Evaluability and feasibility of an intervention combining gaming and social activities to improve mental wellbeing and health behaviour in adolescents facing social challenges

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Additionally, they spend less time being physically active and being with friends and more time on gaming and social media. The eHOOD intervention was developed to address physical and mental wellbeing of adolescents in vulnerable positions using their motivation for gaming to engage them in a community entailing physical and social activity, and education with peers. This study aimed to assess the evaluability of the eHOOD intervention, to develop an evaluation design, and to test the feasibility and acceptability of the evaluation design and the intervention. Methods Evaluability assessment was performed by a working group in a series of workshop-style meetings involving a literature review, creation of a theory of change, and preparation of an evaluation plan including outcome measures, instruments, and data collection procedures. Subsequently the evaluation design and the intervention were tested in a single arm feasibility study. Participants were 13 adolescents aged 13-16 years. The participants met with a coach and a local pedagogue in an after-school club four hours a week for 25 weeks practicing gaming, engaging in physical and social activities, and learning about healthy lifestyle habits through education and communal cooking and dining. Feasibility and acceptability of outcome measures, instruments, and data collection procedures were assessed, and initial changes in outcome measures were measured. Recruitment and retainment of participants were monitored, and participants’ motivation for and benefits of participating were explored. Data were collected with qualitative and quantitative methods. Results An evaluation plan was developed and found to be suitable for use in the subsequent feasibility study. The evaluation design proved feasible and acceptable, and relevant adjustments were identified. Initial changes in wellbeing were observed and the World Health Organization-Five Well-Being Index (WHO-5) was deemed relevant as a primary outcome in future evaluation. The intervention was found feasible and acceptable among participants in the present format. Conclusions This combined evaluability assessment and feasibility study showed that the eHOOD intervention is ready to be tested in a larger study, preferably in a randomised design, to evaluate its effects on adolescent mental wellbeing. Trial registration: ClinicalTrials.gov, March 23, 2026. Identifier: NCT07489365. Retrospectively registered. Evaluability assessment feasibility acceptability evaluation design mental wellbeing loneliness adolescents gaming social activity physical activity Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Introduction Adolescents in Denmark increasingly have poor mental wellbeing and unhealthy lifestyles. According to a recent study based on register data from school nurses’ examinations of school children, at least one concern regarding general wellbeing was raised for 14.2% of 14-year-olds and 12.3% of 15-year-olds (Pommerencke et al., 2024 ). In the Danish version of ’The Health Behaviour in School-aged Children (HBSC) from 2022, consisting of survey data from children aged 11, 13, and 15 years, 12% of girls stated they frequently or very frequently experience loneliness, and 30% of girls reported low mental wellbeing. Furthermore, comparing these findings with the past 10 to 20 years, significant negative trends are observed across a wide range of mental health parameters (Madsen et al., 2023 ). Comparable patterns are seen across Europe and North America (Cosma et al., 2023 ; Rakic et al., 2024 ). As for lifestyle habits, only one-third of girls and around half of boys met the Danish recommendations for physical activity and intake of fruit and vegetables (Madsen et al., 2023 ). In school nurses’ registers (Pommerencke et al., 2024 ) almost 17% of the adolescents aged 14–15 years were classified as overweight following sex- and age-specific body mass index (BMI) cut-offs (Cole & Lobstein, 2012 ). In addition to spending less time being physically active, adolescents also spend less time on face-to-face activities with friends and more time on social media and gaming. According to the Danish HBSC, time spent face to face with friends has significantly decreased in recent years, and 15-year-old boys use on average 159 minutes per day gaming and 141 minutes per day on social media. Correspondingly, 15-year-old girls use on average 70 minutes per day gaming and 190 minutes per day on social media (Madsen et al., 2023 ). Across all the countries in the international HBSC, one-third of pupils aged 11–15 years reported gaming online every day, and 22% reported gaming online for at least four hours per day (Boniel-Nissim et al., 2024 ). Although the potential harm of adolescent use of digital technology is often highlighted in the public debate, research has shown both positive and negative consequences of the comprehensive use of screens among adolescents. For example, a systematic review found that the use of internet technology increased adolescents’ sense of connection to friends while at the same time increasing anxiety and loneliness (Wu et al., 2015 ). A more recent scoping review found positive effects of adolescent use of gaming, social media, and the internet regarding social support, social connection, and communication skills (Haddock et al., 2022 ). Particularly for adolescents in vulnerable social positions, there is concern about the potential negative consequences of digital technology use. For instance, research has shown an association between the daily usage of digital technology and poor mental health (George et al., 2018 ), although no cause-and-effect relationship has been established. A review found that while the digital practices of vulnerable adolescents enable social support and connection, they may also expose them to a range of negative experiences (Kostyrka-Allchorne et al., 2023 ). The implications of adolescents having less physical contact with friends and peers are yet to be fully understood. What we do know is that health and wellbeing in childhood and adolescence have implications for educational achievement and mental wellbeing in adulthood and, thus, overall life achievements (Inchley et al., 2020 ). In a survey among Norwegian adolescents (de Ridder et al., 2013 ), the risk of high school dropout was associated with various health problems such as psychological distress, insomnia, concentration difficulties, and overweight. Untreated mental health issues in adolescence, such as anxiety and depression, are shown to often continue into adulthood (Moffitt et al., 2007 ). In acknowledgement of adolescents' extensive use of digital technology while at the same time recognizing a potential negative impact on their mental health, the eHOOD intervention was developed in 2018 aiming to increase mental and physical health and wellbeing among adolescents facing social challenges. eHOOD combines gaming, physical activity, health education, and social interaction in safe and familiar surroundings, fostering the development of skills and positive social relations with peers and adults–elements of organised leisure communities that have been shown to support mental wellbeing (Kusier et al., 2023 ). It uses adolescents’ motivation for improving their gaming skills to teach and engage them in healthy lifestyle, building on a possible link between physical fitness and cognitive skills associated with gaming skills (Marchetti et al., 2015 ; Trotter et al., 2020 ). The eHOOD intervention has already been used in several Danish municipalities but has never been systematically evaluated. On basis of this, the objective of this study was threefold: 1) to assess the evaluability of the eHOOD intervention, 2) to develop an evaluation design, and 3) to assess the feasibility of the evaluation design and the intervention for use in future, larger-scale evaluations. Our research questions were: What is an appropriate evaluation design for testing the eHOOD intervention? To what extent is the evaluation design feasible in terms of outcomes, measurements, instruments, data collection procedures, and participant acceptability? To what extent is the intervention feasible and acceptable in terms of recruitment, retention of participants, and participant satisfaction and engagement? Methods The study consists of an evaluability assessment followed by a feasibility study in a before-after single arm design, implying that the study was conducted without a control group and with measurements before and after the intervention. In the following, the methods and results of the two studies will be reported separately. In accordance with the guideline on reporting non-randomised pilot and feasibility studies (Lancaster & Thabane, 2019 ), this feasibility study adheres to the CONSORT Extension to Randomised Pilot and Feasibility Studies (Eldridge et al., 2016 ) except that items concerning randomization were omitted. Evaluability assessment The evaluability assessment was conducted prior to intervention start, between August and December 2022. It was carried out through a series of workshop-style meetings and site visits to the location of the planned feasibility study, an after-school club in a Danish municipality. The process of the evaluability assessment was inspired by Brunner, Craig, and Watson (Brunner et al., 2019 ) and conducted in five steps: In the first step, a working group to conduct the evaluability assessment was established. The first author served as the principal investigator, leading the working group. The participants included a manager from Sincera (a Danish private limited liability company), where the intervention was developed; the eHOOD coach; a data analyst from Impactly (a Danish private limited liability company) that delivered an online platform tested for data collection and analysis in the study; a local pedagogue from the after-school club; and a consultant from SENS Innovation (a Danish private limited liability company) that delivered the accelerometers tested for collecting data on physical activity and sleep in the study. In the second step, the first author, the Sincera manager, the eHOOD coach, and the Impactly data analyst constructed an agreed-upon theory of change based on previous experiences with the intervention and a literature review. The theory of change was continuously refined throughout the study and served as the basis for the development of the evaluation plan. In the third step, the first author reviewed the literature regarding the use of outcomes, instruments, and data collection procedures in previous research on adolescents and identified possible data sources. This was done with support from the Sincera manager and the Impactly data analyst. In the fourth step, the first author and the Impactly data analyst made recommendations for evaluation and a draft version of an evaluation plan. In the fifth step, the working group discussed and revised the evaluation plan. The first author had the final say in decisions regarding the evaluation. The outcomes of the evaluability assessment were a theory of change and an evaluation plan outlining outcomes, measurements, data sources, and data collection procedures for the subsequent feasibility study. The theory of change is shown in Fig. 1 . The evaluability assessment resulted in an agreement to proceed to the feasibility study in which the evaluation plan was applied. Before-after single arm feasibility study Setting The intervention was offered in a municipal after-school club in the vicinity of Copenhagen, Denmark. Participants The target population of the eHOOD intervention was adolescents in 7th to 10th grade (corresponding to lower secondary education) with psycho-social challenges. Potential participants were identified by a local pedagogue, who collaborated closely with schoolteachers and