The Stress of Measuring Plantar Tissue Stress in People with Diabetes-Related Foot Ulcers: Biomechanical and Feasibility Findings from Two Prospective Cohort Studies.

Reducing high mechanical stress is imperative to heal diabetes-related foot ulcers. We explored the association of cumulative plantar tissue stress (CPTS) and plantar foot ulcer healing, and the feasibility of measuring CPTS, in two prospective cohort studies (Australia (AU) and The Netherlands (NL)). Both studies used multiple sensors to measure factors to determine CPTS: plantar pressures, weight-bearing activities, and adherence to offloading treatments, with thermal stress response also measured to estimate shear stress in the AU-study. The primary outcome was ulcer healing at 12 weeks. Twenty-five participants were recruited: 13 in the AU-study and 12 in the NL-study. CPTS data were complete for five participants (38%) at baseline and one (8%) during follow-up in the AU-study, and one (8%) at baseline and zero (0%) during follow-up in the NL-study. Reasons for low completion at baseline were technical issues (AU-study: 31%, NL-study: 50%), non-adherent participants (15% and 8%) or combinations (15% and 33%); and at follow-up refusal of participants (62% and 25%). These underpowered findings showed that CPTS was non-significantly lower in people who healed compared with non-healed people (457 [117; 727], 679 [312; 1327] MPa·s/day). Current feasibility of CPTS seems low, given technical challenges and non-adherence, which may reflect the burden of treating diabetes-related foot ulcers.

How to create value with unobtrusive monitoring technology in home-based dementia care: a multimethod study among key stakeholders.

BACKGROUND: There is a growing interest to support extended independent living of people with dementia (PwD) via unobtrusive monitoring (UM) technologies which allow caregivers to remotely monitor lifestyle, health, and safety of PwD. However, these solutions will only be viable if developers obtain a clear picture of how to create value for all relevant stakeholders involved and achieve successful implementation. The aim of this study was therefore to explore the value proposition of UM technology in home-based dementia care and preconditions for successful implementation from a multi-stakeholder perspective. METHODS: We conducted an expert-informed survey among potential stakeholders (n = 25) to identify key stakeholders for UM technology in home-based dementia care. Subsequently, focus groups and semi-structured interviews were conducted among 5 key stakeholder groups (n = 24) including informal caregivers (n = 5), home care professionals (n = 5), PwD (n = 4), directors and managers within home care (n = 4), and policy advisors within the aged care and health insurance sector (n = 6). The sessions addressed the value proposition- and business model canvas and were analyzed using thematic analysis. RESULTS: Stakeholders agreed that UM technology should provide gains such as objective surveillance, timely interventions, and prevention of unnecessary control visits, whereas pains mainly included information overload, unplannable care due to real-time monitoring, and less human interaction. The overall design-oriented need referred to clear situation classifications including urgent care (fall- and wandering detection), non-urgent care (deviations in eating, drinking, sleeping), and future care (risk predictions). Most important preconditions for successful implementation of UM technology included inter-organizational collaboration, a shared vision on re-shaping existing care processes, integrated care ICT infrastructures, clear eligibility criteria for end-users, and flexible care reimbursement systems. CONCLUSIONS: Our findings can guide the value-driven development and implementation of UM technology for home-based dementia care. Stakeholder values were mostly aligned, although stakeholders all had their own perspective on what UM technology should accomplish. Besides, our study highlights the complexity of implementing novel UM technology in home-based dementia care. To achieve successful implementation, organizational and financial preconditions, as well as digital data exchange between home care organizations, will be important.

Improving the Development and Implementation of Audit and Feedback Systems to Support Health Care Workers in Limiting Antimicrobial Resistance in the Hospital: Scoping Review.

