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Self-care support is a key cornerstone of treatment for patients with a cardiovascular disease. The success of any supportive intervention requires adaptation to the distinct needs of individuals. This requirement also applies to eHealth interventions. This study investigates how experts from multiple fields of science assess the potential success of different eHealth design strategies when matched to key self-care needs. An online vignette survey experiment was conducted. Nine vignettes representing different combinations of self-care needs (maintenance, monitoring, management) and eHealth persuasive design strategies (primary task support, dialogue support, social support) were evaluated. In total, 118 experts from 18 different countries participated in the survey. Their evaluations show primary task support as a promising design strategy across all self-care needs. In contrast, dialogue support and social support showed more promise for specific self-care needs. Above all, according to experts, the success of design strategies could be enhanced by (i) personalising the pacing of the intervention and (ii) tailoring the information to the literacy and culture of the person. Adding to that, self-care support should distinctly (iii) support the three self-care needs, be (iv) patient-centered, (v) support the collaboration with caregivers, and (vi) be aligned to the life goals and values of individuals.

Background App-based treatment for urinary incontinence is a proven effective and cost-effective alternative to care as usual, but successful implementation requires that we identify and address the barriers and facilitators associated with app use. Objective The goal of the research was to explore the factors influencing app-based treatment for urinary incontinence and identify which barriers or facilitators are associated with treatment success or failure. Methods We used a sequential explanatory mixed methods design to connect the results of a randomized controlled trial with data from semistructured interviews. This previous RCT had shown the noninferiority of app-based treatment compared with care as usual for urinary incontinence over 4 months. Participants who reported success or failure with app-based treatment, as measured by the change in International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form symptom score, were selected for telephone interview by purposive sampling (n=17). This study reports mainly on the qualitative component of our mixed methods study. Qualitative analyses were conducted in two ways. First, we analyzed the qualitative data of all interviewed participants and discussed the relationships between the main themes. Second, the experiences between the success (n=9) and failure group (n=8) were compared and contrasted to explore factors that were positively or negatively associated with the quantitative effect of app-based treatment. These factors were then interpreted as barriers to and facilitators of successful app-based treatment. Results Four interrelated themes were identified as affecting the app based treatment effect: adherence, personal factors, app factors, and awareness. Qualitative analyses of the relationships between the themes showed that adherence-related factors directly influenced treatment effect in both a positive and negative matter. In turn, adherence was also positively and negatively influenced by the other 3 themes. Additionally, awareness was positively influenced by the treatment effect. Within these themes, several factors were identified that acted as barriers (eg, unrealistic expectation of time investment and interfering personal circumstances), facilitators (eg, strict integration of exercises and prior pelvic floor muscle therapy), or both (eg, personality traits and increased awareness of symptoms). Conclusions This study shows that the effect of app-based treatment for urinary incontinence is mainly influenced by adherence, which in turn is affected by personal factors, app-based factors, and awareness. The identified factors could function as both facilitators and barriers depending on the user and interaction with other themes. Insight into these facilitators and barriers could lead to improved implementation and increased treatment effectiveness by targeting women most likely to benefit and through further development of the app. International Registered Report Identifier (IRRID) RR2-10.1002/nau.23507

Background eHealth interventions are developed to support and facilitate patients with lifestyle changes and self-care tasks after being diagnosed with a cardiovascular disease (CVD). Creating long-lasting effects on lifestyle change and health outcomes with eHealth interventions is challenging and requires good understanding of patient values. Objective The aim of the study was to identify values of importance to patients with CVD to aid in designing a technological lifestyle platform. Methods A mixed method design was applied, combining data from usability testing with an additional online survey study, to validate the outcomes of the usability tests. Results A total of 11 relevant patient values were identified, including the need for security, support, not wanting to feel anxious, tailoring of treatment, and personalized, accessible care. The validation survey shows that all values but one (value 9: To have extrinsic motivation to accomplish goals or activities [related to health/lifestyle]) were regarded as important/very important. A rating of very unimportant or unimportant was given by less than 2% of the respondents (value 1: 4/641, 0.6%; value 2: 10/641, 1.6%; value 3: 9/641, 1.4%; value 4: 5/641, 0.8%; value 5: 10/641, 1.6%; value 6: 4/641, 0.6%; value 7: 10/639, 1.6%; value 8: 4/639, 0.6%; value 10: 3/636, 0.5%; value 11: 4/636, 0.6%) to all values except but one (value 9: 56/636, 8.8%). Conclusions There is a high consensus among patients regarding the identified values reflecting goals and themes central to their lives, while living with or managing their CVD. The identified values can serve as a foundation for future research to translate and integrate these values into the design of the eHealth technology. This may call for prioritization of values, as not all values can be met equally.