after-school club pedagogues. Altogether, the group possessed profound knowledge of the adolescents in the area. Based on a professional assessment of individual needs and anticipated benefits, adolescents with psycho-social challenges such as anxiety, loneliness, school refusal, and being a victim of bullying, were invited to participate. Adolescents who were deemed unable to participate meaningfully in a social community were excluded. Recruitment began in October 2022 and continued until 12–15 potential participants were identified, a target set by the eHOOD team based on prior experience. This goal was successfully achieved in December 2022. Prior to intervention start, eligible participants and their parents were invited to an information meeting hosted by the eHOOD team. The meeting was held one evening at the after-school club where the intervention was going to be tested. Intervention The eHOOD intervention consisted of weekly meetings for the adolescents for 25 weeks. Participants meet up with their eHOOD coach and one or more local pedagogues one evening from five to nine PM every week. Each meeting contained physical activity, preparation and intake of dinner, education, and gaming with instruction. Physical activities included ball games such as football, basketball, and table tennis, fitness training, and traditional children's games depending on local facilities and participants' preferences. Coordination and reaction training were included. Educational sessions included teaching healthy dietary habits, sleeping habits, and exercise habits, focusing on the importance of taking care of one's body and staying fit to be able to perform well in gaming. Gaming sessions were structured and led by the eHOOD coach and contained both training and gaming in teams. Further, participants were paired in teams and were given small assignments to be performed together between the weekly meetings. Homework was meant to form and nurture new relationships and invite teammates to stay in contact outside the physical meetings. As parts of the social and educational activities, communal cooking and dining were included. Participants took turns preparing and serving dinner for their peers together with the local pedagogue. Figure 2 illustrates the elements of the eHOOD intervention. Organisation The eHOOD team managed communication with the municipality and oversaw the implementation of the intervention. Impactly facilitated survey data collection through its proprietary platform, and SENS Innovation handled the collection of accelerometer data. Importantly, the research team retained exclusive responsibility for evaluating the data and interpreting the findings. None of the collaborating partners had any involvement in the analysis, the results, or their presentation, ensuring the independence and integrity of the research process. Evaluation plan Feasibility outcomes were prespecified during the evaluability assessment and concerned the feasibility and acceptability of the evaluation design and the feasibility and acceptability of the intervention (Hallingberg et al., 2018 ; Pearson et al., 2020 ; Teresi et al., 2022 ). Quantitative and qualitative outcome measures were selected for initial testing of detectable changes to be used as outcomes in a future evaluation of the intervention. Outcomes and instruments consisted partly of validated instruments and partly of questionnaires developed for this study. Validated instruments included the 5-item World Health Organization Well-Being Index (WHO-5) and the Three-Item Loneliness Scale (T-ILS). The WHO-5 includes five items each scored from 0 to 5. Thus, raw scores range from 0 to 25 and are multiplied by 4 to transform it to a percentage scale from 0-100, where the max score corresponding to optimal wellbeing is 100, 50–70 points corresponds to the normal range of wellbeing, and a score under 50 points corresponds to a wellbeing below the normal range, equalling risk of depression (Topp et al., 2015 ). The T-ILS includes three items each scored from 1 to 3. Total scores range from 3 to 9, where 9 corresponds to the highest level of loneliness. There is no consensus on a threshold value, but in a Danish study of loneliness among adolescents, they used a score of 5–6, equalling moderate loneliness, and a score of 7–9, equalling severe loneliness (Lasgaard et al., 2019 ). Two questionnaires developed for this study (see Appendix A) covered lifestyle habits and self-rated communication and collaboration skills using items from the Danish HBSC (Madsen et al., 2023 ) and the annual wellbeing survey in Danish public schools ( Https://Www.Uvm.Dk/Folkeskolen/Test-Evaluering-Og-Skoleudvikling/Trivselsmaaling ). The latter questionnaire was supplemented with a small number of self-constructed items concerning participation in organised sports activities and new friendships; subjects that we could not find covered in existing questionnaires. Figure 3 visualises the selected feasibility outcomes as well as the quantitative and qualitative outcomes, instruments, and data collection procedures that were tested, and the timing of measurements. Progression to a future definitive trial was guided by predefined feasibility criteria, including the ability to recruit the intended number of participants within the planned timeframe, acceptable retention with no dropouts, and the feasibility and acceptability of outcome measures and data collection procedures. These criteria were not used as strict thresholds but to inform necessary adjustments and the overall judgement of readiness for a larger-scale evaluation. Data analysis Quantitative data were analyzed descriptively to identify initial changes in selected outcomes. For survey data collected using the Impactly platform, changes in mean values were calculated and reported. Accelerometer data were categorized into the following categories: inactivity (lying/sitting), moderate-intensity activity, high-intensity activity, sleep (calm and restless), and number of steps. For each category, daily minutes were calculated, and weekly averages were derived for each individual participant. At the group level, changes in mean values were calculated to explore trends. Qualitative data collected via interviews and observations were analysed thematically with inspiration from Braun and Clarke (Braun & Clarke, 2006 , 2019 ). Results Participants and data collection All participants in the eHOOD intervention were part of the feasibility study. The participants were 13 adolescents aged 13–16 years with a median age of 14 years at intervention start. The intervention ran from January 2023 to August 2023. Baseline measurements were conducted in February 2023, mid-point measurements in June, and end measurements in August 2023. The feasibility study was completed as planned with no early termination. Participants’ self-reported baseline characteristics are shown in Table 1. Table 2 shows which outcomes were measured, how and when, and the number of participants for whom complete data were collected at each point of measurement. Feasibility and acceptability of evaluation design Measurements, instruments, and data collection procedures Administration of electronic surveys for measuring WHO-5, T-ILS, and self-rated communication and collaboration skills was planned to be a task for the coach during eHOOD sessions. This task turned out to disturb the flow of the sessions for the coach, resulting in missing data collection. To solve this problem, the first and second authors went to the after-school club and filled in the surveys with the participants instead. The delay means that baseline measurements were done in April and not in February as expected. All participants willingly and easily answered the surveys administered by the researchers, and useful data were collected. Measuring physical activity and sleep with accelerometers was challenging in the target group. Out of 13 participants, 11 accepted to wear an accelerometer at baseline, and two did not want to wear it. Of the 11 who wore it, two lost or removed it before seven days had passed. Thus, complete data were collected for nine participants. At mid-measurements eight participants wore an accelerometer for seven consecutive days, but three of them did not wear an accelerometer at baseline. At end of intervention, only four participants accepted to wear an accelerometer again, and two lost it or removed it. Therefore, complete data were only collected for two participants and no data on physical activity and sleep are therefore reported here. The self-administered survey sent to the participants by text message daily for seven consecutive days was acceptable to participants, and questions were easy to answer. Nevertheless, no useful data on lifestyle habits were collected, because only three participants answered each of the seven consecutive days at mid-measurements and two participants at end-measurements. Interviews revealed that most participants did not understand the purpose of answering homonymous questions every day for several days. Further, items regarding alcohol and nicotine use did not generate useful data due to unsuitable wording. Collaboration and communication skills were relevant and acceptable measures to both participants and coach, and they generated useful data. However, data showed that participants’ and coach’ assessments were not consistent. Different wording of the items aimed at participants and coach, respectively, may explain this inconsistency. Initial changes in outcomes The intervention showed potential regarding its ability to increase participants’ wellbeing, reduce loneliness, support participants in building new relationships, and strengthen participants' social skills. To measure the changes in WHO-5 and T-ILS we used baseline measurements and mid-measurements due to low response rates at end measurements. The average WHO-5 score of the eHOOD participants increased from 46.8 at baseline to 57.5 at mid-measurements, indicating a clinically relevant improvement of wellbeing of 10+ points (Topp et al., 2015). The average T-ILS score declined from 5.2 to 4.2, indicating reduced loneliness. All participants reported that they made new friends, and seven out of the 13 participants reported that they had several or many new friends by the end of the intervention. To measure changes in self-rated collaboration skills we used baseline and mid-measurements due to a low response rate at the final measurements. As seen in Figure 4, at baseline six participants said they collaborate well most of the time, and two said they rarely collaborate well. By mid-measurements, nine participants said they collaborate well most of the time, and the remaining three said they sometimes collaborate well. Other items were used for eHOOD coach’s assessment of participants’ collaboration and communication skills. Figure 5 shows that, according to the coach, three participants had good collaboration skills at baseline and eight participants at the end of the intervention. Similarly, two participants had good communication skills at baseline according to the coach and by the end of the intervention, the number had increased to eight participants. Feasibility and acceptability of intervention We investigated participants' expectations and motivation for participating in eHOOD and their self-rated benefits of participating. Most participants said that gaming was attractive to them and that they perceived eHOOD as an opportunity to practice meeting new friends. Many participants expressed hope of making new friends by joining eHOOD, especially friends to meet with physically rather than virtually, as many of them primarily met friends online. Some participants said it took courage to sign up for eHOOD because they did not know the other participants in advance. Some told us about school fatigue and expressed hope that eHOOD could strengthen their self-discipline in relation to school and homework. Some participants expressed problems with raging and foul language during gaming and wished to gain more control over