BACKGROUND: For eHealth technologies in general and audit and feedback (AF) systems specifically, integrating interdisciplinary theoretical underpinnings is essential, as it increases the likelihood of achieving desired outcomes by ensuring a fit among eHealth technology, stakeholders, and their context. In addition, reporting on the development and implementation process of AF systems, including substantiations of choices, enables the identification of best practices and accumulation of knowledge across studies but is often not elaborated on in publications. OBJECTIVE: This scoping review aims to provide insights into the development and implementation strategies for AF systems for a real-world problem that threatens modern health care-antimicrobial resistance-and provide an interdisciplinary conceptual framework that can serve as a checklist and guidance for making informed choices in the development and implementation of future AF systems. METHODS: A scoping review was conducted by querying PubMed, Scopus, Web of Science, IEEE Xplore Digital Library, and Embase (≥2010) for studies describing either the development or implementation process, or both, of an AF system for antimicrobial resistance or infections in hospitals. Studies reporting only on effectiveness or impact were excluded. A total of 3 independent reviewers performed the study selection, and 2 reviewers constructed the conceptual framework through the axial and selective coding of often-used theories, models, and frameworks (TMFs) from the literature on AF and eHealth development and implementation. Subsequently, the conceptual framework was used for the systematic extraction and interpretation of the studies' descriptions of AF systems and their development and implementation. RESULTS: The search resulted in 2125 studies that were screened for eligibility, of which 12 (0.56%); 2012-2020) were included. These studies described the development and implementation processes heterogeneously in terms of study aims, study targets, target groups, methods, and theoretical underpinnings. Few studies have explicitly explained how choices for the development and implementation of AF systems were substantiated by the TMFs. The conceptual framework provided insights into what is reported on the development and implementation process and revealed underreported AF system constructs (eg, AF system design; engagement with the AF system; and comparison, goal setting, and action planning) and development and implementation (eg, champions) constructs. CONCLUSIONS: This scoping review showed the current heterogeneous reporting of AF systems and their development and implementation processes and exemplified how interdisciplinary TMFs can (and should) be balanced in a conceptual framework to capture relevant AF systems and development and implementation constructs. Thereby, it provides a concrete checklist and overall guidance that supports the professionalization and harmonization of AF system development and implementation. For the development and implementation of future AF systems and other eHealth technologies, researchers and health care workers should be supported in selecting and integrating TMFs into their development and implementation process and encouraged to explicitly report on theoretical underpinnings and the substantiation of choices.

Improved outcomes in patients with diabetic foot ulcers despite of differences in baseline characteristics.

The incidence of diabetes is increasing worldwide with concomitant raising number of patients with diabetic foot disease. Diabetic foot disease treatment has received more attention in the past decades, culminating in the creation of multidisciplinary outpatient clinics, but at the same time, complexity of patients seems to have increased. The aim of this article is to study differences in patient characteristics and outcomes (ulcer healing and ulcer-free survival days) in patients with a diabetic foot ulcer in two prospective cohorts with 15 years in between. Prospective cohort study of all patients in one diabetic foot centre of expertise in 2003-2004 and 2014-2018. Clinical outcomes were determined after a follow-up period of 12 months. Outcomes were differences in baseline characteristics and comorbidities, and differences in ulcer-related outcomes between both cohorts. We included all consecutive diabetic foot ulcer patients from our centre for the period 2003-2004 (n = 79) and 2014-2018 (n = 271). Age (67.0 ± 14.3 vs. 71.6 ± 11.5, p = 0.003) and prevalence of end-stage renal disease (1.3% vs. 7.7%, p = 0.036) were significantly higher in the more recent population. The more recent population had higher healing rate (53.2% vs. 76.4%, p < 0.001), higher median ulcer-free survival days once an ulcer had healed [173 days (IQR 85.3-295.5) vs. 257.0 (IQR 157.0-318.0), p = 0.026], and fewer minor amputations (20.3% vs. 8.1%, p = 0.002). People with diabetic foot ulcers treated in 2014-2018 were older and more frequently diagnosed with ESRD, compared to this population in 2003-2004, while other characteristics were similar; ulcer-related outcomes were better.

Information needs of patients with chronic diseases and their relatives for web-based advance care planning: a qualitative interview study.

BACKGROUND: Advance care planning (ACP) enables persons to identify preferences for future treatment and care, and to discuss, record and review these preferences. However, the uptake of ACP among patients with chronic diseases is relatively low. Web-based ACP programs can support patients and their relatives in ACP. However, information needs of patients and their relatives for ACP are unknown. The aim of this study is to explore information needs of patients with chronic disease and their relatives for web-based ACP. METHODS: We conducted semi-structured interviews with patients with chronic diseases and relatives at their home or at the study center. In three cases, the patient and relative were paired since they preferred to be interviewed together. We asked about information they would search for when to start with ACP, where they would search for information, what search terms they would use on the Internet, and what content and information they would consider important on an ACP website. The interviewer asked participants to clarify their responses during the interview. We used thematic analysis to analyze the interviewees' responses. RESULTS: We interviewed nine patients with different chronic diseases including amyotrophic lateral sclerosis (ALS), multiple sclerosis (MS), chronic obstructive pulmonary disease (COPD) and kidney diseases, and seven relatives, namely partners or (adult) children. The interviewees were aged 24 to 80 years, nine were female and seven were male. Both patients with a chronic disease and relatives mentioned comparable information needs. Many interviewees indicated they would use the Internet to search for information about ACP. Mentioned search terms were "advance care planning", "treatment plan", "disease trajectory" and names of patient associations. Information needs concerned their disease trajectory and quality of life, medical treatment decisions, practical support in arranging care, the concept of ACP and guidance in ACP, communication of treatment and care preferences, peer support of others with chronic diseases, and information for relatives. Many appreciated encouragement of their healthcare providers to take a pro-active role in ACP. CONCLUSIONS: We conclude that information needs for ACP included guidance in ACP, support in making decisions about medical treatment, and practical support in arranging care. We recommend adapting web-based ACP information to the information needs of patients and their relatives to increase its findability, uptake and usefulness.

