Exploring the added value of virtual reality biofeedback game DEEP in forensic psychiatric inpatient care-A qualitative study.

Background: Low motivation and suboptimal cognitive skills are common among forensic psychiatric patients. By focusing on doing and experiencing, innovative technologies could offer an alternative to existing treatment for this patient group. One promising technology is DEEP, a VR biofeedback game that teaches diaphragmatic breathing, which has shown its potential in reducing stress in other populations. This exploratory study aimed at identifying if, how and for whom DEEP can be of added value in forensic mental healthcare. Methods: This study used a qualitative approach. Six focus groups with 24 healthcare providers and 13 semi-structured interviews with forensic psychiatric inpatients were conducted in two Dutch forensic mental healthcare organizations. All healthcare providers and patients experienced DEEP before participating. The data were coded inductively, using the method of constant comparison. Results: The data revealed six themes with accompanying (sub)codes, including (1) the possible advantages and (2) disadvantages of DEEP, (3) patient characteristics that could make DEEP more or (4) less suitable and beneficial, (5) ways DEEP could be used in current treatment, and (6) conditions that need to be met to successfully implement DEEP in forensic mental healthcare. The results showed that DEEP can offer novel ways to support forensic psychiatric patients in coping with negative emotions by practicing diaphragmatic breathing. Its appealing design might be suitable to motivate a broad range of forensic psychiatric patient groups. However, DEEP cannot be personalized, which might decrease engagement and uptake of DEEP long-term. Regarding its place in current care, DEEP could be structurally integrated in existing treatment programs or used ad hoc when the need arises. Finally, this study showed that both healthcare providers and patients would need practical support and information to use DEEP. Conclusion: With its experience-based and gamified design, DEEP could be useful for forensic mental healthcare. It is recommended that patients and healthcare providers are included in the evaluation and implementation from the start. Besides, a multilevel approach should be used for formulating implementation strategies. If implemented well, DEEP can offer new ways to provide forensic psychiatric patients with coping strategies to better control their anger.

Compassion apps for better mental health: qualitative review.

BACKGROUND: There is increasing empirical evidence for the positive mental health effects of compassion-based interventions. Although numerous smartphone apps offering compassion-based interventions ('compassion apps') are now available for the general public, the quality of these apps has not yet been reviewed. A qualitative review of existing compassion apps serves as a crucial first step toward testing the efficacy of these apps, by identifying good-quality compassion apps that might be worth the investment of a scientific trial. AIMS: The current study focuses on reviewing the quality of existing compassion apps. METHOD: Existing compassion apps were identified through searches in the Google Play Store and App Store. The 24 included apps were reviewed on their quality by using the Mobile App Rating Scale, and on their consistency with current evidence by comparing them to existing and studied compassion-based interventions. RESULTS: Of the 24 included apps, eight were identified that met the criteria of being consistent with existing and studied compassion-based interventions, and acceptable to good overall quality. The other 16 apps failed to meet one or both of these criteria. CONCLUSIONS: Good-quality compassion apps are available, but many of the available apps fail to meet certain quality criteria. In particular, many apps failed to offer sufficient relevant and correct information, or failed to offer this information in an entertaining and interesting way. It is recommended that future compassion apps are based on a clear definition of compassion, offer evidence- and theory-based exercises and implement tools for increasing engagement.

Implementation of virtual reality in healthcare: a scoping review on the implementation process of virtual reality in various healthcare settings.