their language and behaviour. Others wanted more control over their gaming consumption and to practice prioritizing their time. Overall, motivational factors were the desire to increase social skills, self-discipline, and self-control. Many participants mentioned that cooking, communal dining, and physical activity made eHOOD fun and special. Almost all participants highlighted the combination of activities as something extraordinary because it built a strong social community, and the community retained their interest in eHOOD. Hence, gaming and other social activities attracted the participants to begin with, but the community made them stay. As for recruitment and retention, a sufficient number of participants was recruited within the planned period, and there were no dropouts during the intervention period. No harms or unintended effects related to participation in the intervention were observed or reported during the study period. Discussion Interpretation Relevant adjustments of the evaluation design were identified to optimise data collection and measurement relevance for use in future evaluation and similar interventions targeting adolescents, specifically: Outcome measures The WHO-5 proved feasible and acceptable and showed positive trends in change from baseline to mid-measurements, as the average score increased slightly more than 10 points indicating a clinically relevant change. The average score was well below the mean score of 70 in the general population in Denmark (Topp et al., 2015 ) but within the normal range of 40–80 of adolescents aged 13–15 years in the HBSC (Madsen et al., 2023 ). Our findings regarding participants’ sense of connectedness fostered by their participation suggest that eHOOD, as an organised leisure activity, has the potential to support the mental wellbeing of participants (Kusier et al., 2023 ). On this basis, we believe that mental wellbeing measured with the WHO-5 is a relevant primary outcome in future evaluation. Data collection procedures Our difficulties collecting complete data from all participants is an important learning for future evaluations of interventions targeting adolescents in vulnerable positions. The use of accelerometers proved less suitable in the particular group of participants. Other Danish studies have used SENS Motion accelerometers for 11-year-old children but have failed to report participation and retention rates (Søndergaard et al., 2021 ) or have yet to report the results (Stage et al., 2025 ). Thus, it is not clear whether our lack of success was due to the ages and the psycho-social challenges of the target group—all of which possibly blurred their interest in contributing to our data collection—or whether we could have attained sufficient data if our sample size had been bigger. Alternative approaches, such as integrating physical activity questions into surveys, could enhance data completeness and reliability. Additionally, clear communication about the importance of daily responses to surveys can address gaps in participant adherence. In a recent study of school children parental involvement in the administration of text message surveys was used to secure appropriate response rates (Stage et al., unpublished research), which highlights the need for such adaptations. Supplemental measures Including a measure for self-efficacy could provide a broader understanding of the intervention’s impact, as the development of self-efficacy has proved to be vital to support mental wellbeing in organised leisure activities for adolescents (Kusier et al., 2023 ). Limitations The small sample size and missing data from mid- and end measurements pose limitations that necessitate caution in interpreting the results. The missing data were largely attributed to unstable attendance around the summer holidays, rather than participant disengagement, as evidenced by the absence of dropouts. Another limitation is the delay in some of the baseline measurements, which were done in April instead of February. This means that changes in mean values were observed within a short time interval, potentially reducing the ability to distinguish between natural variations and changes associated with the intervention. Further, the intervention was only tested in a single site. Thus, our findings stem from one particular after-school club with specific pedagogues employed, distinct physical surroundings, and other unique characteristics. Involving more sites would have provided broader insights by capturing the diverse cultures, resources, and operational practices of different after-school clubs. The identified challenges highlight the need for refined strategies in future evaluations to mitigate data gaps. Conclusions Summary of findings The results of our study showed that the eHOOD intervention was ready to be evaluated with the proposed evaluation design, as evidenced by the practical implementation during the feasibility study. Further, the evaluation design proved feasible and acceptable for use in the subsequent evaluation of intervention effectiveness. The feasibility study yielded valuable insights into the appropriateness of outcomes, instruments, and data collection procedures. The intervention itself proved feasible and acceptable regarding recruitment and retainment of participants. High satisfaction expressed by participants highlighted the acceptability of the intervention, particularly regarding the combination of activities and the sense of social community fostered among participants. No dropouts occurred during the intervention period, reflecting strong engagement and commitment. To our knowledge, no similar interventions that have been evaluated exist. Directions for future evaluation Future studies should aim to: Align questions on collaboration and communication skills between participants and coaches to facilitate comparative analysis. Enhance data collection procedures by replacing accelerometers with text-message-based surveys and ensuring participants understand their importance. Introduce supplemental measures, such as self-efficacy and school absenteeism, to capture additional dimensions of intervention impact. Conduct follow-up assessments post-intervention to evaluate long-term effects on wellbeing and social dynamics. While our findings are based on a single feasibility study with a small sample, the study offers methods and insights regarding evaluability assessments and feasibility testing of interventions within similar target groups for researchers undertaking related work. By addressing the limitations and implementing the recommended adjustments, future studies can build on this foundation to yield more comprehensive and generalisable findings. Abbreviations ADHD: Attention Deficit Hyperactivity Disorder ASD: Autism Spectrum Disorder HBSC: Health Behaviour in School-Aged Children T-ILS: Three-Item Loneliness Scale WHO-5: World Health Organization-Five Well-Being Index Declarations Ethics approval and consent to participate The Danish Data Protection Agency assessed the study and categorized it as a quality improvement project, of which registration is redundant. The Regional Health Research Ethics Committees in the Capital Region of Denmark waived the need for ethical approval of the project (ref. no.: F-25073292). Informed consent to participate was obtained from the parents of the participants who were under the age of 16. One participant was 16 years old and, therefore, gave written informed consent herself. The study was performed in accordance with the Declaration of Helsinki. All data were handled in accordance with the GDPR. Consent for publication Not applicable. Availability of data and materials The trial protocol and the datasets used and analysed during the current study are available from the corresponding author on reasonable request. Competing interests The authors declare that they have no competing interests. Funding The study was funded by EU via the Lighthouse Life Science program (pilot project no. 2.3), an initiative launched to support public-private partnerships in life science and welfare technology in developing and testing innovative health solutions to public health challenges. Acknowledgements First, we thank the participating adolescents for their goodwill and participation in the evaluation. We are grateful for the valuable insights generated from their responses to our numerous questions. Also, we would like to express our gratitude to their parents, who allowed us to use their children as respondents. The pedagogues in the after-school club also deserves a thank you for welcoming us at their workplace and providing space for doing interviews and other data collection. Lastly, we thank SENS Innovation for lending us their accelerometers to use in the study. References Boniel-Nissim, M., Marino, C., Galeotti, T., Blinka, L., Ozoliņa, K., Craig, W., Lahti, H., Wong, S. L., Brown, J., Wilson, M., Inchley, J., & Van Den Eijnden, R. (2024). A focus on adolescent social media use and gaming in Europe, central Asia and Canada . http://apps.who.int/bookorders. Braun, V., & Clarke, V. (2006). Using thematic analysis in psychology. Qualitative Research in Psychology , 3 (2), 77–101. https://doi.org/10.1191/1478088706qp063oa Braun, V., & Clarke, V. (2019). Reflecting on reflexive thematic analysis. Qualitative Research in Sport, Exercise and Health , 11 (4), 589–597. https://doi.org/10.1080/2159676X.2019.1628806 Brunner, R., Craig, P., & Watson, N. (2019). Evaluability assessment: An application in a complex community improvement setting. Evaluation , 25 (3), 349–365. https://doi.org/10.1177/1356389019852126 Cole, T. J., & Lobstein, T. (2012). Extended international (IOTF) body mass index cut‐offs for thinness, overweight and obesity. Pediatric Obesity , 7 (4), 284–294. https://doi.org/10.1111/j.2047-6310.2012.00064.x Cosma, A., Abdrakhmanova, S., Taut, D., Schrijvers, K., Catunda, C., & Schnohr, C. (2023). A focus on adolescent mental health and well-being in Europe, central Asia and Canada. Health Behaviour in School-aged Children international report from the 2021/2022 survey. World Health Organization European Region , 1 . de Ridder, K. A. A., Pape, K., Johnsen, R., Holmen, T. L., Westin, S., & Bjørngaard, J. H. (2013). Adolescent Health and High School Dropout: A Prospective Cohort Study of 9000 Norwegian Adolescents (The Young-HUNT). PLoS ONE , 8 (9). https://doi.org/10.1371/journal.pone.0074954 Eldridge, S. M., Chan, C. L., Campbell, M. J., Bond, C. M., Hopewell, S., Thabane, L., & Lancaster, G. A. (2016). CONSORT 2010 statement: extension to randomised pilot and feasibility trials. BMJ , i5239. https://doi.org/10.1136/bmj.i5239 George, M. J., Russell, M. A., Piontak, J. R., & Odgers, C. L. (2018). Concurrent and Subsequent Associations Between Daily Digital Technology Use and High-Risk Adolescents’ Mental Health Symptoms. Child Development , 89 (1), 78–88. https://doi.org/10.1111/CDEV.12819 Haddock, A., Ward, N., Yu, R., & O’Dea, N. (2022). Positive Effects of Digital Technology Use by Adolescents: A Scoping Review of the Literature. International Journal of Environmental Research and Public Health , 19 (21), 14009. https://doi.org/10.3390/IJERPH192114009 Hallingberg, B., Turley, R., Segrott, J., Wight, D., Craig, P., Moore, L., Murphy, S., Robling, M., Simpson, S. A., & Moore, G. (2018). Exploratory studies to decide whether and how to proceed with full-scale evaluations of public health interventions: A systematic review of guidance. In Pilot and Feasibility Studies (Vol. 4, Issue 1). BioMed Central Ltd. https://doi.org/10.1186/s40814-018-0290-8 https://www.uvm.dk/folkeskolen/test-evaluering-og-skoleudvikling/trivselsmaaling . (n.d.). Inchley, J., Currie, D., Budisavljevic, S., Torsheim, T., Jåstad, A., Cosma, A., Kelly, C., & Már Arnarsson, Á. (2020). Spotlight on adolescent health and well-being survey in Europe and Canada International report VOLUME 1. KEY FINDINGS. In Health Behaviour in School-aged Children . HBSC. http://apps.who.int/bookorders. Kostyrka‐Allchorne, K., Stoilova, M., Bourgaize, J., Rahali, M., Livingstone, S., & Sonuga‐Barke, E. (2023). Review: Digital experiences and their impact on the lives of adolescents with pre‐existing anxiety, depression, eating and nonsuicidal self‐injury conditions – a systematic review. Child and Adolescent Mental Health , 28 (1), 22–32. https://doi.org/10.1111/camh.12619 Kusier, A. O., Ubbesen, T. R., & Folker, A. P. (2023). Karakteristika af det mentalt sundhedsfremmende fritidsfælleskab for unge : et litteraturreview . Sundhedsstyrelsen. Lancaster, G. A., & Thabane, L. (2019). Guidelines for reporting non-randomised pilot and feasibility studies. In Pilot and Feasibility Studies (Vol. 5, Issue 1). BioMed Central Ltd. https://doi.org/10.1186/s40814-019-0499-1 Lasgaard, M., Christiansen, J., & Friis, K. (2019). Ensomhed blandt unge. Temaanalyse, vol. 7, Hvordan har du det? (D. Region Midtjylland, Ed.). Madsen, K. R., Román, J. E. I., Damsgaard, M. T., Holstein, B. E., Kristoffersen, M. J., Pedersen, T. P., Michelsen, S. I., Rasmussen, M., & Toftager, M. (2023). Skolebørnsundersøgelsen 2022 . Syddansk Universitet. Marchetti, R., Forte, R., Borzacchini, M., Vazou, S., Tomporowski, P. D., & Pesce, C. (2015). Physical and Motor Fitness, Sport Skills and Executive Function in Adolescents: A Moderated Prediction Model. Psychology , 06 (14), 1915–1929. https://doi.org/10.4236/psych.2015.614189 Moffitt, T. E., Harrington, H. L., Caspi, A., Kim-Cohen, J., Goldberg, D., Gregory, A. M., & Poulton, R. (2007). Depression and generalized anxiety disorder: Cumulative and sequential comorbidity in a birth cohort followed prospectively to age 32 years. Archives of General Psychiatry , 64 (6), 651–660. https://doi.org/10.1001/ARCHPSYC.64.6.651, Pearson, N., Naylor, P. J., Ashe, M. C., Fernandez, M., Yoong, S. L., & Wolfenden, L. (2020). Guidance for conducting feasibility and pilot studies for implementation trials. Pilot and Feasibility Studies , 6 (1). https://doi.org/10.1186/s40814-020-00634-w Pommerencke, L. M., Jørgensen, S. E., & Pedersen, T. P. (2024). Sundhedsprofil for børn og unge ind-og udskolingsundersøgt i skoleåret 2022/23 . www.sdu.dk/sif Rakic, J. G., Hamrik, Z., Dzielska, A., Felder-Puig, R., & Oja, L. (2024). A focus on adolescent physical activity, eating behaviours, weight status and body image in Europe, central Asia and Canada. Health Behaviour in School-aged Children international report from the 2021/2022 survey. World Health Organization European Region , 4 . Søndergaard, A., Wilms, M., Gregersen, M., Brandt, J. M., Krantz, M. F., Rohd, S. B., Johnsen, L. K., Hemager, N., Hjorthøj, C., Ohland, J., Andreassen, A. K., Knudsen, C. B., Veddum, L., Greve, A., Bliksted, V., Mors, O., Krustrup, P., Thorsteinsson, T., Schmidt-Andersen, P., … Nordentoft, M. (2021). Physical Activity and Sleep in 11-Year Old Children With a Familial High Risk of Schizophrenia or Bipolar Disorder. The Danish High Risk and Resilience Study—VIA 11. Schizophrenia Bulletin Open , 3 (1), sgab055. https://doi.org/10.1093/SCHIZBULLOPEN/SGAB055 Stage, A., Vermund, M. C., Bølling, M., Otte, C. R., Oest Müllertz, A. L., Bentsen, P., Nielsen, G., & Elsborg, P. (2025). The impact of a school garden program on children’s food literacy, climate change literacy, school motivation, and physical activity: A study protocol. PLOS One , 20 (4), e0320574. https://doi.org/10.1371/journal.pone.0320574 Teresi, J. A., Yu, X., Stewart, A. L., & Hays, R. D. (2022). Guidelines for Designing and Evaluating Feasibility Pilot Studies. Medical Care , 60 (1), 95–103. https://doi.org/10.1097/MLR.0000000000001664 Topp, C. W., Dinesen Østergaard, S., Søndergaard, S., & Bech, P. (2015). The WHO-5 Well-Being Index: A Systematic Review of the Literature. Psychotherapy and Psychosomatics , 84 , 167–175. https://doi.org/10.1159/000376585 Trotter, M. G., Coulter, T. J., Davis, P. A., Poulus, D. R., & Polman, R. (2020). The Association between Esports Participation, Health and Physical Activity Behaviour. International Journal of Environmental Research and Public Health , 17 (19), 7329. https://doi.org/10.3390/ijerph17197329 Wu, Y.-J., Outley, C., David Matarrita-Cascante, •, & Murphrey, T. P. (2015). A Systematic Review of Recent Research on Adolescent Social Connectedness and Mental Health with Internet Technology Use. Adolescent Research Review , 1 . https://doi.org/10.1007/s40894-015-0013-9 Tables Tables 1 and 2 are available in the supplementary files section Additional Declarations No competing interests reported. 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17:54:57","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-9270725/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-9270725/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":107483264,"identity":"b3e291f7-1999-40ec-9b1c-083c9a9937bb","added_by":"auto","created_at":"2026-04-22 02:27:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":554692,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eTheory of change.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"2.png","url":"https://assets-eu.researchsquare.com/files/rs-9270725/v1/1321e1016daf2bab3b74405b.png"},{"id":107485174,"identity":"23673808-8d0f-41e8-9ef8-73f83e9b884d","added_by":"auto","created_at":"2026-04-22 02:33:49","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":218030,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOverview of content of the eHOOD intervention.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"3.png","url":"https://assets-eu.researchsquare.com/files/rs-9270725/v1/9394a45d119a00635b9e5fdf.png"},{"id":107256015,"identity":"d5abb0c6-b29b-4dcf-acd1-bf750daa8007","added_by":"auto","created_at":"2026-04-19 12:14:49","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":12322,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eOutcomes, instruments, data collection procedures, and timing of measurements.\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"4.png","url":"https://assets-eu.researchsquare.com/files/rs-9270725/v1/f08eb9bcf4c51278a2d7cdfe.png"},{"id":107485164,"identity":"32468bad-4f02-411b-bf89-e3b5c644f3bd","added_by":"auto","created_at":"2026-04-22 02:33:43","extension":"png","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":25659,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eParticipants' self-rated collaboration skills\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"5.png","url":"https://assets-eu.researchsquare.com/files/rs-9270725/v1/bca99528ca065b1a7c0aa56a.png"},{"id":107256018,"identity":"dbf67268-b9fe-472b-906b-114ad95312a9","added_by":"auto","created_at":"2026-04-19 12:14:49","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":146313,"visible":true,"origin":"","legend":"\u003cp\u003e\u003cstrong\u003eAssessment of participants’ collaboration and communication skills\u003c/strong\u003e\u003c/p\u003e","description":"","filename":"1.png","url":"https://assets-eu.researchsquare.com/files/rs-9270725/v1/1d89d3d09a08df98b2748c09.png"},{"id":107705020,"identity":"5f7403ff-1abd-4221-9bd0-2e3ecb530460","added_by":"auto","created_at":"2026-04-24 09:06:33","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1063408,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-9270725/v1/c9956d2a-e4b9-4227-b4f7-1a6fdfe05862.pdf"},{"id":107256012,"identity":"218fd86e-7d25-419b-975d-9906b3d41ba9","added_by":"auto","created_at":"2026-04-19 12:14:49","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":143560,"visible":true,"origin":"","legend":"","description":"","filename":"AppendixA.docx","url":"https://assets-eu.researchsquare.com/files/rs-9270725/v1/ec54eb81e1fcc0d30eb3b17f.docx"},{"id":107484685,"identity":"33b15e59-6621-40b6-85fd-9b7f8b64991d","added_by":"auto","created_at":"2026-04-22 02:32:45","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":20738,"visible":true,"origin":"","legend":"","description":"","filename":"Tables.docx","url":"https://assets-eu.researchsquare.com/files/rs-9270725/v1/6537d3f6ea9bdf0a1a4d3cff.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Evaluability and feasibility of an intervention combining gaming and social activities to improve mental wellbeing and health behaviour in adolescents facing social challenges","fulltext":[{"header":"Introduction","content":"\u003cp\u003eAdolescents in Denmark increasingly have poor mental wellbeing and unhealthy lifestyles. According to a recent study based on register data from school nurses\u0026rsquo; examinations of school children, at least one concern regarding general wellbeing was raised for 14.2% of 14-year-olds and 12.3% of 15-year-olds (Pommerencke et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In the Danish version of \u0026rsquo;The Health Behaviour in School-aged Children (HBSC) from 2022, consisting of survey data from children aged 11, 13, and 15 years, 12% of girls stated they frequently or very frequently experience loneliness, and 30% of girls reported low mental wellbeing. Furthermore, comparing these findings with the past 10 to 20 years, significant negative trends are observed across a wide range of mental health parameters (Madsen et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Comparable patterns are seen across Europe and North America (Cosma et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Rakic et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). As for lifestyle habits, only one-third of girls and around half of boys met the Danish recommendations for physical activity and intake of fruit and vegetables (Madsen et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). In school nurses\u0026rsquo; registers (Pommerencke et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) almost 17% of the adolescents aged 14\u0026ndash;15 years were classified as overweight following sex- and age-specific body mass index (BMI) cut-offs (Cole \u0026amp; Lobstein, \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). In addition to spending less time being physically active, adolescents also spend less time on face-to-face activities with friends and more time on social media and gaming. According to the Danish HBSC, time spent face to face with friends has significantly decreased in recent years, and 15-year-old boys use on average 159 minutes per day gaming and 141 minutes per day on social media. Correspondingly, 15-year-old girls use on average 70 minutes per day gaming and 190 minutes per day on social media (Madsen et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Across all the countries in the international HBSC, one-third of pupils aged 11\u0026ndash;15 years reported gaming online every day, and 22% reported gaming online for at least four hours per day (Boniel-Nissim et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eAlthough the potential harm of adolescent use of digital technology is often highlighted in the public debate, research has shown both positive and negative consequences of the comprehensive use of screens among adolescents. For example, a systematic review found that the use of internet technology increased adolescents\u0026rsquo; sense of connection to friends while at the same time increasing anxiety and loneliness (Wu et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). A more recent scoping review found positive effects of adolescent use of gaming, social media, and the internet regarding social support, social connection, and communication skills (Haddock et al., \u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Particularly for adolescents in vulnerable social positions, there is concern about the potential negative consequences of digital technology use. For instance, research has shown an association between the daily usage of digital technology and poor mental health (George et al., \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2018\u003c/span\u003e), although no cause-and-effect relationship has been established. A review found that while the digital practices of vulnerable adolescents enable social support and connection, they may also expose them to a range of negative experiences (Kostyrka-Allchorne et al., \u003cspan citationid=\"CR14\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eThe implications of adolescents having less physical contact with friends and peers are yet to be fully understood. What we do know is that health and wellbeing in childhood and adolescence have implications for educational achievement and mental wellbeing in adulthood and, thus, overall life achievements (Inchley et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). In a survey among Norwegian adolescents (de Ridder et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2013\u003c/span\u003e), the risk of high school dropout was associated with various health problems such as psychological distress, insomnia, concentration difficulties, and overweight. Untreated mental health issues in adolescence, such as anxiety and depression, are shown to often continue into adulthood (Moffitt et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2007\u003c/span\u003e).