Macro-engagement in mHealth: Exploring user engagement beyond the screen.

While digital technology holds great promise for health and well-being, some users feel sceptical about the time they spend online and how they use their mobile devices. This attitude could hamper uptake of digital health technologies and engagement with them. This study uses the concept of macro-engagement as a starting point to investigate how users of digital behaviour change interventions (DBCIs) engage with their behaviour change goals beyond the screens of their tools. Thirty semi-structured interviews were conducted with individuals who take part in behaviour change processes in different ways (i.e. mental health professionals, digital health experts and users of DBCIs). A qualitative analysis of their data through a grounded theory approach highlighted a wide array of offscreen behaviors and strategies that complement a behavior change process offscreen. Furthermore, implications for designing technology that encourages progressive non-reliance on DBCI usage are drawn out.

Reimagine the ICU: Healthcare Professionals' Perspectives on How Environments (Can) Promote Patient Well-Being.

OBJECTIVE: This study aims (1) to understand the needs and challenges of the current intensive care unit (ICU) environments in supporting patient well-being from the perspective of healthcare professionals (HCPs) and (2) to explore the new potential of ICU environments enabled by technology. BACKGROUND: Evidence-based design has yielded how the design of environments can advocate for patient well-being, and digital technology offers new possibilities for indoor environments. However, the role of technology in facilitating ICU patient well-being has been unexplored. METHOD: This study was conducted in two phases. First, a mixed-method study was conducted with ICU HCPs from four Dutch hospitals. The study investigated the current environmental support for care activities, as well as the factors that positively and negatively contribute to patient experience. Next, a co-creation session was held involving HCPs and health technology experts to explore opportunities for technology to support ICU patient well-being. RESULTS: The mixed-method study revealed nine negative and eight positive patient experience factors. HCPs perceived patient emotional care as most challenging due to the ICU workload and a lack of environmental support in fulfilling patient emotional needs. The co-creation session yielded nine technology-enabled solutions to address identified challenges. Finally, drawing from insights from both studies, four strategies were introduced that guide toward creating technology to provide holistic and personalized care for patients. CONCLUSION: Patient experience factors are intertwined, necessitating a multifactorial approach to support patient well-being. Viewing the ICU environment as a holistic unit, our findings provide guidance on creating healing environments using technology.

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.

How Digital Therapeutics Are Urging the Need for a Paradigm Shift: From Evidence-Based Health Care to Evidence-Based Well-being.

A scientific paradigm consists of a set of shared rules, beliefs, values, methods, and instruments for addressing scientific problems. Currently, health care embraces the paradigm of evidence-based health care (EBH). This paradigm prompts health care institutions to base decisions on the best available evidence, which is commonly generated in large-scale randomized controlled trials. We illustrate the application of EBH via the evaluation of drugs. We show how EBH is challenged when it is applied to the evaluation of digital therapeutics, which refers to technology and data to prevent, manage, or treat a medical disorder or disease. We conclude that amid the growing application of digital therapeutics, the paradigm of EBH is challenged in four domains: population, intervention, comparison, outcome. In the second part of this viewpoint, we argue for a paradigm shift in health care so we can optimally evaluate and implement digital therapeutics, and we sketch out the contours of this novel paradigm. We address the need for considering design in health care and evaluation processes, studying user values so that health care can move from a focus on health to well-being, focusing on individual experiences rather than the average, addressing the need for evaluation in authentic use contexts, and stressing the need for continuous evaluation of the dynamic relations between users, context, and digital therapeutics. We conclude that the transition from EBH toward evidence-based well-being would improve the successful implementation of digital technologies in health care.

Evaluating value mediation in patients with chronic low-back pain using virtual reality: contributions for empirical research in Value Sensitive Design.