Integrating People, Context, and Technology in the Implementation of a Web-Based Intervention in Forensic Mental Health Care: Mixed-Methods Study.

BACKGROUND: While eMental health interventions can have many potential benefits for mental health care, implementation outcomes are often disappointing. In order to improve these outcomes, there is a need for a better understanding of complex, dynamic interactions between a broad range of implementation-related factors. These interactions and processes should be studied holistically, paying attention to factors related to context, technology, and people. OBJECTIVE: The main objective of this mixed-method study was to holistically evaluate the implementation strategies and outcomes of an eMental health intervention in an organization for forensic mental health care. METHODS: First, desk research was performed on 18 documents on the implementation process. Second, the intervention's use by 721 patients and 172 therapists was analyzed via log data. Third, semistructured interviews were conducted with all 18 therapists of one outpatient clinic to identify broad factors that influence implementation outcomes. The interviews were analyzed via a combination of deductive analysis using the nonadoption, abandonment, scale-up, spread, and sustainability framework and inductive, open coding. RESULTS: The timeline generated via desk research showed that implementation strategies focused on technical skills training of therapists. Log data analyses demonstrated that 1019 modules were started, and 18.65% (721/3865) of patients of the forensic hospital started at least one module. Of these patients, 18.0% (130/721) completed at least one module. Of the therapists using the module, 54.1% (93/172 sent at least one feedback message to a patient. The median number of feedback messages sent per therapist was 1, with a minimum of 0 and a maximum of 460. Interviews showed that therapists did not always introduce the intervention to patients and using the intervention was not part of their daily routine. Also, therapists indicated patients often did not have the required conscientiousness and literacy levels. Furthermore, they had mixed opinions about the design of the intervention. Important organization-related factors were the need for more support and better integration in organizational structures. Finally, therapists stated that despite its current low use, the intervention had the potential to improve the quality of treatment. CONCLUSIONS: Synthesis of different types of data showed that implementation outcomes were mostly disappointing. Implementation strategies focused on technical training of therapists, while little attention was paid to changes in the organization, design of the technology, and patient awareness. A more holistic approach toward implementation strategies-with more attention to the organization, patients, technology, and training therapists-might have resulted in better implementation outcomes. Overall, adaptivity appears to be an important concept in eHealth implementation: a technology should be easily adaptable to an individual patient, therapists should be trained to deal flexibly with an eMental health intervention in their treatment, and organizations should adapt their implementation strategies and structures to embed a new eHealth intervention.

Correction: Online Guide for Electronic Health Evaluation Approaches: Systematic Scoping Review and Concept Mapping Study.

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Online Guide for Electronic Health Evaluation Approaches: Systematic Scoping Review and Concept Mapping Study.

BACKGROUND: Despite the increase in use and high expectations of digital health solutions, scientific evidence about the effectiveness of electronic health (eHealth) and other aspects such as usability and accuracy is lagging behind. eHealth solutions are complex interventions, which require a wide array of evaluation approaches that are capable of answering the many different questions that arise during the consecutive study phases of eHealth development and implementation. However, evaluators seem to struggle in choosing suitable evaluation approaches in relation to a specific study phase. OBJECTIVE: The objective of this project was to provide a structured overview of the existing eHealth evaluation approaches, with the aim of assisting eHealth evaluators in selecting a suitable approach for evaluating their eHealth solution at a specific evaluation study phase. METHODS: Three consecutive steps were followed. Step 1 was a systematic scoping review, summarizing existing eHealth evaluation approaches. Step 2 was a concept mapping study asking eHealth researchers about approaches for evaluating eHealth. In step 3, the results of step 1 and 2 were used to develop an "eHealth evaluation cycle" and subsequently compose the online "eHealth methodology guide." RESULTS: The scoping review yielded 57 articles describing 50 unique evaluation approaches. The concept mapping study questioned 43 eHealth researchers, resulting in 48 unique approaches. After removing duplicates, 75 unique evaluation approaches remained. Thereafter, an "eHealth evaluation cycle" was developed, consisting of six evaluation study phases: conceptual and planning, design, development and usability, pilot (feasibility), effectiveness (impact), uptake (implementation), and all phases. Finally, the "eHealth methodology guide" was composed by assigning the 75 evaluation approaches to the specific study phases of the "eHealth evaluation cycle." CONCLUSIONS: Seventy-five unique evaluation approaches were found in the literature and suggested by eHealth researchers, which served as content for the online "eHealth methodology guide." By assisting evaluators in selecting a suitable evaluation approach in relation to a specific study phase of the "eHealth evaluation cycle," the guide aims to enhance the quality, safety, and successful long-term implementation of novel eHealth solutions.