\u003c/p\u003e \u003cp\u003eIn acknowledgement of adolescents' extensive use of digital technology while at the same time recognizing a potential negative impact on their mental health, the eHOOD intervention was developed in 2018 aiming to increase mental and physical health and wellbeing among adolescents facing social challenges. eHOOD combines gaming, physical activity, health education, and social interaction in safe and familiar surroundings, fostering the development of skills and positive social relations with peers and adults\u0026ndash;elements of organised leisure communities that have been shown to support mental wellbeing (Kusier et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). It uses adolescents\u0026rsquo; motivation for improving their gaming skills to teach and engage them in healthy lifestyle, building on a possible link between physical fitness and cognitive skills associated with gaming skills (Marchetti et al., \u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Trotter et al., \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). The eHOOD intervention has already been used in several Danish municipalities but has never been systematically evaluated.\u003c/p\u003e \u003cp\u003eOn basis of this, the objective of this study was threefold: 1) to assess the evaluability of the eHOOD intervention, 2) to develop an evaluation design, and 3) to assess the feasibility of the evaluation design and the intervention for use in future, larger-scale evaluations.\u003c/p\u003e \u003cp\u003eOur research questions were:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eWhat is an appropriate evaluation design for testing the eHOOD intervention?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo what extent is the evaluation design feasible in terms of outcomes, measurements, instruments, data collection procedures, and participant acceptability?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eTo what extent is the intervention feasible and acceptable in terms of recruitment, retention of participants, and participant satisfaction and engagement?\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eThe study consists of an evaluability assessment followed by a feasibility study in a before-after single arm design, implying that the study was conducted without a control group and with measurements before and after the intervention. In the following, the methods and results of the two studies will be reported separately.\u003c/p\u003e \u003cp\u003eIn accordance with the guideline on reporting non-randomised pilot and feasibility studies (Lancaster \u0026amp; Thabane, \u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), this feasibility study adheres to the CONSORT Extension to Randomised Pilot and Feasibility Studies (Eldridge et al., \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2016\u003c/span\u003e) except that items concerning randomization were omitted.\u003c/p\u003e \u003cdiv id=\"Sec3\" class=\"Section2\"\u003e \u003ch2\u003eEvaluability assessment\u003c/h2\u003e \u003cp\u003eThe evaluability assessment was conducted prior to intervention start, between August and December 2022. It was carried out through a series of workshop-style meetings and site visits to the location of the planned feasibility study, an after-school club in a Danish municipality. The process of the evaluability assessment was inspired by Brunner, Craig, and Watson (Brunner et al., \u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) and conducted in five steps:\u003c/p\u003e \u003cp\u003e \u003col\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIn the first step, a working group to conduct the evaluability assessment was established. The first author served as the principal investigator, leading the working group. The participants included a manager from Sincera (a Danish private limited liability company), where the intervention was developed; the eHOOD coach; a data analyst from Impactly (a Danish private limited liability company) that delivered an online platform tested for data collection and analysis in the study; a local pedagogue from the after-school club; and a consultant from SENS Innovation (a Danish private limited liability company) that delivered the accelerometers tested for collecting data on physical activity and sleep in the study.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIn the second step, the first author, the Sincera manager, the eHOOD coach, and the Impactly data analyst constructed an agreed-upon theory of change based on previous experiences with the intervention and a literature review. The theory of change was continuously refined throughout the study and served as the basis for the development of the evaluation plan.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIn the third step, the first author reviewed the literature regarding the use of outcomes, instruments, and data collection procedures in previous research on adolescents and identified possible data sources. This was done with support from the Sincera manager and the Impactly data analyst.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIn the fourth step, the first author and the Impactly data analyst made recommendations for evaluation and a draft version of an evaluation plan.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003cspan\u003e \u003cli\u003e \u003cp\u003eIn the fifth step, the working group discussed and revised the evaluation plan. The first author had the final say in decisions regarding the evaluation.\u003c/p\u003e \u003c/li\u003e \u003c/span\u003e \u003c/ol\u003e \u003c/p\u003e \u003cp\u003eThe outcomes of the evaluability assessment were a theory of change and an evaluation plan outlining outcomes, measurements, data sources, and data collection procedures for the subsequent feasibility study. The theory of change is shown in Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eThe evaluability assessment resulted in an agreement to proceed to the feasibility study in which the evaluation plan was applied.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eBefore-after single arm feasibility study\u003c/h3\u003e\n\u003cdiv id=\"Sec5\" class=\"Section2\"\u003e \u003ch2\u003eSetting\u003c/h2\u003e \u003cp\u003eThe intervention was offered in a municipal after-school club in the vicinity of Copenhagen, Denmark.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eThe target population of the eHOOD intervention was adolescents in 7th to 10th grade (corresponding to lower secondary education) with psycho-social challenges. Potential participants were identified by a local pedagogue, who collaborated closely with schoolteachers and after-school club pedagogues. Altogether, the group possessed profound knowledge of the adolescents in the area. Based on a professional assessment of individual needs and anticipated benefits, adolescents with psycho-social challenges such as anxiety, loneliness, school refusal, and being a victim of bullying, were invited to participate. Adolescents who were deemed unable to participate meaningfully in a social community were excluded. Recruitment began in October 2022 and continued until 12\u0026ndash;15 potential participants were identified, a target set by the eHOOD team based on prior experience. This goal was successfully achieved in December 2022. Prior to intervention start, eligible participants and their parents were invited to an information meeting hosted by the eHOOD team. The meeting was held one evening at the after-school club where the intervention was going to be tested.\u003c/p\u003e\n\u003ch3\u003eIntervention\u003c/h3\u003e\n\u003cp\u003eThe eHOOD intervention consisted of weekly meetings for the adolescents for 25 weeks. Participants meet up with their eHOOD coach and one or more local pedagogues one evening from five to nine PM every week. Each meeting contained physical activity, preparation and intake of dinner, education, and gaming with instruction. Physical activities included ball games such as football, basketball, and table tennis, fitness training, and traditional children's games depending on local facilities and participants' preferences. Coordination and reaction training were included. Educational sessions included teaching healthy dietary habits, sleeping habits, and exercise habits, focusing on the importance of taking care of one's body and staying fit to be able to perform well in gaming. Gaming sessions were structured and led by the eHOOD coach and contained both training and gaming in teams. Further, participants were paired in teams and were given small assignments to be performed together between the weekly meetings. Homework was meant to form and nurture new relationships and invite teammates to stay in contact outside the physical meetings. As parts of the social and educational activities, communal cooking and dining were included. Participants took turns preparing and serving dinner for their peers together with the local pedagogue. Figure\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e illustrates the elements of the eHOOD intervention.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cdiv id=\"Sec8\" class=\"Section2\"\u003e \u003ch2\u003eOrganisation\u003c/h2\u003e \u003cp\u003eThe eHOOD team managed communication with the municipality and oversaw the implementation of the intervention. Impactly facilitated survey data collection through its proprietary platform, and SENS Innovation handled the collection of accelerometer data. Importantly, the research team retained exclusive responsibility for evaluating the data and interpreting the findings. None of the collaborating partners had any involvement in the analysis, the results, or their presentation, ensuring the independence and integrity of the research process.