Erasing stigmas through storytelling: why interactive storytelling environments could reduce health-related stigmas.

In this article we describe how designers can apply storytelling to reduce health-related stigmas. Stigma is a pervasive problem for people with illnesses, such as obesity, and it can persistently hinder coping, treatment, recovery, and prevention. Reducing health-related stigma is complex because it is multi-layered and self-perpetuating, leading to intertwined vicious circles. Interactive storytelling environments can break these vicious circles by delimiting the narrative freedom of stigma actors. We theoretically explain the potential of interactive storytelling environments to reduce stigma through the following seven functions: 1) expose participants to other perspectives, 2) provide a protective frame, 3) intervene in daily conversations, 4) persuade all stigma actors, 5) exchange alternative understandings, 6) elicit understanding and support for stigma victims, and 7) support stigma victims to cope with stigmatization. We elaborate on these functions through a demonstration of an interactive storytelling environment against weight stigma. In conclusion, this article is a call on designers for health and wellbeing, scientists, and practitioners from various disciplines to be sensitive to the pervasiveness of stigma and to collaboratively create destigmatizing storytelling environments.

Guide Development for eHealth Interventions Targeting People With a Low Socioeconomic Position: Participatory Design Approach.

BACKGROUND: People with a low socioeconomic position (SEP) are less likely to benefit from eHealth interventions, exacerbating social health inequalities. Professionals developing eHealth interventions for this group face numerous challenges. A comprehensive guide to support these professionals in their work could mitigate these inequalities. OBJECTIVE: We aimed to develop a web-based guide to support professionals in the development, adaptation, evaluation, and implementation of eHealth interventions for people with a low SEP. METHODS: This study consisted of 2 phases. The first phase involved a secondary analysis of 2 previous qualitative and quantitative studies. In this phase, we synthesized insights from the previous studies to develop the guide's content and information structure. In the second phase, we used a participatory design process. This process included iterative development and evaluation of the guide's design with 11 professionals who had experience with both eHealth and the target group. We used test versions (prototypes) and think-aloud testing combined with semistructured interviews and a questionnaire to identify design requirements and develop and adapt the guide accordingly. RESULTS: The secondary analysis resulted in a framework of recommendations for developing the guide, which was categorized under 5 themes: development, reach, adherence, evaluation, and implementation. The participatory design process resulted in 16 requirements on system, content, and service aspects for the design of the guide. For the system category, the guide was required to have an open navigation strategy leading to more specific information and short pages with visual elements. Content requirements included providing comprehensible information, scientific evidence, a user perspective, information on practical applications, and a personal and informal tone of voice. Service requirements involved improving suitability for different professionals, ensuring long-term viability, and a focus on implementation. Based on these requirements, we developed the final version of "the inclusive eHealth guide." CONCLUSIONS: The inclusive eHealth guide provides a practical, user-centric tool for professionals aiming to develop, adapt, evaluate, and implement eHealth interventions for people with a low SEP, with the aim of reducing health disparities in this population. Future research should investigate its suitability for different end-user goals, its external validity, its applicability in specific contexts, and its real-world impact on social health inequality.

The Design of a Persuasive Game to Motivate People with Asthma in Adherence to Their Maintenance Medication.

Objective: This study aimed to design a persuasive game, using objective adherence data, to motivate people with asthma to adhere to their medication regimen. Methods: A participatory user-centered design approach was employed, involving end-users and other stakeholders throughout the study. The approach consisted of four phases. Semi-structured interviews and a survey were conducted to understand user needs and reasons for poor adherence (Phase 1: define). Key themes were identified, leading to the formulation of behavior change strategies and design and game requirements. Several design directions were ideated, resulting in a concept for a serious game (Phase 2: ideate). Two rounds of user-tests were performed to evaluate a prototype of the serious game in terms of usability, perceived impact on medication adherence and motivation (Phase 3: prototype and Phase 4: evaluate). Results: Findings from semi-structured interviews (n = 6) and the online survey (n = 20) revealed that people's non-adherence was often attributed to the perception of asthma as an episodic condition, the delayed experienced effect of maintenance inhalers, and lack of knowledge regarding difference of effect between maintenance and reliever inhalers. The study used behavior change strategies to translate these insights into design requirements for the development of the narrative-based persuasive game Ademgenoot. This six-week challenge-based game combines various behavior change strategies, including personal goal setting and continuous visual feedback, as well as persuasive game design elements, such as a narrative and rewards, with the aim of enhancing motivation to adhere to their medication regimen. User-testing (n = 8; round 1 and 2) showed that Ademgenoot is feasible in clinical practice and has the potential to support people with mild asthma in adherence to their maintenance medication. Discussion: Future efforts should be directed towards a larger evaluation to assess the impact on motivation and inhaler use behaviour.