The Feasibility and Effectiveness of Web-Based Advance Care Planning Programs: Scoping Review.

BACKGROUND: Advance care planning (ACP) is a process with the overall aim to enhance care in concordance with patients' preferences. Key elements of ACP are to enable persons to define goals and preferences for future medical treatment and care, to discuss these with family and health care professionals, and to document and review these if appropriate. ACP is usually conducted through personal conversations between a health care professional, a patient, and-if appropriate-family members. Although Web-based ACP programs have the potential to support patients in ACP, their effectiveness is unknown. OBJECTIVE: This study aimed to assess the feasibility and effectiveness of Web-based, interactive, and person-centered ACP programs. METHODS: We systematically searched for quantitative and qualitative studies evaluating Web-based, interactive, and person-centered ACP programs in seven databases including EMBASE, Web of Science, Cochrane Central and Google Scholar. Data on the characteristics of the ACP programs' content (using a predefined list of 10 key elements of ACP), feasibility, and effectiveness were extracted using a predesigned form. RESULTS: Of 3434 titles and abstracts, 27 studies met the inclusion criteria, evaluating 11 Web-based ACP programs-10 were developed in the United States and one in Ireland. Studied populations ranged from healthy adults to patients with serious conditions. Programs typically contained the exploration of goals and values (8 programs), exploration of preferences for treatment and care (11 programs), guidance for communication about these preferences with health care professionals or relatives (10 programs), and the possibility to generate a document in which preferences can be recorded (8 programs). Reportedly, participants were satisfied with the ACP programs (11/11 studies), considering them as easy to use (8/8 studies) and not burdensome (7/8 studies). Designs of 13 studies allowed evaluating the effectiveness of five programs. They showed that ACP programs significantly increased ACP knowledge (8/8 studies), improved communication between patients and their relatives or health care professionals (6/6 studies), increased ACP documentation (6/6 studies), and improved concordance between care as preferred by the patients and the decisions of clinicians and health care representatives (2/3 studies). CONCLUSIONS: Web-based, interactive, and person-centered ACP programs were mainly developed and evaluated in the United States. They contained the key elements of ACP, such as discussing and documenting goals and preferences for future care. As participants considered programs as easy to use and not burdensome, they appeared to be feasible. Among the 13 studies that measured the effectiveness of programs, improvement in ACP knowledge, communication, and documentation was reported. The concordance between preferred and received care is yet understudied. Studies with high-quality study designs in different health care settings are warranted to further establish the feasibility and effectiveness of Web-based ACP programs.

Creating value with eHealth: identification of the value proposition with key stakeholders for the resilience navigator app.

BACKGROUND: For a stress-management app to be persuasive and impactful, designers and developers should obtain a clear perspective of the value proposition according to key stakeholders before development. However, this is often not the case. In order to increase the chance of creating an impact by means of the Resilience Navigator app, this study aims to identify key stakeholders and work with them to gain an in-depth understanding of the value proposition of this stress-management app. METHODS: The approach used in this study builds on the approaches taken by Van Limburg et al. and Van Woezik et al. An initial list of stakeholders was identified by means of a literature scan. Stakeholders on this initial list took an online survey to identify key stakeholders with a ranking system. Semi-structured interviews were conducted with a subset of key stakeholders to identify the value proposition using the value proposition canvas as a framework for data collection. Finally, the value proposition was validated by key stakeholders during focus groups. RESULTS: The key stakeholders identified included employees, employers, participation councils within organisations, HR advisors, product owners, company doctors, and business analysts. The interviews produced a list of approximately one hundred values from which fifteen core values were distilled. One example is to take into account time constraints experienced by users during stress periods. In general, the Resilience Navigator app's main goal is to increase awareness of personal stress levels and causes of stress. In addition, the sub-goal is to increase skills for effective stress management. The focus groups validated the idea that the most important values were reflected in the value proposition and had been appropriately translated into design elements, according to key stakeholders. CONCLUSIONS: A thorough, bottom-up identification and validation of the value proposition for the Resilience Navigator app was obtained, reflecting key stakeholders' varying ideas on this piece of eHealth technology. The results will facilitate the continued development of the Resilience Navigator app from the value specification phase to the design phase. In the design phase, the remaining assumptions regarding the app's value proposition should be tested using rapid prototyping.