Value Sensitive Design (VSD) is the most well-known method to consider values in design. It consists of three iterative phases of investigation: conceptual, empirical, and technical. Although the approach is promising, the role of empirical research remains unclear. We address two opportunities for extending the role of empirical research in VSD. First, we argue that empirical research enables us to identify values in context. Second, we explain that empirical research enables us to anticipate how technology mediates the values of users. We make our point by means of an empirical study in a real-life controlled experimental context into the value mediation of virtual reality (VR) in patients with chronic low-back pain. Using value-oriented semi-structured interviews with twenty patients, we first analyze what values these patients consider important, and how the values are experienced. The second set of interviews held after all patients used VR four weeks at home, aims to provide insight into value changes as mediated by VR. We end the article by a comparison of our empirical results with previous, often speculative, literature into values in VR. We show that empirical research benefits the VSD process by providing in-depth insight into the effects of context and technology on values and the ability to translate these insights into recommendations for more responsible design and implementation of the technology. Supplementary information: The online version contains supplementary material available at 10.1007/s12553-022-00671-w.

From Digital Health to Digital Well-being: Systematic Scoping Review.

BACKGROUND: Digital health refers to the proper use of technology for improving the health and well-being of people and enhancing the care of patients through the intelligent processing of clinical and genetic data. Despite increasing interest in well-being in both health care and technology, there is no clear understanding of what constitutes well-being, which leads to uncertainty in how to create well-being through digital health. In an effort to clarify this uncertainty, Brey developed a framework to define problems in technology for well-being using the following four categories: epistemological problem, scope problem, specification problem, and aggregation problem. OBJECTIVE: This systematic scoping review aims to gain insights into how to define and address well-being in digital health. METHODS: We followed the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. Papers were identified from 6 databases and included if they addressed the design or evaluation of digital health and reported the enhancement of patient well-being as their purpose. These papers were divided into design and evaluation papers. We studied how the 4 problems in technology for well-being are considered per paper. RESULTS: A total of 117 studies were eligible for analysis (n=46, 39.3% design papers and n=71, 60.7% evaluation papers). For the epistemological problem, the thematic analysis resulted in various definitions of well-being, which were grouped into the following seven values: healthy body, functional me, healthy mind, happy me, social me, self-managing me, and external conditions. Design papers mostly considered well-being as healthy body and self-managing me, whereas evaluation papers considered the values of healthy mind and happy me. Users were rarely involved in defining well-being. For the scope problem, patients with chronic care needs were commonly considered as the main users. Design papers also regularly involved other users, such as caregivers and relatives. These users were often not involved in evaluation papers. For the specification problem, most design and evaluation papers focused on the provision of care support through a digital platform. Design papers used numerous design methods, whereas evaluation papers mostly considered pre-post measurements and randomized controlled trials. For the aggregation problem, value conflicts were rarely described. CONCLUSIONS: Current practice has found pragmatic ways of circumventing or dealing with the problems of digital health for well-being. Major differences exist between the design and evaluation of digital health, particularly regarding their conceptualization of well-being and the types of users studied. In addition, we found that current methodologies for designing and evaluating digital health can be improved. For optimal digital health for well-being, multidisciplinary collaborations that move beyond the common dichotomy of design and evaluation are needed.

This is Me: Evaluation of a boardgame to promote social engagement, wellbeing and agency in people with dementia through mindful life-storytelling.

Receiving a dementia diagnosis is a difficult experience for most people and often affects their wellbeing negatively. To support people's wellbeing, in a therapeutic context, life-storytelling, reminiscence and mindfulness are used with people with dementia. In an everyday context, traditional games are used as a resource for stimulating memory, cognition and social activity. While an increasing number of creative strategies are available to support people with dementia, the area of board games design and their effect on wellbeing is underexplored. This paper reports on the evaluation of the This is Me (TIM) mindful life-storytelling board game by the European project MinD. Using a co-design methodology, TIM was developed with and for people with mild to moderate dementia to support their wellbeing by enhancing self-empowerment and social engagement. A focus group methodology was used to evaluate TIM with 50 people with dementia and 19 carers across four countries. TIM was evaluated with regard to the usability and experience of the design as well as people's emotional wellbeing, social engagement and agency. The thematic analysis demonstrated that the combination of life-storytelling and mindfulness allowed players to engage in meaningful social interaction and, as a result, they reported enjoyment, learning, more acceptance of the past and present situation, and that they perceived looking forward into the future together with others as helpful. The study demonstrates that design can be a useful means to support people with dementia in aspects of emotional wellbeing, social engagement and a sense of agency.