BACKGROUND: Virtual reality (VR) is increasingly used in healthcare settings as recent technological advancements create possibilities for diagnosis and treatment. VR is a technology that uses a headset to simulate a reality in which the user is immersed in a virtual environment, creating the impression that the user is physically present in this virtual space. Despite the potential added value of virtual reality technology in healthcare, its uptake in clinical practice is still in its infancy and challenges arise in the implementation of VR. Effective implementation could improve the adoption, uptake, and impact of VR. However, these implementation procedures still seem to be understudied in practice. This scoping review aimed to examine the current state of affairs in the implementation of VR technology in healthcare settings and to provide an overview of factors related to the implementation of VR. METHODS: To give an overview of relevant literature, a scoping review was undertaken of articles published up until February 2022, guided by the methodological framework of Arksey and O'Malley (2005). The databases Scopus, PsycINFO, and Web of Science were systematically searched to identify records that highlighted the current state of affairs regarding the implementation of VR in healthcare settings. Information about each study was extracted using a structured data extraction form. RESULTS: Of the 5523 records identified, 29 were included in this study. Most studies focused on barriers and facilitators to implementation, highlighting similar factors related to the behavior of adopters of VR and the practical resources the organization should arrange for. However, few studies focus on systematic implementation and on using a theoretical framework to guide implementation. Despite the recommendation of using a structured, multi-level implementation intervention to support the needs of all involved stakeholders, there was no link between the identified barriers and facilitators, and specific implementation objectives or suitable strategies to overcome these barriers in the included articles. CONCLUSION: To take the implementation of VR in healthcare to the next level, it is important to ensure that implementation is not studied in separate studies focusing on one element, e.g., healthcare provider-related barriers, as is common in current literature. Based on the results of this study, we recommend that the implementation of VR entails the entire process, from identifying barriers to developing and employing a coherent, multi-level implementation intervention with suitable strategies. This implementation process could be supported by implementation frameworks and ideally focus on behavior change of stakeholders such as healthcare providers, patients, and managers. This in turn might result in increased uptake and use of VR technologies that are of added value for healthcare practice.

Strength Back - A qualitative study on the co-creation of a positive psychology digital health intervention for spinal surgery patients.

Introduction: Spinal surgery patients often experience pain as well as stress, anxiety or even depression before surgery, highlighting the need for better mental preparation before undergoing surgery. Acceptance and Commitment Therapy and positive psychology have proven effective in coping with chronic pain and providing long-term skills that enhance psychological flexibility and mental well-being.The aim of this study is to develop a digital intervention (app) based on Acceptance and Commitment Therapy and positive psychology in co-creation with all stakeholders, including patients and professionals. The aim of the intervention is to increase psychological flexibility and positive skills of spinal surgery patients to promote long-term resilience. Materials and methods: In this qualitative study, individual, semi-structured interviews were held with healthcare professionals (N = 9) and spinal surgery patients (N = 12) to identify contextual factors and needs for the app. Subsequently, three focus-group sessions were held with healthcare professionals and newly recruited patients to specify relevant values. Also, a first version of the app, named Strength Back, was developed using a participatory design. Results: The interviews confirmed the need for information and digital support to cope with insecurity, anxiety and pain, both before and after surgery. Based on iterative steps in the focus-group sessions, thirteen modules were developed focusing on procedural information, pain education, psychological flexibility and mental well-being. Discussion: The intervention Strength Back, containing information as well as Acceptance and Commitment Therapy and positive psychology exercises, has the potential to increase psychological flexibility, enhance well-being and improve postoperative recovery after spinal surgery.

A Mobile Self-control Training App to Improve Self-control and Physical Activity in People With Severe Mental Illness: Protocol for 2 Single-Case Experimental Designs.