The Importance of Systematically Reporting and Reflecting on eHealth Development: Participatory Development Process of a Virtual Reality Application for Forensic Mental Health Care.

BACKGROUND: The use of electronic health (eHealth) technologies in practice often is lower than expected, mostly because there is no optimal fit among a technology, the characteristics of prospective users, and their context. To improve this fit, a thorough systematic development process is recommended. However, more knowledge about suitable development methods is necessary to create a tool kit that guides researchers in choosing development methods that are appropriate for their context and users. In addition, there is a need for reflection on the existing frameworks for eHealth development to be able to constantly improve them. OBJECTIVE: The two main objectives of this case study were to present and reflect on the (1) methods used in the development process of a virtual reality application for forensic mental health care and (2) development model that was used: the CeHRes Roadmap (the Centre for eHealth Research Roadmap). METHODS: In the development process, multiple methods were used to operationalize the first 2 phases of the CeHRes Roadmap: the contextual inquiry and value specification. To summarize the most relevant information for the goals of this study, the following information was extracted per method: (1) research goal, (2) explanation of the method used, (3) main results, (4) main conclusions, and (5) lessons learned about the method. RESULTS: Information on 10 methods used is presented in a structured manner. These 10 methods were stakeholder identification, project team composition, focus groups, literature study, semistructured interviews, idea generation with scenarios, Web-based questionnaire, value specification, idea generation with prototyping, and a second round of interviews. The lessons learned showed that although each method added new insights to the development process, not every method appeared to be the most appropriate for each research goal. CONCLUSIONS: Reflection on the methods used pointed out that brief methods with concrete examples or scenarios fit the forensic psychiatric patients the best, among other things, because of difficulties with abstract reasoning and low motivation to invest much time in participating in research. Formulating clear research questions based on a model's underlying principles and composing a multidisciplinary project team with prospective end users appeared to be important in this study. The research questions supported the project team in keeping the complex development processes structured and prevented tunnel vision. With regard to the CeHRes Roadmap, continuous stakeholder involvement and formative evaluations were evaluated as strong points. A suggestion to further improve the Roadmap is to explicitly integrate the use of domain-specific theories and models. To create a tool kit with a broad range of methods for eHealth development and further improve development models, studies that report and reflect on development processes in a consistent and structured manner are needed.

eHealth and quality in health care: implementation time.

The use of information and communication technologies in health and health care could improve healthcare quality in many ways. Today's evidence base demonstrates the (cost-)effectiveness of online education, self-management support and tele-monitoring in several domains of health and care. While new results gradually provide more evidence for eHealth's impact on quality issues, now is the time to come to grips with implementation issues. Documented drawbacks such as low acceptance, low adoption or low adherence need our attention today to make the most of eHealth' potential. Improvement science is beginning to deliver the tools to address these persistent behavioural and cultural issues. The ceHRes Roadmap, for instance, is a plural and pragmatic approach that includes users' needs. It is now imperative to improve our implementation strategies in order to scale up eHealth technologies. This will accelerate the much needed transformation of our healthcare systems and sustain access, affordability and quality for all in the near future.

Blending online therapy into regular face-to-face therapy for depression: content, ratio and preconditions according to patients and therapists using a Delphi study.

BACKGROUND: Blending online modules into face-to-face therapy offers perspectives to enhance patient self-management and to increase the (cost-)effectiveness of therapy, while still providing the support patients need. The aim of this study was to outline optimal usage of blended care for depression, according to patients and therapists. METHODS: A Delphi method was used to find consensus on suitable blended protocols (content, sequence and ratio). Phase 1 was an explorative phase, conducted in two rounds of online questionnaires, in which patients' and therapists' preferences and opinions about online psychotherapy were surveyed. In phase 2, data from phase 1 was used in face-to-face interviews with therapists to investigate how blended therapy protocols could be set up and what essential preconditions would be. RESULTS: Twelve therapists and nine patients completed the surveys. Blended therapy was positively perceived among all respondents, especially to enhance the self-management of patients. According to most respondents, practical therapy components (assignments, diaries and psycho-education) may be provided via online modules, while process-related components (introduction, evaluation and discussing thoughts and feelings), should be supported face-to-face. The preferred blend of online and face-to-face sessions differs between therapists and patients; most therapists prefer 75% face-to-face sessions, most patients 50 to 60%. The interviews showed that tailoring treatment to individual patients is essential in secondary mental health care, due to the complexity of their problems. The amount and ratio of online modules needs to be adjusted according to the patient's problems, skills and characteristics. Therapists themselves should also develop skills to integrate online and face-to-face sessions. CONCLUSIONS: Blending online and face-to-face sessions in an integrated depression therapy is viewed as a positive innovation by patients and therapists. Following a standard blended protocol, however, would be difficult in secondary mental health care. A database of online modules could provide flexibility to tailor treatment to individual patients, which asks motivation and skills of both patients and therapists. Further research is necessary to determine the (cost-)effectiveness of blended care, but this study provides starting points and preconditions to blend online and face-to-face sessions and create a treatment combining the best of both worlds.