Overview and Strategy Analysis of Technology-Based Nonpharmacological Interventions for In-Hospital Delirium Prevention and Reduction: Systematic Scoping Review.

BACKGROUND: Delirium prevention is crucial, especially in critically ill patients. Nonpharmacological multicomponent interventions for preventing delirium are increasingly recommended and technology-based interventions have been developed to support them. Despite the increasing number and diversity in technology-based interventions, there has been no systematic effort to create an overview of these interventions for in-hospital delirium prevention and reduction. OBJECTIVE: This systematic scoping review was carried out to answer the following questions: (1) what are the technologies currently used in nonpharmacological technology-based interventions for preventing and reducing delirium? and (2) what are the strategies underlying these currently used technologies? METHODS: A systematic search was conducted in Scopus and Embase between 2015 and 2020. A selection was made in line with the Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR). Studies were eligible if they contained any type of technology-based interventions and assessed delirium-/risk factor-related outcome measures in a hospital setting. Data extraction and quality assessment were performed using a predesigned data form. RESULTS: A total of 31 studies were included and analyzed focusing on the types of technology and the strategies used in the interventions. Our review revealed 8 different technology types and 14 strategies that were categorized into the following 7 pathways: (1) restore circadian rhythm, (2) activate the body, (3) activate the mind, (4) induce relaxation, (5) provide a sense of security, (6) provide a sense of control, and (7) provide a sense of being connected. For all technology types, significant positive effects were found on either or both direct and indirect delirium outcomes. Several similarities were found across effective interventions: using a multicomponent approach or including components comforting the psychological needs of patients (eg, familiarity, distraction, soothing elements). CONCLUSIONS: Technology-based interventions have a high potential when multidimensional needs of patients (eg, physical, cognitive, emotional) are incorporated. The 7 pathways pinpoint starting points for building more effective technology-based interventions. Opportunities were discussed for transforming the intensive care unit into a healing environment as a powerful tool to prevent delirium. TRIAL REGISTRATION: PROSPERO International Prospective Register of Systematic Reviews CRD42020175874; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=175874.

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.

A Mobile App Adopting an Identity Focus to Promote Physical Activity (MoveDaily): Iterative Design Study.

BACKGROUND: Web-based and mobile interventions to influence physical activity behavior have had limited effects on sustained behavior change. One reason may be that the interventions aim to change largely habitual behavior. Following an identity-oriented approach could be a successful strategy to behavior change because people are committed to behave in line with their self-perception of identity. OBJECTIVE: In this paper, we take a closer look at the role of motivation in long-term adherence to lifestyle interventions. The paper outlines a method for web-based or mobile intervention development that allows exploration of integrating behavior change theory into the design process. We will describe the development of a mobile app that allows people to be self-determined and to value and self-regulate physical activity by adopting an identity-oriented approach. METHODS: This paper describes a Research through Design (RtD) process in which design activities are carried out as part of the knowledge-generating process. Two RtD phases were completed, followed by a conceptual design phase. In the first RtD phase, 8 participants used diary cards to study initial attitudes toward starting with small changes in physical activity. In the second RtD phase, 26 participants used a web-based app to study changes in physical activity. We used an adapted version of the Self-Report Habit Index (SRHI) to evaluate individuals' perceptions of a particular behavior with respect to the three facets of a habit. The conceptual design phase consolidated the results from first two RtD phases into a design of a mobile app that combines an identity approach with gamification principles. The conceptual design was evaluated in a user-experience study with 4 participants. RESULTS: In the first RtD phase, we found that interacting daily with diary cards and reflecting on physical activity patterns is a promising strategy but works better through a digital medium. In the second RtD phase, SHRI ratings from all participants generally increased each week. In the conceptual design phase, we found that the concept of the mobile app was positively evaluated by participants. However, participants mentioned that terms such as "identity" do not resonate with them and that scenarios could be simpler. CONCLUSIONS: This paper provides deeper insights into designing for electronic health (eHealth) interventions and services and suggests a new way that motivation can be shaped by the design of an intervention and adherence to physical activity. To the best of our knowledge, this was the first iterative design study in which the effects of adopting an identity approach to both motivation and physical activity were included and observed. Initial promising results were found for using a web-based intervention where habits and identification with the personal importance of a behavior were repetitively triggered.