BACKGROUND: Lack of physical activity is a common issue with detrimental consequences for the health of people with severe mental illness (SMI). Existing physical activity interventions show suboptimal effects as they require substantial cognitive skills, including goal setting and writing, whereas cognitive deficits are common in this population. To bolster the effectiveness of physical activity interventions, self-control training (SCT), in which users practice the ability to override unwanted thoughts and behaviors, can be used in addition. Recent research has demonstrated the initial effectiveness of a mobile SCT app, but this has not been studied in psychiatric clinical practice. OBJECTIVE: This study aims to evaluate to what extent adding a mobile SCT app designed for and with people with SMI to a mobile lifestyle intervention aimed at increasing physical activity increases physical activity and self-control levels. METHODS: A mixed methods approach incorporating 2 single-case experimental designs (SCEDs) and qualitative interviews was used to evaluate and optimize SCT. Overall, 12 participants with SMI will be recruited from 2 organizations offering outpatient and inpatient care to people with SMI. Each experiment will include 6 patients. SCED I is a concurrent multiple-baseline design across participants that explores initial effectiveness and optimal intervention duration. Using accelerometry and experience sampling questionnaires, participants' physical activity and self-control will be monitored for ≥5 days from baseline, followed by the sequential introduction of Google Fit, the physical activity intervention, for 7 days and the addition of SCIPP: Self-Control Intervention App for 28 days. SCED II is an introduction/withdrawal design in which optimized SCT will be introduced and withdrawn to validate the findings from SCED I. In both experiments, the daily average of total activity counts per hour and the state level of self-control will serve as the primary and secondary outcome measures. Data will be analyzed using visual analysis and piecewise linear regression models. RESULTS: The study was designated as not subject to the Dutch Medical Research Involving Human Subjects Act by the Medical Research Ethical Committee Oost-Nederland and approved by the Ethics Committee/domain Humanities and Social Sciences of the Faculty of Behavioural, Management, and Social Sciences at the University of Twente. Participant recruitment started in January 2022, and we expect to publish the results in early 2023. CONCLUSIONS: The mobile SCT app is expected to be feasible and effective. It is self-paced and scalable and can increase patient motivation, making it a suitable intervention for people with SMI. SCED is a relatively novel yet promising method for gaining insights into whether and how mobile apps work that can handle heterogeneous samples and makes it possible to involve a diverse population with SMI without having to include a large number of participants. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): PRR1-10.2196/37727.

The Role of Compassionate Technology in Blended and Digital Mental Health Interventions: Systematic Scoping Review.

BACKGROUND: An essential value in mental health care is compassion: awareness of suffering, tolerating difficult feelings in the face of suffering, and acting or being motivated to alleviate suffering. Currently, technologies for mental health care are on the rise and could offer several advantages, such as more options for self-management by clients and more accessible and economically viable care. However, digital mental health interventions (DMHIs) have not been widely implemented in daily practice. Developing and evaluating DMHIs around important mental health care values, such as compassion, could be key for a better integration of technology in the mental health care context. OBJECTIVE: This systematic scoping review explored the literature for previous instances where technology for mental health care has been linked to compassion or empathy to investigate how DMHIs can support compassion in mental health care. METHODS: Searches were conducted in the PsycINFO, PubMed, Scopus, and Web of Science databases, and screening by 2 reviewers resulted in 33 included articles. From these articles, we extracted the following data: technology types, goals, target groups, and roles of the technologies in the intervention; study designs; outcome measures; and the extent to which the technologies met a 5-step proposed definition of compassion. RESULTS: We found 3 main ways in which technology can contribute to compassion in mental health care: by showing compassion to people, by enhancing self-compassion in people, or by facilitating compassion between people. However, none of the included technologies met all 5 elements of compassion nor were they evaluated in terms of compassion. CONCLUSIONS: We discuss the potential of compassionate technology, its challenges, and the need to evaluate technology for mental health care on compassion. Our findings could contribute to the development of compassionate technology, in which elements of compassion are explicitly embedded in its design, use, and evaluation.

Why patients diagnosed with bipolar disorder start, continue or discontinue health-related apps supporting their self-management.