eHealth implementation in Europe: a scoping review on legal, ethical, financial, and technological aspects.

Background: The evolution of eHealth development has shifted from standalone tools to comprehensive digital health environments, fostering data exchange among diverse stakeholders and systems. Nevertheless, existing research and implementation frameworks have primarily emphasized technological and organizational aspects of eHealth implementation, overlooking the intricate legal, ethical, and financial considerations. It is essential to discover what legal, ethical, financial, and technological challenges should be considered to ensure successful and sustainable implementation of eHealth. Objective: This review aims to provide insights into barriers and facilitators of legal, ethical, financial, and technological aspects for successful implementation of complex eHealth technologies, which impacts multiple levels and multiple stakeholders. Methods: A scoping review was conducted by querying PubMed, Scopus, Web of Science, and ACM Digital Library (2018-2023) for studies describing the implementation process of eHealth technologies that facilitate data exchange. Studies solely reporting clinical outcomes or conducted outside Europe were excluded. Two independent reviewers selected the studies. A conceptual framework was constructed through axial and inductive coding, extracting data from literature on legal, ethical, financial, and technological aspects of eHealth implementation. This framework guided systematic extraction and interpretation. Results: The search resulted in 7.308 studies that were screened for eligibility, of which 35 (0.48%) were included. Legal barriers revolve around data confidentiality and security, necessitating clear regulatory guidelines. Ethical barriers span consent, responsibility, liability, and validation complexities, necessitating robust frameworks. Financial barriers stem from inadequate funding, requiring (commercial) partnerships and business models. Technological issues include interoperability, integration, and malfunctioning, necessitating strategies for enhancing data reliability, improving accessibility, and aligning eHealth technology with existing systems for smoother integration. Conclusions: This research highlights the multifaceted nature of eHealth implementation, encompassing legal, ethical, financial, and technological considerations. Collaborative stakeholder engagement is paramount for effective decision-making and aligns with the transition from standalone eHealth tools to integrated digital health environments. Identifying suitable stakeholders and recognizing their stakes and values enriches implementation strategies with expertise and guidance across all aspects. Future research should explore the timing of these considerations and practical solutions for regulatory compliance, funding, navigation of responsibility and liability, and business models for reimbursement strategies.

From theory to practice in implementation science: qualitative insights from the implementation model developed by a commercial eMental Health provider.

BACKGROUND: Although eMental health interventions are a viable solution to address disparities in access to mental healthcare and increase its efficiency, they still face challenges of implementation. Literature highlights numerous barriers such as diffusion of responsibility and unclear expectations of what implementation entails might hinder this process. While research mostly focuses on analyzing these barriers, there is an urgent need to increase uptake in practice. In turn, commercial companies focus mostly on increasing uptake, while overlooking research outputs. To bridge the gap between research and practice, attention to how implementation occurs in practice is required. This study investigates "Make it Happen" (MiH), the implementation model developed by the eMental Health company Minddistrict, aiming to gain more insight into operationalizing implementation frameworks by 1) describing MiH and its conceptual underpinnings, and 2) gaining lessons learned from the development of MiH. Ultimately, this work aims at improving existing scientific frameworks by extending them with knowledge from practice. METHODS: First, individual interviews and focus groups with Minddistrict implementation managers were performed. Second, individual interviews with project leads in mental healthcare organizations that were involved in the implementation of Minddistrict were conducted. Within Minddistrict, 7 implementation managers and account managers were involved, in addition to 11 project leads from mental healthcare organizations. Data were elaborated with thematic analysis. RESULTS: A comprehensive description of MiH and its 5 main phases was achieved. During the 1) Onboarding phase, implementing organizations are guided by Minddistrict to build a team responsible for implementation, which then 2) designs patient and client journeys, 3) builds, tailors and configures their offer, 4) trains key-users and, 5) evaluates the success of implementation. All participants had extensive and aligned definitions and articulated expectations on implementation. Points of improvement for the model such as role ambiguity and excessive workload were identified. As strengths, internal motivation and good relationships with the provider were valued. CONCLUSION: The present study highlights the importance of clear role division and stakeholder engagement in implementation processes, and suggest that a strong collaboration between companies and academia could optimize implementation efforts and ensure a better fit between humans, context, and technologies.