\u003c/p\u003e \u003c/div\u003e\n\u003ch3\u003eEvaluation plan\u003c/h3\u003e\n\u003cp\u003eFeasibility outcomes were prespecified during the evaluability assessment and concerned the feasibility and acceptability of the evaluation design and the feasibility and acceptability of the intervention (Hallingberg et al., \u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e2018\u003c/span\u003e; Pearson et al., \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Teresi et al., \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Quantitative and qualitative outcome measures were selected for initial testing of detectable changes to be used as outcomes in a future evaluation of the intervention. Outcomes and instruments consisted partly of validated instruments and partly of questionnaires developed for this study. Validated instruments included the 5-item World Health Organization Well-Being Index (WHO-5) and the Three-Item Loneliness Scale (T-ILS). The WHO-5 includes five items each scored from 0 to 5. Thus, raw scores range from 0 to 25 and are multiplied by 4 to transform it to a percentage scale from 0-100, where the max score corresponding to optimal wellbeing is 100, 50\u0026ndash;70 points corresponds to the normal range of wellbeing, and a score under 50 points corresponds to a wellbeing below the normal range, equalling risk of depression (Topp et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2015\u003c/span\u003e). The T-ILS includes three items each scored from 1 to 3. Total scores range from 3 to 9, where 9 corresponds to the highest level of loneliness. There is no consensus on a threshold value, but in a Danish study of loneliness among adolescents, they used a score of 5\u0026ndash;6, equalling moderate loneliness, and a score of 7\u0026ndash;9, equalling severe loneliness (Lasgaard et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). Two questionnaires developed for this study (see Appendix A) covered lifestyle habits and self-rated communication and collaboration skills using items from the Danish HBSC (Madsen et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e) and the annual wellbeing survey in Danish public schools (\u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003eHttps://Www.Uvm.Dk/Folkeskolen/Test-Evaluering-Og-Skoleudvikling/Trivselsmaaling\u003c/span\u003e\u003cspan address=\"http://Https://Www.Uvm.Dk/Folkeskolen/Test-Evaluering-Og-Skoleudvikling/Trivselsmaaling\" targettype=\"URL\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e). The latter questionnaire was supplemented with a small number of self-constructed items concerning participation in organised sports activities and new friendships; subjects that we could not find covered in existing questionnaires. Figure\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e visualises the selected feasibility outcomes as well as the quantitative and qualitative outcomes, instruments, and data collection procedures that were tested, and the timing of measurements.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003eProgression to a future definitive trial was guided by predefined feasibility criteria, including the ability to recruit the intended number of participants within the planned timeframe, acceptable retention with no dropouts, and the feasibility and acceptability of outcome measures and data collection procedures. These criteria were not used as strict thresholds but to inform necessary adjustments and the overall judgement of readiness for a larger-scale evaluation.\u003c/p\u003e \u003cdiv id=\"Sec10\" class=\"Section2\"\u003e \u003ch2\u003eData analysis\u003c/h2\u003e \u003cp\u003eQuantitative data were analyzed descriptively to identify initial changes in selected outcomes. For survey data collected using the Impactly platform, changes in mean values were calculated and reported. Accelerometer data were categorized into the following categories: inactivity (lying/sitting), moderate-intensity activity, high-intensity activity, sleep (calm and restless), and number of steps. For each category, daily minutes were calculated, and weekly averages were derived for each individual participant. At the group level, changes in mean values were calculated to explore trends. Qualitative data collected via interviews and observations were analysed thematically with inspiration from Braun and Clarke (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2006\u003c/span\u003e, \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2019\u003c/span\u003e).\u003c/p\u003e \u003c/div\u003e"},{"header":"Results","content":"\u003cp\u003e\u003cem\u003eParticipants and data collection\u003c/em\u003e\u003cem\u003e\u003cbr\u003e\u003c/em\u003eAll participants in the eHOOD intervention were part of the feasibility study. The participants were 13 adolescents aged 13\u0026ndash;16 years with a median age of 14 years at intervention start. The intervention ran from January 2023 to August 2023. Baseline measurements were conducted in February 2023, mid-point measurements in June, and end measurements in August 2023. The feasibility study was completed as planned with no early termination. Participants\u0026rsquo; self-reported baseline characteristics are shown in Table 1.\u003c/p\u003e\n\u003cp\u003eTable 2 shows which outcomes were measured, how and when, and the number of participants for whom complete data were collected at each point of measurement.\u003c/p\u003e\n\u003ch3\u003eFeasibility and acceptability of evaluation design\u0026nbsp;\u003c/h3\u003e\n\u003cp\u003e\u003cem\u003eMeasurements, instruments, and data collection procedures\u003c/em\u003e\u003cem\u003e\u003cbr\u003e\u003c/em\u003eAdministration of electronic surveys for measuring WHO-5, T-ILS, and self-rated communication and collaboration skills was planned to be a task for the coach during eHOOD sessions.\u0026nbsp;This task turned out to disturb the flow of the sessions for the coach, resulting in missing data collection. To solve this problem, the first and second authors went to the after-school club and filled in the surveys with the participants instead. The delay means that baseline measurements were done in April and not in February as expected. All participants willingly and easily answered the surveys administered by the researchers, and useful data were collected.\u003c/p\u003e\n\u003cp\u003eMeasuring physical activity and sleep with accelerometers was challenging in the target group. Out of 13 participants, 11 accepted to wear an accelerometer at baseline, and two did not want to wear it. Of the 11 who wore it, two lost or removed it before seven days had passed.\u0026nbsp;Thus, complete data were collected for nine participants. At mid-measurements eight participants wore an accelerometer for seven consecutive days, but three of them did not wear an accelerometer at baseline. At end of intervention, only four participants accepted to wear an accelerometer again, and two lost it or removed it. Therefore, complete data were only collected for two participants and no data on physical activity and sleep are therefore reported here.\u003cbr\u003eThe self-administered survey sent to the participants by text message daily for seven consecutive days was acceptable to participants, and questions were easy to answer. Nevertheless, no useful data on lifestyle habits were collected, because only three participants answered each of the seven consecutive days at mid-measurements and two participants at end-measurements. Interviews revealed that most participants did not understand the purpose of answering homonymous questions every day for several days. Further, items regarding alcohol and nicotine use did not generate useful data due to unsuitable wording.\u003c/p\u003e\n\u003cp\u003eCollaboration and communication skills were relevant and acceptable measures to both participants and coach, and they generated useful data. However, data showed that participants\u0026rsquo; and coach\u0026rsquo; assessments were not consistent.\u0026nbsp;Different wording of the items aimed at participants and coach, respectively, may explain this inconsistency.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eInitial changes in outcomes\u0026nbsp;\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe intervention showed potential regarding its ability to increase participants\u0026rsquo; wellbeing, reduce loneliness, support participants in building new relationships, and strengthen participants\u0026apos; social skills. To measure the changes in WHO-5 and T-ILS we used baseline measurements and mid-measurements due to low response rates at end measurements. The average WHO-5 score of the eHOOD participants increased from 46.8 at baseline to 57.5 at mid-measurements, indicating a clinically relevant improvement of wellbeing of 10+ points\u0026nbsp;(Topp et al., 2015). The average T-ILS score declined from 5.2 to 4.2, indicating reduced loneliness.\u003c/p\u003e\n\u003cp\u003eAll participants reported that they made new friends, and seven out of the 13 participants reported that they had several or many new friends by the end of the intervention.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eTo measure changes in self-rated collaboration skills we used baseline and mid-measurements due to a low response rate at the final measurements. As seen in Figure 4, at baseline six participants said they collaborate well most of the time, and two said they rarely collaborate well. By mid-measurements, nine participants said they collaborate well most of the time, and the remaining three said they sometimes collaborate well.\u003c/p\u003e\n\u003cp\u003eOther items were used for eHOOD coach\u0026rsquo;s assessment of participants\u0026rsquo; collaboration and communication skills. Figure 5 shows that, according to the coach, three participants had good collaboration skills at baseline and eight participants at the end of the intervention. Similarly, two participants had good communication skills at baseline according to the coach and by the end of the intervention, the number had increased to eight participants.\u003c/p\u003e\n\u003ch3\u003eFeasibility and acceptability of intervention\u003c/h3\u003e\n\u003cp\u003eWe investigated participants\u0026apos; expectations and motivation for participating in eHOOD and their self-rated benefits of participating. Most participants said that gaming was attractive to them and that they perceived eHOOD as an opportunity to practice meeting new friends. Many participants expressed hope of making new friends by joining eHOOD, especially friends to meet with physically rather than virtually, as many of them primarily met friends online. Some participants said it took courage to sign up for eHOOD because they did not know the other participants in advance. Some told us about school fatigue and expressed hope that eHOOD could strengthen their self-discipline in relation to school and homework. Some participants expressed problems with raging and foul language during gaming and wished to gain more control over their language and behaviour. Others wanted more control over their gaming consumption and to practice prioritizing their time. Overall, motivational factors were the desire to increase social skills, self-discipline, and self-control. Many participants mentioned that cooking, communal dining, and physical activity made eHOOD fun and special. Almost all participants highlighted the combination of activities as something extraordinary because it built a strong social community, and the community retained their interest in eHOOD. Hence, gaming and other social activities attracted the participants to begin with, but the community made them stay. As for recruitment and retention, a sufficient number of participants was recruited within the planned period, and there were no dropouts during the intervention period. No harms or unintended effects related to participation in the intervention were observed or reported during the study period.\u003c/p\u003e"},{"header":"Discussion","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e \u003ch2\u003eInterpretation\u003c/h2\u003e \u003cp\u003eRelevant adjustments of the evaluation design were identified to optimise data collection and measurement relevance for use in future evaluation and similar interventions targeting adolescents, specifically:\u003c/p\u003e \u003cp\u003e \u003cstrong\u003eOutcome measures\u003c/strong\u003e \u003cp\u003eThe WHO-5 proved feasible and acceptable and showed positive trends in change from baseline to mid-measurements, as the average score increased slightly more than 10 points indicating a clinically relevant change. The average score was well below the mean score of 70 in the general population in Denmark (Topp et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2015\u003c/span\u003e) but within the normal range of 40\u0026ndash;80 of adolescents aged 13\u0026ndash;15 years in the HBSC (Madsen et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). Our findings regarding participants\u0026rsquo; sense of connectedness fostered by their participation suggest that eHOOD, as an organised leisure activity, has the potential to support the mental wellbeing of participants (Kusier et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e). On this basis, we believe that mental wellbeing measured with the WHO-5 is a relevant primary outcome in future evaluation.