WHAT IS KNOWN ABOUT THE SUBJECT?: Self-management is essential in the treatment of those who have bipolar disorder. There are many apps to support self-management, but we know that these apps only sometimes cover the users' needs. WHAT IS ADDED TO EXISTING KNOWLEDGE?: In our research, we made an inventory of apps that people with bipolar disorder use to cover their needs in self-management. We also have searched for the reasons to start, continue, switch or quit the use of those apps. We found that 44% (n = 18) of our respondents use health-related apps for self-management purposes. Apps for physical activity, planning and structure and apps for relaxation were most used. In the use of apps, the "freedom of choice" and user-friendliness are the most important in continuing the use of apps, while malfunctioning and "not fitting in individual needs" the main reasons were for quitting the use of apps. IMPLICATIONS FOR PRACTICE: Various apps can be used for self-management purposes as long as these apps meet the individual user's requirements. Clinicians and patients should have a broad view when looking for suitable apps and not limit the search to just professional apps. In developing new apps, patients, clinicians and developers should collaborate in the development process, requirements and design. ABSTRACT: INTRODUCTION: Self-management is one of the cornerstones in the treatment of bipolar disorder (BD). Complementing interventions by apps are seen as a good opportunity to support self-management. However, there is insufficient knowledge about understanding the use of health-related applications by consumers with BD for self-management purposes. AIM: The study aims to gain insight from patients diagnosed with BD about reasons to use, continue or discontinue health-related apps. METHOD: This study employed a mixed-method design in which 41 participants diagnosed with BD participated in a quantitative survey, and 11 participants also participated in an in-depth interview. RESULTS: The survey showed that 44% (n = 18) of the participants use health-related apps, and 26.8% (n = 11) use those apps consistently. Interviews revealed that adjustability, usability, trustworthiness and the guarantee of privacy were the main reasons determining whether participants used or terminated the use of a health-related app. IMPLICATIONS FOR PRACTICE: Although we found that a substantial number of patients diagnosed with BD use one or more apps to support self-management, their use is often discontinued due to content that needs more robust to address their needs. Besides appropriate content, tailoring and persuasive technologies will likely promote the continued use of an app for self-management purposes. Cooperation between those diagnosed with bipolar disorder and health professionals (like mental health nurses) in developing and designing applications that are aimed to support self-management in BD is necessary for successful implementation and adaptation.

Challenges and opportunities in mobile e-coaching.

Background: Mobile e-health technologies have proven to provide tailored assessment, intervention, and coaching capabilities for various usage scenarios. Thanks to their spread and adoption, smartphones are one of the most important carriers for such applications. Problem: However, the process of design, realization, evaluation, and implementation of these e-health solutions is wicked and challenging, requiring multiple stakeholders and expertise. Method: Here, we present a tailorable intervention and interaction e-health solution that allows rapid prototyping, development, and evaluation of e-health interventions at scale. This platform allows researchers and clinicians to develop ecological momentary assessment, just-in-time adaptive interventions, ecological momentary intervention, cohort studies, and e-coaching and personalized interventions quickly, with no-code, and in a scalable way. Result: The Twente Intervention and Interaction Instrument (TIIM) has been used by over 320 researchers in the last decade. We present the ecosystem and synthesize the main scientific output from clinical and research studies in different fields. Discussion: The importance of mobile e-coaching for prediction, management, and prevention of adverse health outcomes is increasing. A profound e-health development strategyand strategic, technical, and operational investments are needed to prototype, develop, implement, and evaluate e-health solutions. TIIM ecosystem has proven to support these processes. This paper ends with the main research opportunities in mobile coaching, including intervention mechanisms, fine-grained monitoring, and inclusion of objective biomarker data.

A Web-Based Positive Psychology App for Patients With Bipolar Disorder: Development Study.

BACKGROUND: Patients with bipolar disorder (BD) report lower quality of life and lower levels of well-being than the general population. Despite the growing availability of psychotherapeutic and self-management interventions, important unmet needs remain. These unmet needs are closely linked to positive psychology domains. Although a growing number of studies have evaluated the impact of positive psychology interventions (PPIs) on patients with severe mental illness in general, only few have addressed the application of positive psychology for BD. OBJECTIVE: This study aimed to gain insight into the opinions of patients with BD and health care professionals about (web-based) PPIs for BD and to develop and pilot-test an app containing PPIs specifically designed for patients with BD. METHODS: The study was conducted in accordance with the Center for eHealth and Disease Management road map principles and incorporated cocreation and designing for implementation. Data were collected using focus group discussions, questionnaires, rapid prototyping, and web-based feedback on a prototype from the participants. In total, 3 focus groups were conducted with 62% (8/13) of patients with BD and 38% (5/13) of professionals. The collected data were used to develop a smartphone app containing short PPIs. The content was based on PPIs for which a solid base of evidence is available. Finally, a pilot test was conducted to test the app. RESULTS: Focus groups revealed that PPIs as part of the current BD treatment can potentially meet the following needs: offering hope, increasing self-esteem, expressing feelings, acceptance, and preventing social isolation. Some patients expressed concern that PPIs may provoke a manic or hypomanic episode by increasing positive affect. The pilot of the app showed that the PPIs are moderately to highly valued by the participants. There were no adverse effects such as increase in manic or hypomanic symptoms. CONCLUSIONS: With the systematic use of user involvement (patients and professionals) in all steps of the development process, we were able to create an app that can potentially fulfill some of the current unmet needs in the treatment of BD. We reached consensus among consumers and professionals about the potential benefits of PPIs to address the unmet needs of patients with BD. The use of PPI for BD is intriguing and can be usefully explored in further studies. We emphasize that more evaluation studies (quantitative and qualitative) that are focused on the effect of PPIs in the treatment of BD should be conducted. In addition, to establish the working mechanisms in BD, explorative, qualitative, designed studies are required to reveal whether PPIs can address unmet needs in BD.