Background Adoption and evaluation of contact tracing tools based on information and communications technology may expand the reach and efficacy of traditional contact tracing methods in fighting COVID-19. The Dutch Ministry of Health, Welfare and Sports initiated and developed CoronaMelder, a COVID-19 contact tracing app. This app is based on a Google/Apple Exposure Notification approach and aims to combat the spread of the coronavirus among individuals by notifying those who are at increased risk of infection due to proximity to someone who later tests positive for COVID-19. The app should support traditional contact tracing by faster tracing and greater reach compared to regular contact tracing procedures. Objective The main goal of this study is to investigate whether the CoronaMelder is able to support traditional contact tracing employed by public health authorities. To achieve this, usability tests were conducted to answer the following question: is the CoronaMelder user-friendly, understandable, reliable and credible, and inclusive? Methods Participants (N=44) of different backgrounds were recruited: youth with varying educational levels, youth with an intellectual disability, migrants, adults (aged 40-64 years), and older adults (aged >65 years) via convenience sampling in the region of Twente in the Netherlands. The app was evaluated with scenario-based, think-aloud usability tests and additional interviews. Findings were recorded via voice recordings, observation notes, and the Dutch User Experience Questionnaire, and some participants wore eye trackers to measure gaze behavior. Results Our results showed that the app is easy to use, although problems occurred with understandability and accessibility. Older adults and youth with a lower education level did not understand why or under what circumstances they would receive notifications, why they must share their key (ie, their assigned identifier), and what happens after sharing. In particular, youth in the lower-education category did not trust or understand Bluetooth signals, or comprehend timing and follow-up activities after a risk exposure notification. Older adults had difficulties multitasking (speaking with a public health worker and simultaneously sharing the key in the app). Public health authorities appeared to be unprepared to receive support from the app during traditional contact tracing because their telephone conversation protocol lacks guidance, explanation, and empathy. Conclusions The study indicated that the CoronaMelder app is easy to use, but participants experienced misunderstandings about its functioning. The perceived lack of clarity led to misconceptions about the app, mostly regarding its usefulness and privacy-preserving mechanisms. Tailored and targeted communication through, for example, public campaigns or social media, is necessary to provide correct information about the app to residents in the Netherlands. Additionally, the app should be presented as part of the national coronavirus measures instead of as a stand-alone app offered to the public. Public health workers should be trained to effectively and empathetically instruct users on how to use the CoronaMelder app.

BACKGROUND Adoption and evaluation of contact tracing tools based on information and communications technology may expand the reach and efficacy of traditional contact tracing methods in fighting COVID-19. The Dutch Ministry of Health, Welfare and Sports initiated and developed CoronaMelder, a COVID-19 contact tracing app. This app is based on a Google/Apple Exposure Notification approach and aims to combat the spread of the coronavirus among individuals by notifying those who are at increased risk of infection due to proximity to someone who later tests positive for COVID-19. The app should support traditional contact tracing by faster tracing and greater reach compared to regular contact tracing procedures. OBJECTIVE The main goal of this study is to investigate whether the CoronaMelder is able to support traditional contact tracing employed by public health authorities. To achieve this, usability tests were conducted to answer the following question: is the CoronaMelder user-friendly, understandable, reliable and credible, and inclusive? METHODS Participants (N=44) of different backgrounds were recruited: youth with varying educational levels, youth with an intellectual disability, migrants, adults (aged 40-64 years), and older adults (aged >65 years) via convenience sampling in the region of Twente in the Netherlands. The app was evaluated with scenario-based, think-aloud usability tests and additional interviews. Findings were recorded via voice recordings, observation notes, and the Dutch User Experience Questionnaire, and some participants wore eye trackers to measure gaze behavior. RESULTS Our results showed that the app is easy to use, although problems occurred with understandability and accessibility. Older adults and youth with a lower education level did not understand why or under what circumstances they would receive notifications, why they must share their key (ie, their assigned identifier), and what happens after sharing. In particular, youth in the lower-education category did not trust or understand Bluetooth signals, or comprehend timing and follow-up activities after a risk exposure notification. Older adults had difficulties multitasking (speaking with a public health worker and simultaneously sharing the key in the app). Public health authorities appeared to be unprepared to receive support from the app during traditional contact tracing because their telephone conversation protocol lacks guidance, explanation, and empathy. CONCLUSIONS The study indicated that the CoronaMelder app is easy to use, but participants experienced misunderstandings about its functioning. The perceived lack of clarity led to misconceptions about the app, mostly regarding its usefulness and privacy-preserving mechanisms. Tailored and targeted communication through, for example, public campaigns or social media, is necessary to provide correct information about the app to residents in the Netherlands. Additionally, the app should be presented as part of the national coronavirus measures instead of as a stand-alone app offered to the public. Public health workers should be trained to effectively and empathetically instruct users on how to use the CoronaMelder app.