Positive effects of audit and feedback on antimicrobial use in hospitalized patients limited to audited patients.

Objective: Audit and feedback is an antimicrobial stewardship (AMS) strategy, with the potential to also optimize antimicrobial use in non-audited patients. This study aimed to determine whether audit and feedback reduce antimicrobial use in both audited and non-audited patients. Design: Before-after trial with a 1-year intervention period and 2.5-year historical cohort. Setting: 750-bed community hospital in the Netherlands. Patients: All patients admitted to the urology wards during the 3.5-year study period were observed. Patients were classified as using antimicrobials if any antimicrobial was used for therapeutic reasons. Patients using antimicrobials prophylactically were excluded from measurements. Intervention: The AMS team provided audit and feedback on antimicrobial use for patients using antimicrobials for 2 days. Retrospectively, antimicrobial use and length of stay (LOS) were compared with the historical cohort. Results: Audits modified antimicrobial treatment in 52.8% of the cases. De-escalating, stopping, and switching from intravenous to oral treatment accounted for 72% of these modifications. Compared to patients from the cohort, who also used antimicrobials for 2 days, antimicrobial use decreased from 14.21 DDD/patient (95% CI, 13.08-15.34) to 11.45 DDD/patient (95% CI, 8.26-14.64; P = .047) for audited patients. Furthermore, mean LOS decreased from 7.42 days (95% CI, 6.79-8.06) to 6.13 days (95% CI, 5.38-6.89; P = .031). However, looking at all patients admitted to the urology wards, the percentage of patients using antimicrobials and total antimicrobial use remained unchanged. Conclusions: Audit and feedback reduce antimicrobial use and LOS, but only for audited patients. Positive effects are not automatically transferred to patients for whom no audits have been performed.

Understanding acceptance of contactless monitoring technology in home-based dementia care: a cross-sectional survey study among informal caregivers.

Background: There is a growing interest to support home-based dementia care via contactless monitoring (CM) technologies which do not require any body contact, and allow informal caregivers to remotely monitor the health and safety of people with dementia (PwD). However, sustainable implementation of CM technologies requires a better understanding of informal caregivers' acceptance. This study aimed to examine the (1) general acceptance of CM technology for home-based dementia care, (2) acceptance of different sensor types and use scenarios, and (3) differences between accepters and refusers of CM technology. Method: A cross-sectional online survey was conducted among n = 304 informal caregivers of community-dwelling PwD [Mean(SD) age = 58.5 (10.7)] in the Netherlands and Germany. The survey contained a textual and graphical introduction to CM technologies, as well as questions targeting (1) general acceptance of CM technology, (2) acceptance of seven different contactless sensor types, (3) acceptance of five different use scenarios, and (4) caregivers' own and their care recipients' personal characteristics. Data were examined using descriptive and bivariate analyses. Results: Participants' general acceptance of CM technology was slightly positive. We found significant differences in acceptability between contactless sensor types (p < .001). RF-based sensors (e.g., radar) and light sensors were considered most acceptable, whereas camera-based sensors and audio sensors (e.g., microphones, smart speakers) were seen as least acceptable for home-based dementia care. Furthermore, participants' acceptance of different use scenarios for CM technology varied significantly (p < .001). The intention to use CM technology was highest for detecting emergencies (e.g., falls, wandering), and lowest for predicting acute situations (e.g., fall prediction). Lastly, accepters and refusers of CM technology significantly differed regarding gender (p = .010), their relation with the PwD (p = .003), eHealth literacy (p = .025), personal innovativeness (p < .001), usage of safety technology (p = .002), and the PwD's type of cognitive impairment (p = .035) and housing situation (p = .023). Conclusion: Our findings can inform the development and implementation of acceptable CM technology to support home-based dementia care. Specifically, we show which sensor types and use scenarios should be prioritized from the informal caregiver's view. Additionally, our study highlights several personal characteristics associated with informal caregivers' acceptance of CM technology that should be taken into account during implementation.

Designing and Evaluating IT Applications for Informal Caregivers: Protocol for a Scoping Review.