Environmental design for dementia care - towards more meaningful experiences through design.

Dementia is generally considered to be one of the most pressing societal issues now and in the years to come. Although insights from different disciplines have contributed to a better understanding of dementia and the development of interventions targeting dementia symptoms, there is a lack of integration of insights from these different perspectives for the purposes of design for dementia. The aim of this paper is to show how insights from environmental psychology and advances in technology can inform a user-centred multidisciplinary design approach. To this end, first a brief meta-review of (systematic) reviews from the fields of assistive technology for dementia care and healing environments research is presented, after which gaps and opportunities for a multidisciplinary design approach are identified. To illustrate what such an approach could look like, two exploratory case studies are presented in which technology-enhanced prototypes of an experience handrail (aimed at facilitating wayfinding by providing meaningful sensory experiences) and a virtual nature installation (aimed at providing relaxation and stimulating social engagement) were implemented at a Dutch care centre for people with dementia. Preliminary evaluations indicate that these designs contribute to the wellbeing of people with dementia and confirm the fruitfulness of the design approach presented in this paper. Furthermore, this approach may not only provide a means to optimize existing environments and enhance ease of living, but may also lead to novel solutions to the challenges people with dementia face on a day-to-day basis, and improve their quality of life.

A Theoretical Framework and Conceptual Design for Engaging Children in Therapy at Home-The Design of a Wearable Breathing Trainer.

Wearable technologies are being implemented in the health and medical context with increasing frequency. Such technologies offer valuable opportunities to stimulate self-management in these domains. In this context, engagement plays a crucial role. An engaged patient is a patient who is emotionally involved and committed to the therapy or care process. Particularly for children who have to follow some sort of therapy, engagement is important to ensure a successful outcome of the therapy. To design for engagement, a framework based on theories of motivation in child therapy was developed. This framework was applied to the design of a wearable breathing trainer for children with asthma and dysfunctional breathing. As such, the present paper provides knowledge about the implementation of theory on engagement and motivation in design. Expert and first user evaluations found that the resulting prototype is appealing, perceived as useful, and may engage children in breathing training and stimulate self-management.

How to Increase Reach and Adherence of Web-Based Interventions: A Design Research Viewpoint.

Nowadays, technology is increasingly used to increase people's well-being. For example, many mobile and Web-based apps have been developed that can support people to become mentally fit or to manage their daily diet. However, analyses of current Web-based interventions show that many systems are only used by a specific group of users (eg, women, highly educated), and that even they often do not persist and drop out as the intervention unfolds. In this paper, we assess the impact of design features of Web-based interventions on reach and adherence and conclude that the power that design can have has not been used to its full potential. We propose looking at design research as a source of inspiration for new (to the field) design approaches. The paper goes on to specify and discuss three of these approaches: personalization, ambient information, and use of metaphors. Central to our viewpoint is the role of positive affect triggered by well-designed persuasive features to boost adherence and well-being. Finally, we discuss the future of persuasive eHealth interventions and suggest avenues for follow-up research.