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eData collection procedures\u003c/strong\u003e \u003cp\u003eOur difficulties collecting complete data from all participants is an important learning for future evaluations of interventions targeting adolescents in vulnerable positions. The use of accelerometers proved less suitable in the particular group of participants. Other Danish studies have used SENS Motion accelerometers for 11-year-old children but have failed to report participation and retention rates (S\u0026oslash;ndergaard et al., \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) or have yet to report the results (Stage et al., \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2025\u003c/span\u003e). Thus, it is not clear whether our lack of success was due to the ages and the psycho-social challenges of the target group\u0026mdash;all of which possibly blurred their interest in contributing to our data collection\u0026mdash;or whether we could have attained sufficient data if our sample size had been bigger. Alternative approaches, such as integrating physical activity questions into surveys, could enhance data completeness and reliability. Additionally, clear communication about the importance of daily responses to surveys can address gaps in participant adherence. In a recent study of school children parental involvement in the administration of text message surveys was used to secure appropriate response rates (Stage et al., unpublished research), which highlights the need for such adaptations.\u003c/p\u003e \u003c/p\u003e \u003cp\u003e \u003cstrong\u003eSupplemental measures\u003c/strong\u003e \u003cp\u003eIncluding a measure for self-efficacy could provide a broader understanding of the intervention\u0026rsquo;s impact, as the development of self-efficacy has proved to be vital to support mental wellbeing in organised leisure activities for adolescents (Kusier et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2023\u003c/span\u003e).\u003c/p\u003e \u003c/p\u003e \u003c/div\u003e \u003cdiv id=\"Sec21\" class=\"Section2\"\u003e \u003ch2\u003eLimitations\u003c/h2\u003e \u003cp\u003eThe small sample size and missing data from mid- and end measurements pose limitations that necessitate caution in interpreting the results. The missing data were largely attributed to unstable attendance around the summer holidays, rather than participant disengagement, as evidenced by the absence of dropouts. Another limitation is the delay in some of the baseline measurements, which were done in April instead of February. This means that changes in mean values were observed within a short time interval, potentially reducing the ability to distinguish between natural variations and changes associated with the intervention.\u003c/p\u003e \u003cp\u003eFurther, the intervention was only tested in a single site. Thus, our findings stem from one particular after-school club with specific pedagogues employed, distinct physical surroundings, and other unique characteristics. Involving more sites would have provided broader insights by capturing the diverse cultures, resources, and operational practices of different after-school clubs.\u003c/p\u003e \u003cp\u003eThe identified challenges highlight the need for refined strategies in future evaluations to mitigate data gaps.\u003c/p\u003e \u003c/div\u003e"},{"header":"Conclusions","content":"\u003cp\u003e\u003cem\u003eSummary of findings\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe results of our study showed that the eHOOD intervention was ready to be evaluated with the proposed evaluation design, as evidenced by the practical implementation during the feasibility study. Further, the evaluation design proved feasible and acceptable for use in the subsequent evaluation of intervention effectiveness. The feasibility study yielded valuable insights into the appropriateness of outcomes, instruments, and data collection procedures.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003eThe intervention itself proved feasible and acceptable regarding recruitment and retainment of participants. High satisfaction expressed by participants highlighted the acceptability of the intervention, particularly regarding the combination of activities and the sense of social community fostered among participants. No dropouts occurred during the intervention period, reflecting strong engagement and commitment. To our knowledge, no similar interventions that have been evaluated exist.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eDirections for future evaluation\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eFuture studies should aim to:\u003c/p\u003e\n\u003cul type=\"disc\"\u003e\n \u003cli\u003eAlign questions on collaboration and communication skills between participants and coaches to facilitate comparative analysis.\u003c/li\u003e\n \u003cli\u003eEnhance data collection procedures by replacing accelerometers with text-message-based surveys and ensuring participants understand their importance.\u003c/li\u003e\n \u003cli\u003eIntroduce supplemental measures, such as self-efficacy and school absenteeism, to capture additional dimensions of intervention impact.\u003c/li\u003e\n \u003cli\u003eConduct follow-up assessments post-intervention to evaluate long-term effects on wellbeing and social dynamics.\u003c/li\u003e\n\u003c/ul\u003e\n\u003cp\u003eWhile our findings are based on a single feasibility study with a small sample, the study offers methods and insights regarding evaluability assessments and feasibility testing of interventions within similar target groups for researchers undertaking related work. By addressing the limitations and implementing the recommended adjustments, future studies can build on this foundation to yield more comprehensive and generalisable findings.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cp\u003eADHD: Attention Deficit Hyperactivity Disorder\u003c/p\u003e\n\u003cp\u003eASD: Autism Spectrum Disorder\u003c/p\u003e\n\u003cp\u003eHBSC: Health Behaviour in School-Aged Children\u003c/p\u003e\n\u003cp\u003eT-ILS: Three-Item Loneliness Scale\u003c/p\u003e\n\u003cp\u003eWHO-5: World Health Organization-Five Well-Being Index\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch3\u003eEthics approval and consent to participate\u003c/h3\u003e\n\u003cp\u003eThe Danish Data Protection Agency assessed the study and categorized it as a quality improvement project, of which registration is redundant.\u0026nbsp;The Regional Health Research Ethics Committees in the Capital Region of Denmark waived the need for ethical approval of the project (ref. no.: F-25073292). Informed consent to participate was obtained from the parents of the participants who were under the age of 16.\u0026nbsp;One participant was 16 years old and, therefore, gave written informed consent herself. The study was performed in accordance with the Declaration of Helsinki.\u003cem\u003e\u0026nbsp;\u003c/em\u003eAll data were handled in accordance with the GDPR.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eConsent for publication\u003c/h3\u003e\n\u003cp\u003eNot applicable.\u003c/p\u003e\n\u003ch3\u003eAvailability of data and materials\u003c/h3\u003e\n\u003cp\u003eThe trial protocol and the datasets used and analysed during the current study are available from the corresponding author on reasonable request.\u003c/p\u003e\n\u003ch3\u003eCompeting interests\u003c/h3\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u0026nbsp;\u003c/p\u003e\n\u003ch3\u003eFunding\u003c/h3\u003e\n\u003cp\u003eThe study was funded by EU via the Lighthouse Life Science program (pilot project no. 2.3), an initiative launched to support public-private partnerships in life science and welfare technology in developing and testing innovative health solutions to public health challenges.\u003c/p\u003e\n\u003ch3\u003eAcknowledgements\u003c/h3\u003e\n\u003cp\u003eFirst, we thank the participating adolescents for their goodwill and participation in the evaluation. We are grateful for the valuable insights generated from their responses to our numerous questions. Also, we would like to express our gratitude to their parents, who allowed us to use their children as respondents. The pedagogues in the after-school club also deserves a thank you for welcoming us at their workplace and providing space for doing interviews and other data collection. Lastly, we thank SENS Innovation for lending us their accelerometers to use in the study.\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n \u003cli\u003eBoniel-Nissim, M., Marino, C., Galeotti, T., Blinka, L., Ozoliņa, K., Craig, W., Lahti, H., Wong, S. L., Brown, J., Wilson, M., Inchley, J., \u0026amp; Van Den Eijnden, R. (2024). \u003cem\u003eA focus on adolescent social media use and gaming in Europe, central Asia and Canada\u003c/em\u003e. http://apps.who.int/bookorders.\u003c/li\u003e\n \u003cli\u003eBraun, V., \u0026amp; Clarke, V. (2006). Using thematic analysis in psychology. \u003cem\u003eQualitative Research in Psychology\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(2), 77\u0026ndash;101. https://doi.org/10.1191/1478088706qp063oa\u003c/li\u003e\n \u003cli\u003eBraun, V., \u0026amp; Clarke, V. (2019). Reflecting on reflexive thematic analysis. \u003cem\u003eQualitative Research in Sport, Exercise and Health\u003c/em\u003e, \u003cem\u003e11\u003c/em\u003e(4), 589\u0026ndash;597. https://doi.org/10.1080/2159676X.2019.1628806\u003c/li\u003e\n \u003cli\u003eBrunner, R., Craig, P., \u0026amp; Watson, N. (2019). Evaluability assessment: An application in a complex community improvement setting. \u003cem\u003eEvaluation\u003c/em\u003e, \u003cem\u003e25\u003c/em\u003e(3), 349\u0026ndash;365. https://doi.org/10.1177/1356389019852126\u003c/li\u003e\n \u003cli\u003eCole, T. J., \u0026amp; Lobstein, T. (2012). Extended international (IOTF) body mass index cut‐offs for thinness, overweight and obesity. \u003cem\u003ePediatric Obesity\u003c/em\u003e, \u003cem\u003e7\u003c/em\u003e(4), 284\u0026ndash;294. https://doi.org/10.1111/j.2047-6310.2012.00064.x\u003c/li\u003e\n \u003cli\u003eCosma, A., Abdrakhmanova, S., Taut, D., Schrijvers, K., Catunda, C., \u0026amp; Schnohr, C. (2023). A focus on adolescent mental health and well-being in Europe, central Asia and Canada. Health Behaviour in School-aged Children international report from the 2021/2022 survey. \u003cem\u003eWorld Health Organization European Region\u003c/em\u003e, \u003cem\u003e1\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003ede Ridder, K. A. A., Pape, K., Johnsen, R., Holmen, T. L., Westin, S., \u0026amp; Bj\u0026oslash;rngaard, J. H. (2013). Adolescent Health and High School Dropout: A Prospective Cohort Study of 9000 Norwegian Adolescents (The Young-HUNT). \u003cem\u003ePLoS ONE\u003c/em\u003e, \u003cem\u003e8\u003c/em\u003e(9). https://doi.org/10.1371/journal.pone.0074954\u003c/li\u003e\n \u003cli\u003eEldridge, S. M., Chan, C. L., Campbell, M. J., Bond, C. M., Hopewell, S., Thabane, L., \u0026amp; Lancaster, G. A. (2016). CONSORT 2010 statement: extension to randomised pilot and feasibility trials. \u003cem\u003eBMJ\u003c/em\u003e, i5239. https://doi.org/10.1136/bmj.i5239\u003c/li\u003e\n \u003cli\u003eGeorge, M. J., Russell, M. A., Piontak, J. R., \u0026amp; Odgers, C. L. (2018). Concurrent and Subsequent Associations Between Daily Digital Technology Use and High-Risk Adolescents\u0026rsquo; Mental Health Symptoms. \u003cem\u003eChild Development\u003c/em\u003e, \u003cem\u003e89\u003c/em\u003e(1), 78\u0026ndash;88. https://doi.org/10.1111/CDEV.12819\u003c/li\u003e\n \u003cli\u003eHaddock, A., Ward, N., Yu, R., \u0026amp; O\u0026rsquo;Dea, N. (2022). Positive Effects of Digital Technology Use by Adolescents: A Scoping Review of the Literature. \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e, \u003cem\u003e19\u003c/em\u003e(21), 14009. https://doi.org/10.3390/IJERPH192114009\u003c/li\u003e\n \u003cli\u003eHallingberg, B., Turley, R., Segrott, J., Wight, D., Craig, P., Moore, L., Murphy, S., Robling, M., Simpson, S. A., \u0026amp; Moore, G. (2018). Exploratory studies to decide whether and how to proceed with full-scale evaluations of public health interventions: A systematic review of guidance. In \u003cem\u003ePilot and Feasibility Studies\u003c/em\u003e (Vol. 4, Issue 1). BioMed Central Ltd. https://doi.org/10.1186/s40814-018-0290-8\u003c/li\u003e\n \u003cli\u003e\u003cem\u003ehttps://www.uvm.dk/folkeskolen/test-evaluering-og-skoleudvikling/trivselsmaaling\u003c/em\u003e. (n.d.).