An overview of facilitators and barriers in the development of eHealth interventions for people of low socioeconomic position: A Delphi study.

OBJECTIVE: eHealth interventions can improve the health outcomes of people with a low socioeconomic position (SEP) by promoting healthy lifestyle behaviours. However, developing and implementing these interventions among the target group can be challenging for professionals. To facilitate the uptake of effective interventions, this study aimed to identify the barriers and facilitators anticipated or experienced by professionals in the development, reach, adherence, implementation and evaluation phases of eHealth interventions for people with a low SEP. METHOD: We used a Delphi method, consisting of two online questionnaires, to determine the consensus on barriers and facilitators anticipated or experienced during eHealth intervention phases and their importance. Participants provided open-ended responses in the first round and rated statements in the second round. The interquartile range was used to calculate consensus, and the (totally) agree ratings were used to assess importance. RESULTS: Twenty-seven professionals participated in the first round, and 19 (70.4%) completed the second round. We found a consensus for 34.8% of the 46 items related to highly important rated barriers, such as the lack of involvement of low-SEP people in the development phase, lack of knowledge among professionals about reaching the target group, and lack of knowledge among lower-SEP groups about using eHealth interventions. Additionally, we identified a consensus for 80% of the 60 items related to highly important rated facilitators, such as rewarding people with a low SEP for their involvement in the development phase and connecting eHealth interventions to the everyday lives of lower-SEP groups to enhance reach. CONCLUSION: Our study provides valuable insights into the barriers and facilitators of developing eHealth interventions for people with a low SEP by examining current practices and offering recommendations for future improvements. Strengthening facilitators can help overcome these barriers. To achieve this, we recommend defining the roles of professionals and lower-SEP groups in each phase of eHealth intervention and disseminating this study's findings to professionals to optimize the impact of eHealth interventions for this group.

Games in Times of a Pandemic: Structured Overview of COVID-19 Serious Games.

BACKGROUND: The COVID-19 pandemic introduced an urgent need for effective strategies to disseminate crucial knowledge and improve people's subjective well-being. Complementing more conventional approaches to knowledge dissemination, game-based interventions were developed to create awareness and educate people about the pandemic, hoping to change their attitudes and behavior. OBJECTIVE: This study provided an overview and analysis of digital and analog game-based interventions in the context of the COVID-19 pandemic. As major pandemics and other large-scale disruptive events are expected to increase in frequency in the coming decades, this analysis aimed to inform the design, uptake, and effects of similar future interventions. METHODS: From November 2021 to April 2022, Scopus, Google, and YouTube were searched for articles and videos describing COVID-19-themed game-based interventions. Information regarding authorship, year of development or launch, country of origin, license, deployment, genre or type, target audience, player interaction, in-game goal, and intended transfer effects was extracted. Information regarding intervention effectiveness was retrieved where possible. RESULTS: A diverse assortment of 23 analog and 43 digital serious games was identified, approximately one-third of them (25/66, 38%) through scientific articles. Most of these games were developed by research institutions in 2020 (13/66, 20%) and originated in Europe and North America (38/66, 58%). A limited number (20/66, 30%) were tested on relatively small samples, using a diversity of research methods to assess the potential changes in participants' knowledge, attitudes, and behaviors as well as their gameplay experience. Although most of the evaluated games (11/20, 55%) effectively engaged and motivated the players, increased awareness, and improved their understanding of COVID-19-related issues, the games' success in influencing people's behavior was often unclear or limited. CONCLUSIONS: To increase the impact of similar future interventions aimed at disseminating knowledge and influencing people's attitudes and behaviors during a large-scale crisis, some considerations are suggested. On the basis of the study results and informed by existing game theories, recommendations are made in relation to game development, deployment, and distribution; game users, design, and use; game design terminology; and effectiveness testing for serious games.

Dynamic Digital Twin: Diagnosis, Treatment, Prediction, and Prevention of Disease During the Life Course.

A digital twin (DT), originally defined as a virtual representation of a physical asset, system, or process, is a new concept in health care. A DT in health care is not a single technology but a domain-adapted multimodal modeling approach incorporating the acquisition, management, analysis, prediction, and interpretation of data, aiming to improve medical decision-making. However, there are many challenges and barriers that must be overcome before a DT can be used in health care. In this viewpoint paper, we build on the current literature, address these challenges, and describe a dynamic DT in health care for optimizing individual patient health care journeys, specifically for women at risk for cardiovascular complications in the preconception and pregnancy periods and across the life course. We describe how we can commit multiple domains to developing this DT. With our cross-domain definition of the DT, we aim to define future goals, trade-offs, and methods that will guide the development of the dynamic DT and implementation strategies in health care.

