, unanimously conceptualized by participants as a mobile app. The functions, information, and interface of the app were designed using iterative co-design—with young people and an expert development team. Principles outlined by the Mobile App Rating Scale (MARS) [35], which outline a set of quality criteria and consist of 29 items organized in 4 objective (engagement, functionality, aesthetics, and information quality) and 2 subjective (subjective quality and perceived impact) subscales, were followed. MARS provides a checklist of criteria and definitions to assist developers in creating high-quality health apps.

The team consisted of researchers, designers, information technology developers, and young people. The collaborative approach served to ensure the thorough, interdisciplinary exploration of the psychological phenomena and the appropriate, grounded in theory, and participant data co-design, and development of the new technology.

A total of 25 participants residing in an urban setting in Australia took part in the study (Table 1). We planned to have each group be a mixed of genders (all participant identified as either male or female); however, 3 male participants who signed up for the 12-to-15-years-old age group did not attend on the day and did not respond to further communication attempts. Thus, this age group was only represented by female participants. Two 16-to-19-years-old groups were run in parallel because of a large amount of participant interest in that age range.

The app name was chosen by participants from the youngest age group (12-15 years) and was incorporated as a core concept of the app. Users are invited to reflect on their current physical and psychological well-being, identify their concerns or niggles, step back and reflect on their emotions, consider whether they need to discuss them with Kids Helpline, read about others’ similar experiences, learn from a wealth of carefully selected information and resources, plan to-do lists, take action, and track their progress. Upon successfully completing the recovery journey, they can share their story with peers. There are additional app features to increase the customizability, usability, and engagement of the app. For example, users can select from 7 color templates or use quizzes to assess their distress, resilience, and well-being (Figure 7). A notable positive aspect of the recovery journey involves being able to access a network of support from family, friends, and the community, which Niggle aimed to expand by creating an in-app community and including hotlink buttons to Kids Helpline as the first version of users’ “safety net.” Using the hotlink offers app users queue priority for receiving immediate support. Multiple additional features were conceptualized based on the workshops and will gradually be implemented in future app updates.

This paper presents the theoretical development and concept design phases of Niggle—a smartphone app to assist young people on every step of their recovery journey to well-being. App quality was ensured by following principles outlined by the MARS [35].

We grounded our research in the experiences of young people through participatory research [38,40,41,50] and co-design [37] to develop a clear understanding of their recovery journey and to allow young people to have more control over the process. While thematic analysis was rigorously applied to interpret data [53] and emerging themes were commonly supported by participants, we acknowledge that variability may exist regarding experiences in view of age, gender, ethnicity, race, and class differences. The young people who participated generally described the recovery journey as a multistage process, and their group discussions helped define 6 distinct stages. There was strong consensus that transition through these stages was nonlinear, and each stage was characterized by multiple barriers and helpful strategies. Therefore, Niggle corresponds to the intervention-delivery model through its nonlinear and highly customizable design.

Journey mapping allowed us to explore the barriers that young people encounter in help seeking and how they differ at each stage. An in-depth understanding of these concerns can assist health care providers in better addressing a young person's needs. For example, while denial, stigma, fearfulness, and avoidance seem to be present throughout the journey, specific logistics such as time, transportation, costs, and the availability of services are pertinent to the more active planning action and taking action stages.

Applying visual research methods allowed us to increase our confidence of overcoming the potential linguistic barriers that our youngest participants may have experienced. Thus, we present the useful strategies and tools young people rely upon to overcome barriers and how they can be translated into co-designed digital intervention features to support recovery.

