Zest Study Summary

Summary of Results of the Zest Study


A research study conducted at 

TIRR Memorial Hermann’s 

Spinal Cord Injury and Disability Research Center (SCIDR)

Funded by the National Institute on Disability, Independent Living, and Rehabilitation Research (NIDILRR), Texas Model Spinal Cord Injury System, Award #90SI5027, 

2016-2021, NCE 2021-2023.

Summary of Results of the Zest Study 

Promoting the Psychological Health of Women with SCI: A Virtual World Intervention


The purpose of the study was to address the psychological health of women with spinal cord injury (WwSCI). 


The goal was to develop and test a group psychological health promotion program for WwSCI using the online virtual world of Second Life (SL). The study had three aims.


Aim 1. Modify an existing program tailoring it to the health promotion needs of WwSCI. 

Aim 2. Test the new program (Zest) to see if it improved psychological health in WwSCI. Half of the study participants were randomly assigned (like flipping a coin) to a group that participated in the Zest program. Half were assigned to a control group that received intervention materials at the end of the study. Our primary outcomes were depression, self-esteem, and life satisfaction. We also looked for changes in stress, social connections, and self-efficacy (a belief in one’s ability to succeed when facing challenges or more simply self-confidence).


Aim 3. Explore how the Zest program improved our primary outcomes (depression, self-esteem, life satisfaction). Specifically, we tested whether changes in stress, social connections, and self-efficacy led to improved depression, self-esteem, and life satisfaction. 


Development of the Zest Intervention Program

The research team worked with a Community Advisory Board (CAB) of WwSCI to create the Zest program. We used our existing program for women with wide ranging physical disabilities as the foundation for the program. 

With input from CAB members, we made several important changes to the program. The changes included:

- depression

- resilience

- body image 

- sexuality

- healthy boundaries

We then beta-tested the program (did a trial run-through) with a group of WwSCI in the virtual world of SL. The beta-testers provided feedback and offered suggestions for improving the program. The research team further modified the program based on the beta-testers’ input. We reviewed new and modified materials with the CAB. Finally, we began the full national randomized controlled trial.


Zest Program Description

The program consisted of 10 weekly group sessions. Women met as avatars in the private, secure virtual world of SL for 2-hour sessions. The sessions were led by two group leaders. One of the leaders was a woman with a SCI, and the other leader was a licensed psychologist. The Zest sessions included information, group discussion, peer support, relaxation training, and action planning. As part of the action planning process, we ended every session by inviting participants to share the specific actions they planned to take in the coming week to move them closer to their goal (e.g., call a friend, practice meditation for 10 minutes 4 days). We also started every session with an update on group members’ successes and challenges in completing their action plan.

Session topics included:

Group of avatar women in the virtual world of Second Life with their attention directed at a presentation board.  

Study Methods

We wanted to know if the SL-based program was feasible and acceptable to study participants. We also wanted to know if the program was successful in improving psychological health. To examine these questions, we asked all study participants, regardless of group assignment, to complete questionnaires three times: before the program began, after the 10 weekly sessions, and at a 6-month follow-up. The questionnaires included measures of depression, self-esteem, life satisfaction, perceived stress, social support (social connections), self-efficacy. We also asked women who participated in the Zest program to answer questions evaluating the program.


To enroll in the study, participants had to identify as a woman, live in the US, be at least 18 years old, have a traumatic SCI, and have been injured for at least a year. They also needed to be able to speak and read in English and have access to a computer with high speed internet. Women who enrolled in the study first completed our pre-test questionnaire. They then were randomized (like flipping a coin) to either the Zest program or the control group. Women in the Zest program were offered a short SL training program and then began the 10-week Zest intervention. 


Women in the control group did not attend the Zest program sessions. They only received the Zest program materials at the end of the study. The control group had a particularly important role in the study. They allowed the researchers to compare the two groups and determine if those assigned to the Zest program showed greater improvements over time than those assigned to the control group.


Study Results

Program Feasibility, Acceptability, and Satisfaction. To examine feasibility, acceptability, and satisfaction, we looked at drop-out rates, session attendance, and program satisfaction ratings. Drop-out rates were low. Five participants dropped at the start of the Zest program, attending no more than one session. Reasons for dropping included unexpected change in circumstances or concerns about the time commitment. Session attendance was good. Of those who attended two or more sessions, most (73%) missed no more than one session, and 47% had perfect attendance. 


All participants rated the program positively (58% “excellent”, 39% “very good”, 3% “good”, 0% “fair”, 0% “poor”). Nearly all (99%) said they made at least some positive changes as a result of the Zest program. Most (96%) said they found SL “very” or “somewhat” enjoyable. In addition, 84% said that SL was “very” or “somewhat” easy to use. When asked what they liked best about the Zest program, more than three-quarters (76%) noted the interaction with other women with SCI. Action planning was a distant second with 14%. Similarly, when asked to share the most important thing they learned from the program, more than a quarter (27%) mentioned learning that they are not alone and are not alone in their experiences.


Preliminary Efficacy. In our efficacy analyses, we found that women in the Zest group showed more improvement in all three of our primary outcome variables compared to the control group. They reported decreased depression and increased self-esteem and life satisfaction after the intervention. These improvements were maintained at the 6-month follow-up. This suggests that the improvements were not short-term and that the Zest program may have longer-lasting benefits.


Finally, we explored how the Zest program resulted in improved depression, self-esteem, and life satisfaction. We proposed that the program would help people better manage their stress, increase their self-efficacy (self-confidence), and enhance their social connections. We thought that these changes would then lead to improvement in our primary outcomes (depression, self-esteem, and life satisfaction). Our results showed that the Zest group did show expected improvements in stress and self-efficacy compared to the control group. However, the Zest group did not show greater improvement on our measure of social connection than the control group. Our results supported that improvements in self-efficacy may have led to the increases in self-esteem and life satisfaction. In addition, the improvements in stress (decreased stress) may have led to the reductions in depression.


Conclusions


Relevant Resources for WwSCI