Methods for Human-Centered eHealth Development: Narrative Scoping Review.

BACKGROUND: Thorough holistic development of eHealth can contribute to a good fit among the technology, its users, and the context. However, despite the availability of frameworks, not much is known about specific research activities for different aims, phases, and settings. This results in researchers having to reinvent the wheel. Consequently, there is a need to synthesize existing knowledge on research activities for participatory eHealth development processes. OBJECTIVE: The 3 main goals of this review are to create an overview of the development strategies used in studies based on the CeHRes (Center for eHealth Research) Roadmap, create an overview of the goals for which these methods can be used, and provide insight into the lessons learned about these methods. METHODS: We included eHealth development studies that were based on the phases and/or principles of the CeHRes Roadmap. This framework was selected because of its focus on participatory, iterative eHealth design in context and to limit the scope of this review. Data were extracted about the type of strategy used, rationale for using the strategy, research questions, and reported information on lessons learned. The most frequently mentioned lessons learned were summarized using a narrative, inductive approach. RESULTS: In the included 160 papers, a distinction was made between overarching development methods (n=10) and products (n=7). Methods are used to gather new data, whereas products can be used to synthesize previously collected data and support the collection of new data. The identified methods were focus groups, interviews, questionnaires, usability tests, literature studies, desk research, log data analyses, card sorting, Delphi studies, and experience sampling. The identified products were prototypes, requirements, stakeholder maps, values, behavior change strategies, personas, and business models. Examples of how these methods and products were applied in the development process and information about lessons learned were provided. CONCLUSIONS: This study shows that there is a plethora of methods and products that can be used at different points in the development process and in different settings. To do justice to the complexity of eHealth development, it seems that multiple strategies should be combined. In addition, we found no evidence for an optimal single step-by-step approach to develop eHealth. Rather, researchers need to select the most suitable research methods for their research objectives, the context in which data are collected, and the characteristics of the participants. This study serves as a first step toward creating a toolkit to support researchers in applying the CeHRes Roadmap to practice. In this way, they can shape the most suitable and efficient eHealth development process.

Responsible Relations: A Systematic Scoping Review of the Therapeutic Alliance in Text-Based Digital Psychotherapy.