\u003c/li\u003e\n \u003cli\u003eInchley, J., Currie, D., Budisavljevic, S., Torsheim, T., J\u0026aring;stad, A., Cosma, A., Kelly, C., \u0026amp; M\u0026aacute;r Arnarsson, \u0026Aacute;. (2020). Spotlight on adolescent health and well-being survey in Europe and Canada International report VOLUME 1. KEY FINDINGS. In \u003cem\u003eHealth Behaviour in School-aged Children\u003c/em\u003e. HBSC. http://apps.who.int/bookorders.\u003c/li\u003e\n \u003cli\u003eKostyrka‐Allchorne, K., Stoilova, M., Bourgaize, J., Rahali, M., Livingstone, S., \u0026amp; Sonuga‐Barke, E. (2023). Review: Digital experiences and their impact on the lives of adolescents with pre‐existing anxiety, depression, eating and nonsuicidal self‐injury conditions \u0026ndash; a systematic review. \u003cem\u003eChild and Adolescent Mental Health\u003c/em\u003e, \u003cem\u003e28\u003c/em\u003e(1), 22\u0026ndash;32. https://doi.org/10.1111/camh.12619\u003c/li\u003e\n \u003cli\u003eKusier, A. O., Ubbesen, T. R., \u0026amp; Folker, A. P. (2023).\u0026nbsp;\u003cem\u003eKarakteristika af det mentalt sundhedsfremmende fritidsf\u0026aelig;lleskab for unge : et litteraturreview\u003c/em\u003e. Sundhedsstyrelsen.\u003c/li\u003e\n \u003cli\u003eLancaster, G. A., \u0026amp; Thabane, L. (2019). Guidelines for reporting non-randomised pilot and feasibility studies. In \u003cem\u003ePilot and Feasibility Studies\u003c/em\u003e (Vol. 5, Issue 1). BioMed Central Ltd. https://doi.org/10.1186/s40814-019-0499-1\u003c/li\u003e\n \u003cli\u003eLasgaard, M., Christiansen, J., \u0026amp; Friis, K. (2019).\u0026nbsp;\u003cem\u003eEnsomhed blandt unge. Temaanalyse, vol. 7, Hvordan har du det?\u003c/em\u003e (D. Region Midtjylland, Ed.).\u003c/li\u003e\n \u003cli\u003eMadsen, K. R., Rom\u0026aacute;n, J. E. I., Damsgaard, M. T., Holstein, B. E., Kristoffersen, M. J., Pedersen, T. P., Michelsen, S. I., Rasmussen, M., \u0026amp; Toftager, M. (2023). \u003cem\u003eSkoleb\u0026oslash;rnsunders\u0026oslash;gelsen 2022\u003c/em\u003e. Syddansk Universitet.\u003c/li\u003e\n \u003cli\u003eMarchetti, R., Forte, R., Borzacchini, M., Vazou, S., Tomporowski, P. D., \u0026amp; Pesce, C. (2015). Physical and Motor Fitness, Sport Skills and Executive Function in Adolescents: A Moderated Prediction Model. \u003cem\u003ePsychology\u003c/em\u003e, \u003cem\u003e06\u003c/em\u003e(14), 1915\u0026ndash;1929. https://doi.org/10.4236/psych.2015.614189\u003c/li\u003e\n \u003cli\u003eMoffitt, T. E., Harrington, H. L., Caspi, A., Kim-Cohen, J., Goldberg, D., Gregory, A. M., \u0026amp; Poulton, R. (2007). Depression and generalized anxiety disorder: Cumulative and sequential comorbidity in a birth cohort followed prospectively to age 32 years. \u003cem\u003eArchives of General Psychiatry\u003c/em\u003e, \u003cem\u003e64\u003c/em\u003e(6), 651\u0026ndash;660. https://doi.org/10.1001/ARCHPSYC.64.6.651,\u003c/li\u003e\n \u003cli\u003ePearson, N., Naylor, P. J., Ashe, M. C., Fernandez, M., Yoong, S. L., \u0026amp; Wolfenden, L. (2020). Guidance for conducting feasibility and pilot studies for implementation trials. \u003cem\u003ePilot and Feasibility Studies\u003c/em\u003e, \u003cem\u003e6\u003c/em\u003e(1). https://doi.org/10.1186/s40814-020-00634-w\u003c/li\u003e\n \u003cli\u003ePommerencke, L. M., J\u0026oslash;rgensen, S. E., \u0026amp; Pedersen, T. P. (2024).\u0026nbsp;\u003cem\u003eSundhedsprofil for b\u0026oslash;rn og unge ind-og udskolingsunders\u0026oslash;gt i skole\u0026aring;ret 2022/23\u003c/em\u003e. www.sdu.dk/sif\u003c/li\u003e\n \u003cli\u003eRakic, J. G., Hamrik, Z., Dzielska, A., Felder-Puig, R., \u0026amp; Oja, L. (2024). A focus on adolescent physical activity, eating behaviours, weight status and body image in Europe, central Asia and Canada. Health Behaviour in School-aged Children international report from the 2021/2022 survey. \u003cem\u003eWorld Health Organization European Region\u003c/em\u003e, \u003cem\u003e4\u003c/em\u003e.\u003c/li\u003e\n \u003cli\u003eS\u0026oslash;ndergaard, A., Wilms, M., Gregersen, M., Brandt, J. M., Krantz, M. F., Rohd, S. B., Johnsen, L. K., Hemager, N., Hjorth\u0026oslash;j, C., Ohland, J., Andreassen, A. K., Knudsen, C. B., Veddum, L., Greve, A., Bliksted, V., Mors, O., Krustrup, P., Thorsteinsson, T., Schmidt-Andersen, P., \u0026hellip; Nordentoft, M. (2021). Physical Activity and Sleep in 11-Year Old Children With a Familial High Risk of Schizophrenia or Bipolar Disorder. The Danish High Risk and Resilience Study\u0026mdash;VIA 11. \u003cem\u003eSchizophrenia Bulletin Open\u003c/em\u003e, \u003cem\u003e3\u003c/em\u003e(1), sgab055. https://doi.org/10.1093/SCHIZBULLOPEN/SGAB055\u003c/li\u003e\n \u003cli\u003eStage, A., Vermund, M. C., B\u0026oslash;lling, M., Otte, C. R., Oest M\u0026uuml;llertz, A. L., Bentsen, P., Nielsen, G., \u0026amp; Elsborg, P. (2025). The impact of a school garden program on children\u0026rsquo;s food literacy, climate change literacy, school motivation, and physical activity: A study protocol. \u003cem\u003ePLOS One\u003c/em\u003e, \u003cem\u003e20\u003c/em\u003e(4), e0320574. https://doi.org/10.1371/journal.pone.0320574\u003c/li\u003e\n \u003cli\u003eTeresi, J. A., Yu, X., Stewart, A. L., \u0026amp; Hays, R. D. (2022). Guidelines for Designing and Evaluating Feasibility Pilot Studies. \u003cem\u003eMedical Care\u003c/em\u003e, \u003cem\u003e60\u003c/em\u003e(1), 95\u0026ndash;103. https://doi.org/10.1097/MLR.0000000000001664\u003c/li\u003e\n \u003cli\u003eTopp, C. W., Dinesen \u0026Oslash;stergaard, S., S\u0026oslash;ndergaard, S., \u0026amp; Bech, P. (2015). The WHO-5 Well-Being Index: A Systematic Review of the Literature. \u003cem\u003ePsychotherapy and Psychosomatics\u003c/em\u003e, \u003cem\u003e84\u003c/em\u003e, 167\u0026ndash;175. https://doi.org/10.1159/000376585\u003c/li\u003e\n \u003cli\u003eTrotter, M. G., Coulter, T. J., Davis, P. A., Poulus, D. R., \u0026amp; Polman, R. (2020). The Association between Esports Participation, Health and Physical Activity Behaviour. \u003cem\u003eInternational Journal of Environmental Research and Public Health\u003c/em\u003e, \u003cem\u003e17\u003c/em\u003e(19), 7329. https://doi.org/10.3390/ijerph17197329\u003c/li\u003e\n \u003cli\u003eWu, Y.-J., Outley, C., David Matarrita-Cascante, \u0026bull;, \u0026amp; Murphrey, T. P. (2015). A Systematic Review of Recent Research on Adolescent Social Connectedness and Mental Health with Internet Technology Use. \u003cem\u003eAdolescent Research Review\u003c/em\u003e, \u003cem\u003e1\u003c/em\u003e. https://doi.org/10.1007/s40894-015-0013-9\u003c/li\u003e\n\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTables 1 and 2 are available in the supplementary files section\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Evaluability assessment, feasibility, acceptability, evaluation design, mental wellbeing, loneliness, adolescents, gaming, social activity, physical activity","lastPublishedDoi":"10.21203/rs.3.rs-9270725/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-9270725/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eBackground\u003c/p\u003e\n\u003cp\u003eAdolescents in Denmark increasingly report poor mental wellbeing and health behaviour. Additionally, they spend less time being physically active and being with friends and more time on gaming and social media. The eHOOD intervention was developed to address physical and mental wellbeing of adolescents in vulnerable positions using their motivation for gaming to engage them in a community entailing physical and social activity, and education with peers. This study aimed to assess the evaluability of the eHOOD intervention, to develop an evaluation design, and to test the feasibility and acceptability of the evaluation design and the intervention.\u003c/p\u003e\n\u003cp\u003eMethods\u003c/p\u003e\n\u003cp\u003eEvaluability assessment was performed by a working group in a series of workshop-style meetings involving a literature review, creation of a theory of change, and preparation of an evaluation plan including outcome measures, instruments, and data collection procedures. Subsequently the evaluation design and the intervention were tested in a single arm feasibility study. Participants were 13 adolescents aged 13-16 years. The participants met with a coach and a local pedagogue in an after-school club four hours a week for 25 weeks practicing gaming, engaging in physical and social activities, and learning about healthy lifestyle habits through education and communal cooking and dining.\u003c/p\u003e\n\u003cp\u003eFeasibility and acceptability of outcome measures, instruments, and data collection procedures were assessed, and initial changes in outcome measures were measured. Recruitment and retainment of participants were monitored, and participants’ motivation for and benefits of participating were explored. Data were collected with qualitative and quantitative methods.\u003c/p\u003e\n\u003cp\u003eResults\u003c/p\u003e\n\u003cp\u003eAn evaluation plan was developed and found to be suitable for use in the subsequent feasibility study. The evaluation design proved feasible and acceptable, and relevant adjustments were identified. Initial changes in wellbeing were observed and the World Health Organization-Five Well-Being Index (WHO-5) was deemed relevant as a primary outcome in future evaluation. The intervention was found feasible and acceptable among participants in the present format.\u003c/p\u003e\n\u003cp\u003eConclusions\u003c/p\u003e\n\u003cp\u003eThis combined evaluability assessment and feasibility study showed that the eHOOD intervention is ready to be tested in a larger study, preferably in a randomised design, to evaluate its effects on adolescent mental wellbeing.\u003c/p\u003e\n\u003cp\u003eTrial registration: ClinicalTrials.gov, March 23, 2026. Identifier: NCT07489365. Retrospectively registered.\u003c/p\u003e","manuscriptTitle":"Evaluability and feasibility of an intervention combining gaming and social activities to improve mental wellbeing and health behaviour in adolescents facing social challenges","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2026-04-19 12:14:44","doi":"10.21203/rs.3.rs-9270725/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2026-05-06T08:11:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-05T13:33:28+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"49392036241828245069906998201032017160","date":"2026-04-25T17:11:25+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"68346858902976915637495646656748077085","date":"2026-04-22T23:40:12+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-04-20T12:22:55+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"166520975532944571870847268791328473563","date":"2026-04-14T14:54:03+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2026-04-09T14:21:08+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2026-04-09T14:13:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2026-04-08T07:07:21+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2026-04-08T06:55:21+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2026-04-08T06:38:02+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"f307b924-88ff-42c2-963f-d9b33db627c5","owner":[],"postedDate":"April 19th, 2026","published":true,"recentEditorialEvents":[{"type":"decision","content":"Revision requested","date":"2026-05-06T08:11:58+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2026-05-05T13:33:28+00:00","index":131,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2026-05-16T09:09:34+00:00","versionOfRecord":[],"versionCreatedAt":"2026-04-19 12:14:44","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-9270725","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-9270725","identity":"rs-9270725","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}