Recovery has been theorized as being both an outcome and a process, and is still being debated in the literature [54]. Supporters of recovery as a process argue that its conceptualization as restoration of capacities to the stage preceding illness is partial and flawed, and our findings support this view. We found that recovery consists of the complementary experiences of restoration from mental illness and advancement through the stages of well-being (identifying, processing, and taking action, which results in growth). The themes that we identified largely align with those in descriptive psychological models of behavior change such as the transtheoretical model (TTM) [55]. The first stages of the TTM reflect a process of precontemplation (no intention to seek help in the near future) and contemplation (considering a change some time in the future based on the potential positives and negatives of that change) similar to those defined by our participants as recognizing that something is not right and labeling the problem). The subsequent TTM stages include preparation (an intention to seek help in the immediate future), corresponding to our processing the problem and planning action stages; the fourth TTM stage action (or currently seeking help) is similar to the taking action stage of the well-being journey. The TTM includes the stages of maintenance (help seeking when needed in an attempt to avoid relapse of problems) and termination (when help seeking is no longer required), which in our participants’ discourse emerged as maintaining health habits and growth. Lastly, in line with our findings, the TTM also recognizes that relapse is a common and normal part of the change cycle and defines ‘recovery’ as a process, rather than a state, or outcome.

Aligned with those of Prochaska et al [55], our findings, based on the participants’ discussions, confirm that the recovery journey could be nonlinear. We argue that there is not a single, predetermined solution for dealing with each stage. While motivational work might assist with contemplation in the TTM, it may also be applicable to all stages of the journey. Similarly, skills training does not need to be limited to the action stage, as it may be appropriate for building confidence during contemplation or preparation. Our results reflect the TTM’s applicability to young Australians in an era of unprecedented technological development, information overload, and shifting help-seeking pathways.

Consistent with previous findings [31], our findings also identified barriers such as stigma, embarrassment, poor mental health literacy, and a preference for self-reliance to youth help seeking, while facilitators included perceived positive past experiences, and social support.

Despite efforts to capture diverse experiences, the participant sample was relatively homogenous. Most participants identified as female, urban residents, educated, White, living with parents or guardians, and single. None were employed full-time. We presume that young people from other backgrounds (such as Aboriginal and Torres Strait Islander, or culturally and linguistically diverse groups) would have provided a different account of recovery, mental health, self-care, and support safety nets. Yet, further work by our team, outside of the scope of the current project, is ongoing to confirm the relevancy of the stages reflected in the app design to a diverse group of young people, that includes young people from Indigenous backgrounds, young people with mental health diagnoses, and young people with diverse socioeconomic status.

The fact that male participants did not attend the workshop for the youngest age group (despite initially signing up), may reflect previous findings showing that the lowest rate of mental health help seeking is among young men, with only approximately 13% engaging with mental health services compared to 31% among young women [56,57]. This phenomenon has been linked to stigma (male role expectations and perceptions of appearing weak) [58], as well as low mental health literacy [31,56]. We hope that the Niggle app will be used to address some of these issues by offering confidential access to support and psychoeducation to all users.

Using preselected photos to elicit discussions on well-being may have biased participant discussions; however, we believe that this photographic prompt served to open deeper discussions. Future research might benefit from using verbal and visual data in tandem (ie, both photo elicitation and photo voice [59]) and by encouraging young people to produce their own images.

App quality and efficacy evaluation projects, including feedback sessions with young people and a series of Randomized Controlled Trials will be carried out to determine the efficacy and effectiveness of Niggle.

This study contributes to the field of well-being, mental illness, recovery, eHealth, and mHealth for young people. It demonstrates the usefulness of research into the alignment of theoretical models to specific demographics for the development of theoretically-sound digital health technologies. The recovery journey described by our participants confirms the applicability of the TTM [55] to support behavior change and well-being amongst young people in the context of eHealth. Despite international health policies increasingly placing well-being at their center [60], no agreement exists as to what constitutes well-being. The definitions presented in this paper, grounded in participants’ complex personal accounts can assist with the development of policies and guidance for well-being and recovery interventions, regardless of the delivery method.

While there is a vast number of health apps targeting a range of users and issues, many lack theoretical grounding, quality, reliability, and applicability to key stakeholders. This paper offers an insight into health app development through in-depth phenomenological research, co-design, adherence to app quality principles, and the involvement of diverse expertise.

We hope that Niggle will help young people access useful resources and support to increase their well-being. As of November 2019, version 1 of the app is freely available on Australian app stores. In the first year it was used by 12,823 individuals. Global release is planned once data privacy and security standards for international transfer and management have been carefully implemented.