Introduction: Developing a good therapeutic alliance is considered essential for the responsible delivery of psychotherapy. Text-based digital psychotherapy has become increasingly common, yet much remains unclear about the alliance and its importance for delivering mental health care via a digital format. To employ text-based digital therapies responsibly, more insight is needed into the type and strength of the therapeutic alliance online. Methods: A systematic scoping review was performed searching four databases: Scopus, PsycINFO, Web of Science, and Wiley Online Library. A total of 23 studies were selected and data was extracted and tabulated to explore the characteristics of studies on text-based psychotherapy, measurements of the therapeutic alliance and associations of the alliance with treatment outcome. Results: The therapeutic alliance in text-based digital interventions was studied with a variety of client groups, though mostly for clients diagnosed with anxiety and/or depression issues. Treatment modalities were predominantly internet-based cognitive behavioral therapy (ICBT) and tailored platforms for distinct client groups (e.g., PTSD). Almost all treatments used asynchronous text-based communication, such as e-mails and integrated messaging functions, which were mainly used to give feedback on tasks. For measurements, a version of the Working Alliance Inventory (WAI) was used in most studies. Measurements with the WAI or WAI- short form indicated a good therapeutic alliance with a weighted mean score of 5.66 (on a scale of 1 to 7) and a weighted standard deviation of 0.84. Relations between the therapeutic alliance and treatment outcomes were mostly positive, with many studies reporting significant associations (n = 8 out of 10) or significant effects of the therapeutic alliance on treatment outcomes (n = 5 out of 6). Discussion: Our scoping review suggests that a good therapeutic alliance can be established in digital psychotherapy through text-based communication, and shows support for a positive relationship between the alliance and treatment outcomes. These findings illustrate that text-based online psychotherapy can be a responsible treatment option as far as the establishment of the therapeutic alliance is concerned. However, current measures of the therapeutic alliance might miss important aspects of the alliance in digital treatment, such as the presence of empathy or compassion.

A self-control training app to increase self-control and reduce aggression - A full factorial design.

BACKGROUND: Research has shown that self-control training (SCT) is an effective intervention to increase self-control and behaviour driven by self-control, such as reactive aggression. We developed an app that offers SCT by asking users to use their non-dominant hand for daily tasks, and aimed to examine whether participants that received SCT via app or e-mail, and received either one daily task or five tasks at once, improved more in self-control and decreased in aggression compared to each other and a control group. METHODS: The design of this study was based on a pilot study in which a first version of the SCT app was developed and tested with students via a pretest-posttest design. Based on the outcomes of the pilot study, a 2 × 2 full factorial design (N = 204) with control group (n = 69) was used, with delivery via e-mail versus app and receiving one daily task versus five at once as factors. During four measuring points, self-control was assessed via the Brief Self-Control Scale (BSCS) and the Go/No-Go task, aggression was assessed using the Brief Aggression Questionnaire (BAQ). In the final questionnaire, open-ended questions were asked to gain insight into the app's points of improvement. Quantitative data were analysed using repeated measures linear mixed models, qualitative data were analysed via inductive coding. RESULTS: While no interaction effects were found, analyses showed that only the BSCS-scores of participants that used the app significantly improved over time (F[3, 196.315] = 4.090, p = .008), no improvements were observed in the e-mail and control condition. No meaningful differences in aggression, the Go/No-Go task, and between the one- and five-task conditions and control groups were found. Qualitative data showed that while the opinions on SCT-tasks differed, participants were overall satisfied with the intervention, but wanted more reminders. CONCLUSIONS: The results of this study showed that an SCT app has the potential to bolster self-control. No convincing effects on aggression were found in this student sample, which might be explained by the relatively low levels of aggression in this target group. Consequently, the app should also be investigated in populations with aggression regulation problems. Future research might also focus on the use of SCT to improve other types of behaviour driven by self-control, such as physical activity or smoking. Finally, a more personalized version of the app, in which users can select the number and types of SCT-tasks, should be developed and evaluated.

Can a monologue-style ECA more effectively motivate eHealth users in initial distress than textual guidance?

Stress is a prevalent issue amongst patients with chronic conditions. As eHealth interventions are gaining importance, it becomes more relevant to invoke the possibilities from the eHealth technology itself to provide motivational acts during experiences of stress as to enhance adherence to the intervention. Embodied Conversational Agents (ECA's) also known as 'robots on screen' can potentially provide a remedy. Within our eHealth experiment we applied a between-subjects design and experimentally studied the difference in appraisal of motivation and guidance. We deployed a functionally modest, monologue-style ECA and compared them with textual guidance. This way, we filtered out the considerable positive impact of interactive features that go along with dialogue-style ECA's. The study was carried out amongst eHealth users of which half were deliberately put in a stressful pre-condition. The rationale was two-sided; first, we hypothesized that it would induce a need for motivational support. Second, it would provide a fair representation of eHealth users in real life. Furthermore, we investigated hypothesized positive effects from a gender match between participant and ECA. The results demonstrated preferential ECA effects compared to text but only in the no stress conditions. Although our set-up controlled for user distraction by putting the facilitating ECA in a pane separate from the eHealth environment, we suspect that the enduring visual presence of the ECA during task completion had still inhibited distressed users. Discussing this phenomenon, our stance is that the hypothesis that ECA support is always superior to textual guidance is open for re-evaluation. Text may sometimes serve users equally well because it lacks human-like aspects that in stressful circumstances can become confrontational. We discuss the potential of ECA's to motivate, but also elaborate on the caveats. Further implications for the ECA, intervention adherence, and eHealth study fields are discussed in relation to stress.