Game mechanics in eHealth interventions promoting self-management in young people with chronic diseases: a protocol for a systematic review and meta-analyses from the eHealth Junior Consortium.

INTRODUCTION: Young people (aged 10-25 years) with chronic diseases are vulnerable to have reduced social participation and quality of life. It is important to empower young people to engage in their chronic diseases self-management. In comparison with traditional face-to-face care, interventions delivered through the internet and related technologies (eHealth) are less stigmatising and more accessible. Gamified eHealth self-management interventions may be particularly promising for young people. This systematic review aims at identifying (1) the game mechanics that have been implemented in eHealth interventions to support young people's self-management of their chronic (somatic or psychiatric) diseases, (2) the investigators' rationale for implementing such game mechanics and, if possible, (3) the effects of these interventions. METHODS AND ANALYSIS: The Preferred Reporting Items for Systematic reviews and Meta-Analysis statement guidelines will be followed. A systematic search of the literature will be conducted in Embase, Psycinfo and Web of Science from inception until 30 August 2022. Studies will be eligible if focused on (1) young people (aged 10-25 years) with chronic diseases and (2) describing gamified eHealth self-management interventions. When possible, the effects of the gamified interventions will be compared with non-gamified interventions or care-as-usual. Primary quantitative, qualitative or mixed-method studies written in English will be included. Two independent reviewers will (1) select studies, (2) extract and summarise the implemented game mechanics as well as the characteristics of the intervention and study, (3) evaluate their methodological quality and (4) synthesise the evidence. The reviewers will reach a consensus through discussion, and if required, a third researcher will be consulted. ETHICS AND DISSEMINATION: As systematic reviews use publicly available data, no formal ethical review and approval are needed. Findings will be published in peer-reviewed journals, presented at conferences and communicated to relevant stakeholders including patient organisations via the eHealth Junior Consortium. PROSPERO REGISTRATION NUMBER: CRD42021293037.

The Barriers and Facilitators of eHealth-Based Lifestyle Intervention Programs for People With a Low Socioeconomic Status: Scoping Review.

BACKGROUND: Promoting health behaviors and preventing chronic diseases through a healthy lifestyle among those with a low socioeconomic status (SES) remain major challenges. eHealth interventions are a promising approach to change unhealthy behaviors in this target group. OBJECTIVE: This review aims to identify key components, barriers, and facilitators in the development, reach, use, evaluation, and implementation of eHealth lifestyle interventions for people with a low SES. This review provides an overview for researchers and eHealth developers, and can assist in the development of eHealth interventions for people with a low SES. METHODS: We performed a scoping review based on Arksey and O'Malley's framework. A systematic search was conducted on PubMed, MEDLINE (Ovid), Embase, Web of Science, and the Cochrane Library, using terms related to a combination of the following key constructs: eHealth, lifestyle, low SES, development, reach, use, evaluation, and implementation. There were no restrictions on the date of publication for articles retrieved upon searching the databases. RESULTS: The search identified 1323 studies, of which 42 met our inclusion criteria. An update of the search led to the inclusion of 17 additional studies. eHealth lifestyle interventions for people with a low SES were often delivered via internet-based methods (eg, websites, email, Facebook, and smartphone apps) and offline methods, such as texting. A minority of the interventions combined eHealth lifestyle interventions with face-to-face or telephone coaching, or wearables (blended care). We identified the use of different behavioral components (eg, social support) and technological components (eg, multimedia) in eHealth lifestyle interventions. Facilitators in the development included iterative design, working with different disciplines, and resonating intervention content with users. Facilitators for intervention reach were use of a personal approach and social network, reminders, and self-monitoring. Nevertheless, barriers, such as technological challenges for developers and limited financial resources, may hinder intervention development. Furthermore, passive recruitment was a barrier to intervention reach. Technical difficulties and the use of self-monitoring devices were common barriers for users of eHealth interventions. Only limited data on barriers and facilitators for intervention implementation and evaluation were available. CONCLUSIONS: While we found large variations among studies regarding key intervention components, and barriers and facilitators, certain factors may be beneficial in building and using eHealth interventions and reaching people with a low SES. Barriers and facilitators offer promising elements that eHealth developers can use as a toolbox to connect eHealth with low SES individuals. Our findings suggest that one-size-fits-all eHealth interventions may be less suitable for people with a low SES. Future research should investigate how to customize eHealth lifestyle interventions to meet the needs of different low SES groups, and should identify the components that enhance their reach, use, and effectiveness.