BACKGROUND: A growing number of informal caregivers in many countries are important for effective functioning of health care in our society. Hence, they must receive the required support and services to continue providing care. IT applications can be used to support informal caregivers in their caregiving activities. However, evidence-informed guidelines for developing such IT applications and their evaluation are scarce. Hence, this scoping review can aid researchers and designers by providing design recommendations for IT apps for caregivers and potentially improve the design of IT applications for caregivers to meet their needs better. OBJECTIVE: This study aims to describe the proposal for a scoping review of current practices and recommendations in designing and evaluating IT applications for informal caregivers. The scoping review will also discuss the opportunities and challenges in designing these IT applications. METHODS: We will use a 5-step scoping review methodology to map relevant literature published as follows: (1) identify the research question, (2) identify relevant studies, (3) select relevant studies for review, (4) chart the data from selected literature, and (5) summarize and report results. A structured search will be conducted in PubMed, Scopus, IEEE digital library, Web of Science, and ACM Digital Library databases. In addition, hand searches of reference lists and keyword searches in Google Scholar will also be conducted. Inclusion criteria will be researched (journal and conference) articles focused on IT applications designed for use by informal caregivers and study type to be qualitative studies. Two reviewers will independently identify articles for review and extract data. Conflicts will be discussed, and a third reviewer will be consulted if a consensus cannot be reached. These data will be analyzed using thematic analysis. RESULTS: The results from this scoping review will be presented in a narrative form, and additional data on study characteristics will be presented in diagrams or tabular format. Uppsala University first initiated this scoping review protocol in December 2021 as part of the European Union-funded project ENTWINE. This work was also supported by the Swedish Research Council and the Swedish Cancer Society. The results will be presented in August 2023 and will be disseminated through a report to the European Union and a peer-reviewed journal publication. In addition, the team plans to share its findings on various public platforms, including social media, blog posts, and relevant conferences and workshops. CONCLUSIONS: This is, to our knowledge, the first study to map the literature on the design and evaluation of IT applications for informal caregivers. The scoping review's results will detail the requirements, design suggestions, and user preferences, as well as the usability criteria and features of IT applications for informal caregivers. A mapping of studies could inform the design and implementation of future IT applications for informal caregivers. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): DERR1-10.2196/47650.

Design suggestions for a persuasive e-coaching application: A study on informal caregivers' needs.

Objective: Informal caregivers such as relatives or close friends of patients are essential for caregiving at home. However, caregiving is a complex experience that may affect the caregivers' well-being. Therefore, there is a need to provide support for caregivers, which we address in this article by proposing design suggestions for an e-coaching application. This study identifies the unmet needs of caregivers in Sweden and provides design suggestions for an e-coaching application using the persuasive system design (PSD) model. The PSD model offers a systematic approach to designing IT interventions. Methods: A qualitative research design was used, and semi-structured interviews were conducted with 13 informal caregivers from different municipalities in Sweden. A thematic analysis was performed to analyze the data. The PSD model was used to map the needs emerging from this analysis to propose design suggestions for an e-coaching application for caregivers. Results: Six needs were identified, and based on them, we proposed design suggestions for an e-coaching application using the PSD model. These unmet needs are monitoring and guidance, assistance to avail formal care services, access to practical information without being overwhelmed, feeling of community, access to informal support, and grief acceptance. The last two needs could not be mapped using the existing PSD model, resulting in an extended PSD model. Conclusion: This study revealed the important needs of informal caregivers based on which design suggestions for an e-coaching application were presented. We also proposed an adapted PSD model. This adapted PSD model can be further used for designing digital interventions in caregiving.

Implementation of eMental health technologies for informal caregivers: A multiple case study.

Introduction: Informal caregivers offer continuous unpaid support to loved ones who are unable to live independently. Providing care can be a very burdensome commitment, that heavily impacts informal caregivers' mental health. eMental health is a possible, yet challenging, solution to improve caregivers' mental health and their overall experience of caregiving. In fact, eMental health technologies often face challenges of implementation. The present work gathers knowledge on how to best deal with these challenges by collecting testimonies of implementation experts of eight eMental health technologies for informal caregivers with the aim of comparing them and extracting lessons learned. Methods: For this multiple case study, technologies were selected (through informal suggestions and independent search) according to the following inclusion criteria: they were intended for informal caregivers as main user group, were aimed at improving informal caregivers' mental wellbeing and caregiving experience and were available and running in real life settings in Europe. Ten interviews were conducted (two pilots and eight included cases). The interviewees were asked to provide a description of the technology and its aims and their implementation approach, method and frameworks used. Finally, determinants of implementation, the influence of the Covid-19 pandemic on implementation processes and lessons learned were investigated. Results: The results highlight key differences between technologies developed within academia and the industry regarding efficacy testing and use and use and choice of frameworks. Also, similarities in terms of recognized barriers such as financing are illustrated. Discussion: Possible ways to overcome main barriers and examples of best practices, such as structuring a business model and discussing tool maintenance and long-term hosting in advance, are discussed.