Shaping Blended Care: Adapting an Instrument to Support Therapists in Using eMental Health.

BACKGROUND: Although eMental health interventions, especially when delivered in a blended way, have great potential to improve the quality and efficiency of mental health care, their use in practice lags behind expectations. The Fit for Blended Care (FfBC) instrument was developed to support therapists and clients in shaping blended care in a way that optimally fits their needs. However, this existing version cannot be directly applied to specific branches of mental health care as it is too broad and generic. OBJECTIVE: The goal of this study is to adapt the existing FfBC instrument to fit a specific, complex setting-forensic mental health care-by means of participatory development with therapists. METHODS: The participatory process was divided into 4 phases and was executed by a project team consisting of 1 manager, 3-5 therapists, and 1 researcher. In phase 1, general requirements for the adaptation of the existing instrument were discussed in 2 focus groups with the project team. In phase 2, patient-related factors that influence the use of an existing web-based intervention were elicited through semistructured interviews with all 18 therapists working at an outpatient clinic. In phase 3, multiple focus groups with the project teams were held to create the first version of the adapted FfBC instrument. In phase 4, a digital prototype of the instrument was used with 8 patients, and the experiences of the 4 therapists were discussed in a focus group. RESULTS: In phase 1, it became clear that the therapists' main requirement was to develop a much shorter instrument with a few items, in which the content was specifically tailored to the characteristics of forensic psychiatric outpatients. The interviews showed a broad range of patient-related factors, of which 5 were used in the instrument: motivation for blended treatment; writing about thoughts, feelings, and behavior; conscientiousness; psychosocial problems; and social support. In addition, a part of the instrument was focused on the practical necessary preconditions that patients should fill by themselves before the treatment was developed. The use of the web-based prototype of the instrument in treatment resulted in overall positive experiences with the content; however, therapists indicated that the items should be formulated in a more patient-centered way to encourage their involvement in discussing the factors. CONCLUSIONS: The participatory, iterative process of this study resulted in an adapted version of the FfBC instrument that fits the specific forensic context and supports shared decision making. In general, the adaptiveness of the instrument is important: its content and implementation should fit the type of care, the organization, and eHealth intervention. To adapt the instrument to other contexts, the guidelines described in this paper can be followed.

Applying an Agent-based Model to Simulate Just-In-Time Support for Keeping Users of eLearning Courses Motivated.

Persuasive technology can support users of self-paced eLearning courses during critical moments of low motivation. Agent-based models (ABMs) - a relatively unfamiliar phenomenon within the persuasive technology and eLearning domains- offers a potentially relevant methodology to understand when the support should be delivered. Using ABMs, the dynamics of motivational user states can be simulated. Subsequently, emerging user patterns can be traced that can potentially provide insight in the ebb and flow of motivation. For the purpose of this study, we designed an exploratory ABM on motivation based on the mental energy notion of which the foundations can be found both within the literature of motivational psychology and agent-based modeling. During the simulations we succeeded in generating moments of critically low user motivation. In addition, we were able to simulate the positive impact of external user support at those critical moments. These results suggest that it is plausible to put further energy in developing ABM models with the ultimate goal of feeding persuasive technology with the ability to deliver just-in-time user support during eLearning.

The Concept and Components of Engagement in Different Domains Applied to eHealth: A Systematic Scoping Review.