Game Design in Mental Health Care: Case Study-Based Framework for Integrating Game Design Into Therapeutic Content.

While there has been increasing interest in the use of gamification in mental health care, there is a lack of design knowledge on how elements from games could be integrated into existing therapeutic treatment activities in a manner that is balanced and effective. To help address this issue, we propose a design process framework to support the development of mental health gamification. Based on the concept of experienced game versus therapy worlds, we highlight 4 different therapeutic components that could be gamified to increase user engagement. By means of a Dual-Loop model, designers can balance the therapeutic and game design components and design the core elements of a mental health care gamification. To support the proposed framework, 4 cases of game design in mental health care (eg, therapeutic protocols for addiction, anxiety, and low self-esteem) are presented.

Attitudes Toward Health, Healthcare, and eHealth of People With a Low Socioeconomic Status: A Community-Based Participatory Approach.

Low socioeconomic status (SES) is associated with a higher prevalence of unhealthy lifestyles compared to a high SES. Health interventions that promote a healthy lifestyle, like eHealth solutions, face limited adoption in low SES groups. To improve the adoption of eHealth interventions, their alignment with the target group's attitudes is crucial. This study investigated the attitudes of people with a low SES toward health, healthcare, and eHealth. We adopted a mixed-method community-based participatory research approach with 23 members of a community center in a low SES neighborhood in the city of Rotterdam, the Netherlands. We conducted a first set of interviews and analyzed these using a grounded theory approach resulting in a group of themes. These basic themes' representative value was validated and refined by an online questionnaire involving a different sample of 43 participants from multiple community centers in the same neighborhood. We executed three focus groups to validate and contextualize the results. We identified two general attitudes based on nine profiles toward health, healthcare, and eHealth. The first general attitude, optimistically engaged, embodied approximately half our sample and involved light-heartedness toward health, loyalty toward healthcare, and eagerness to adopt eHealth. The second general attitude, doubtfully disadvantaged, represented roughly a quarter of our sample and was related to feeling encumbered toward health, feeling disadvantaged within healthcare, and hesitance toward eHealth adoption. The resulting attitudes strengthen the knowledge of the motivation and behavior of people with low SES regarding their health. Our results indicate that negative health attitudes are not as evident as often claimed. Nevertheless, intervention developers should still be mindful of differentiating life situations, motivations, healthcare needs, and eHealth expectations. Based on our findings, we recommend eHealth should fit into the person's daily life, ensure personal communication, be perceived usable and useful, adapt its communication to literacy level and life situation, allow for meaningful self-monitoring and embody self-efficacy enhancing strategies.

Mental Health Therapy Protocols and eHealth Design: Focus Group Study.

BACKGROUND: Electronic health (eHealth) programs are often based on protocols developed for the original face-to-face therapies. However, in practice, therapists and patients may not always follow the original therapy protocols. This form of personalization may also interfere with the intended implementation and effects of eHealth interventions if designers do not take these practices into account. OBJECTIVE: The aim of this explorative study was to gain insights into the personalization practices of therapists and patients using cognitive behavioral therapy, one of the most commonly applied types of psychotherapy, in a youth addiction care center as a case context. METHODS: Focus group discussions were conducted asking therapists and patients to estimate the extent to which a therapy protocol was followed and about the type and reasons for personalization of a given therapy protocol. A total of 7 focus group sessions were organized involving therapists and patients. We used a commonly applied protocol for cognitive behavioral therapy as a therapy protocol example in youth mental health care. The first focus group discussions aimed at assessing the extent to which patients (N=5) or therapists (N=6) adapted the protocol. The second focus group discussions aimed at estimating the extent to which the therapy protocol is applied and personalized based on findings from the first focus groups to gain further qualitative insight into the reasons for personalization with groups of therapists and patients together (N=7). Qualitative data were analyzed using thematic analysis. RESULTS: Therapists used the protocol as a "toolbox" comprising different therapy tools, and personalized the protocol to enhance the therapeutic alliance and based on their therapy-provision experiences. Therapists estimated that they strictly follow 48% of the protocol, adapt 30%, and replace 22% by other nonprotocol therapeutic components. Patients personalized their own therapy to conform the assignments to their daily lives and routines, and to reduce their levels of stress and worry. Patients estimated that 29% of the provided therapy had been strictly followed by the therapist, 48% had been adjusted, and 23% had been replaced by other nonprotocol therapeutic components. CONCLUSIONS: A standard cognitive behavioral therapy protocol is not strictly and fully applied but is mainly personalized. Based on these results, the following recommendations for eHealth designers are proposed to enhance alignment of eHealth to therapeutic practice and implementation: (1) study and copy at least the applied parts of a protocol, (2) co-design eHealth with therapists and patients so they can allocate the components that should be open for user customization, and (3) investigate if components of the therapy protocol that are not applied should remain part of the eHealth applied. To best generate this information, we suggest that eHealth designers should collaborate with therapists, patients, protocol developers, and mental health care managers during the development process.

Genre scripts and appreciation of negative emotion in the reception of film.

The Distancing-Embracing model reserves a role for genre scripts in the hedonic valuation of negative emotion in art. Genre scripts, as defined in the target article, leave higher-level recipient intuitions out of scope. We argue that, in film genre scripts, lower-level stylistic features lend access to more complex conceptual knowledge, including pragmatic principles. The argument implies a consideration of the communicative dimension of aesthetic works, which could strengthen both factors of the Distancing-Embracing model.

Using a digital game for training desirable behavior in cognitive-behavioral therapy of burnout syndrome: a controlled study.

Burnout is a globally increasing illness, and as a result, many forms of burnout therapy have arisen. The use of digital games can be psychotherapeutically effective because they can transform exercises that are by themselves unattractive into intrinsically motivated action. This pilot study aims to test whether a specially designed game contributes to patients learning desired behavior and achieving other specific therapeutic goals in an online cognitive-behavioral therapy (CBT)-based burnout treatment context. In total, 101 participants took part in the experiment, under four conditions: (a) Game+Therapy, (b) Therapy Only, (c) Game Only, and (d) No Game+No Therapy. Pre- and postmeasures were taken online. Results showed that the two therapy conditions (Game+Therapy and Therapy Only) showed a greater decrease in complaints and disengagement, and a stronger increase in coping skills than the nontherapy conditions (Game Only and No Game+No Therapy). As expected, the Game+Therapy condition outperformed the Therapy Only condition on combined improvement measures of burnout symptoms. However, analyses of individual measures showed no effects. It can be cautiously concluded that the therapeutic digital game may be a useful tool when embedded in a therapeutic burnout treatment program and is probably more efficient than CBT, as it is used in current practice.

Robust anger: recognition of deteriorated dynamic bodily emotion expressions.

In two studies, the robustness of anger recognition of bodily expressions is tested. In the first study, video recordings of an actor expressing four distinct emotions (anger, despair, fear, and joy) were structurally manipulated as to image impairment and body segmentation. The results show that anger recognition is more robust than other emotions to image impairment and to body segmentation. Moreover, the study showed that arms expressing anger were more robustly recognised than arms expressing other emotions. Study 2 added face blurring as a variable to the bodily expressions and showed that it decreased accurate emotion recognition-but more for recognition of joy and despair than for anger and fear. In sum, the paper indicates the robustness of anger recognition in multileveled deteriorated bodily expressions.

Categorizing moving objects into film genres: the effect of animacy attribution, emotional response, and the deviation from non-fiction.

The reported study follows the footsteps of Heider, and Simmel (1944) [Heider, F., & Simmel, M. (1944). An experimental study of apparent behavior. American Journal of Psychology, 57, 243-249] and Michotte (1946/1963) [Michotte, A. (1963). The perception of causality (T.R. Miles & E. Miles, Trans.). London: Methuen (Original work published 1946)] who demonstrated the role of object movement in attributions of life-likeness to figures. It goes one step further in studying the categorization of film scenes as to genre as a function of object movements. In an animated film scene portraying a chase, movements of the chasing object were systematically varied as to parameters: velocity, efficiency, fluency, detail, and deformation. The object movements were categorized by viewers into genres: non-fiction, comedy, drama, and action. Besides this categorization, viewers rated their animacy attribution and emotional response. Results showed that non-expert viewers were consistent in categorizing the genres according to object movement parameters. The size of its deviation from the unmanipulated movement scene determined the assignment of any target scene to one of the fiction genres: small and moderate deviations resulted in categorization as drama and action, and large deviations as comedy. The results suggest that genre classification is achieved by, at least, three distinct cognitive processes: (a) animacy attribution, which influences the fiction versus non-fiction classification; (b) emotional responses, which influences the classification of a specific fiction genre; and (c) the amount of deviation from reality, at least with regard to movements.