Within the context of eHealth interventions, a shared understanding of what constitutes engagement in and with eHealth technologies is missing. A clearer understanding of engagement could provide a valuable starting point for guidelines relating to the design and development of eHealth technologies. Given the cross-disciplinary use of the term "engagement," investigating how engagement (and its components) is conceptualized in different domains could lead to determining common components that are deemed important for eHealth technological design. As such, the aim of this paper was 3-fold: (a) to investigate in which domains engagement features, (b) to determine what constitutes engagement in these different domains, and (c) to determine whether there are any common components that seem to be important. A comprehensive systematic scoping review of the existing literature was conducted in order to identify the domains in which engagement is used, to extract the associated definitions of engagement, and to identify the dimensionality or components thereof. A search of five bibliographic databases yielded 1,231 unique records. All titles, abstracts, and full texts were screened based on specific inclusion and exclusion criteria. This led to 69 articles being included for further analyses. The results showed that engagement is used in seven functional domains, categorized as follows: student (n = 18), customer (n = 12), health (n = 11), society (n = 10), work (n = 9), digital (n = 8), and transdisciplinary (n = 1) domains. It seems that some domains are more mature regarding their conceptualization and theorizing on engagement than others. Further, engagement was found to be predominantly conceptualized as a multidimensional construct with three common components (behavior, cognition, and affective) shared between domains. Although engagement is prolifically used in different disciplines, it is evident that little shared consensus as to its conceptualization within and between domains exists. Despite this, engagement is foremost seen as a state of being engaged in/with something, which is part of, but should not be confused with, the process of engagement. Behavior, cognition, and affect are important components of engagement and should be specified for each new context.

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.

Implementation Strategies to Enhance the Implementation of eHealth Programs for Patients With Chronic Illnesses: Realist Systematic Review.

BACKGROUND: There is growing evidence of the positive effects of electronic health (eHealth) interventions for patients with chronic illness, but implementation of such interventions into practice is challenging. Implementation strategies that potentially impact implementation outcomes and implementation success have been identified. Which strategies are actually used in the implementation of eHealth interventions for patients with chronic illness and which ones are the most effective is unclear. OBJECTIVE: This systematic realist review aimed to summarize evidence from empirical studies regarding (1) which implementation strategies are used when implementing eHealth interventions for patients with chronic illnesses living at home, (2) implementation outcomes, and (3) the relationship between implementation strategies, implementation outcomes, and degree of implementation success. METHODS: A systematic literature search was performed in the electronic databases MEDLINE, Embase, PsycINFO, Scopus, Allied and Complementary Medicine Database, Cumulative Index to Nursing and Allied Health Literature, and Cochrane Library. Studies were included if they described implementation strategies used to support the integration of eHealth interventions into practice. Implementation strategies were categorized according to 9 categories defined by the Expert Recommendations for Implementing Change project: (1) engage consumers, (2) use evaluative and iterative strategies, (3) change infrastructure, (4) adapt and tailor to the context, (5) develop stakeholder interrelationships, (6) use financial strategies, (7) support clinicians, (8) provide interactive assistance, and (9) train and educate stakeholders. Implementation outcomes were extracted according to the implementation outcome framework by Proctor and colleagues: (1) acceptability, (2) adoption, (3) appropriateness, (4) cost, (5) feasibility, (6) fidelity, (7) penetration, and (8) sustainability. Implementation success was extracted according to the study authors' own evaluation of implementation success in relation to the used implementation strategies. RESULTS: The implementation strategies management support and engagement, internal and external facilitation, training, and audit and feedback were directly related to implementation success in several studies. No clear relationship was found between the number of implementation strategies used and implementation success. CONCLUSIONS: This is the first review examining implementation strategies, implementation outcomes, and implementation success of studies reporting the implementation of eHealth programs for patients with chronic illnesses living at home. The review indicates that internal and external facilitation, audit and feedback, management support, and training of clinicians are of importance for eHealth implementation. The review also points to the lack of eHealth studies that report implementation strategies in a comprehensive way and highlights the need to design robust studies focusing on implementation strategies in the future. TRIAL REGISTRATION: PROSPERO CRD42018085539; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=85539.

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.