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., Stress; eHealth; Support; Embodied conversational agent; ECA; Persuasive technology

Background An increasing number of eHealth interventions aim to support healthy behaviors that facilitate weight loss. However, there is limited evidence of the effectiveness of the interventions and little focus on weight loss maintenance. Knowledge about end user values and needs is essential to create meaningful and effective eHealth interventions, and to identify persuasive system design (PSD) principles and behavior change techniques (BCTs) that may contribute to the behavior change required for successful long-term weight loss maintenance. Objective This study aimed to provide insight into the design of eHealth interventions supporting behavior change for long-term weight maintenance. The study sought to identify the values and needs of people with obesity aiming to maintain weight after weight loss, and to identify PSD principles, BCTs, and design requirements that potentially enable an eHealth intervention to meet end user values and needs. Methods This study presents the concept of integrating PSD principles and BCTs into the design process of eHealth interventions to meet user values and needs. In this study, individual interviews and focus groups were conducted with people with obesity (n=23) and other key stakeholders (n=27) to explore end user values and needs related to weight loss maintenance. Design thinking methods were applied during the focus group sessions to identify design elements and to explore how eHealth solutions can support the needs to achieve sustainable weight loss maintenance. The PSD model and behavior change taxonomy by Michie were used to identify PSD principles and BCT clusters to meet end user values and needs. Results A total of 8 key end user values were identified, reflecting user needs for weight loss maintenance support: self-management, personalized care, autonomy, feel supported, positive self-image, motivation, happiness, and health. Goals and planning, feedback and monitoring, repetition and substitution, shaping knowledge, social support, identity, and self-belief were some of the BCT clusters identified to address these concepts, together with PSD principles such as personalization, tailoring, self-monitoring, praise, and suggestions. Conclusions The process of translating end user values and needs into design elements or features of eHealth technologies is an important part of the design process. To our knowledge, this is the first study to explore how PSD principles and BCTs can be integrated when designing eHealth self-management interventions for long-term weight loss maintenance. End users and other key stakeholders highlighted important factors to be considered in the design of eHealth interventions supporting sustained behavior change. The PSD principles and BCTs identified provide insights and suggestions about design elements and features to include for supporting weight loss maintenance. The findings indicate that a combination of BCTs and PSD principles may be needed in evidence-based eHealth interventions to stimulate motivation and adherence to support healthy behaviors and sustained weight loss maintenance. Trial Registration ClinicalTrials.gov NCT04537988; https://clinicaltrials.gov/ct2/show/NCT04537988

Background Electronic health (eHealth) is a rapidly evolving field informed by multiple scientific disciplines. Because of this, the use of different terms and concepts to explain the same phenomena and lack of standardization in reporting interventions often leaves a gap that hinders knowledge accumulation. Interventions focused on self-management support of cardiovascular diseases through the use of remote monitoring technologies are a cross-disciplinary area potentially affected by this gap. A review of the underlying frameworks, models, and theories that have informed projects at this crossroad could advance future research and development efforts. Objective This research aimed to identify and compare underlying approaches that have informed interventions focused on self-management support of cardiovascular diseases through the use of remote monitoring technologies. The objective was to achieve an understanding of the distinct approaches by highlighting common or conflicting principles, guidelines, and methods. Methods The metaethnography approach was used to review and synthesize researchers’ reports on how they applied frameworks, models, and theories in their projects. Literature was systematically searched in 7 databases: Scopus, Web of Science, EMBASE, CINAHL, PsycINFO, Association for Computing Machinery Digital Library, and Cochrane Library. Included studies were thoroughly read and coded to extract data for the synthesis. Studies were mainly related by the key ingredients of the underlying approaches they applied. The key ingredients were finally translated across studies and synthesized into thematic clusters. Results Of 1224 initial results, 17 articles were included. The articles described research and development of 10 different projects. Frameworks, models, and theories (n=43) applied by the projects were identified. Key ingredients (n=293) of the included articles were mapped to the following themes of eHealth development: (1) it is a participatory process; (2) it creates new infrastructures for improving health care, health, and well-being; (3) it is intertwined with implementation; (4) it integrates theory, evidence, and participatory approaches for persuasive design; (5) it requires continuous evaluation cycles; (6) it targets behavior change; (7) it targets technology adoption; and (8) it targets health-related outcomes. Conclusions The findings of this review support and exemplify the numerous possibilities in the use of frameworks, models, and theories to guide research and development of eHealth. Participatory, user-centered design, and integration with empirical evidence and theoretical modeling were widely identified principles in the literature. On the contrary, less attention has been given to the integration of implementation in the development process and supporting novel eHealth-based health care infrastructures. To better integrate theory and evidence, holistic approaches can combine patient-centered studies with consolidated knowledge from expert-based approaches. Trial Registration PROSPERO CRD42018104397; https://tinyurl.com/y8ajyajt International Registered Report Identifier (IRRID) RR2-10.2196/13334

Background Personal health records (PHRs) provide the opportunity for self-management support, enhancing communication between patients and caregivers, and maintaining and/or improving the quality of chronic disease management. Their implementation is a multi-level and complex process, requiring a holistic approach that takes into account the technology, its users and the context of implementation. The aim of this research is to evaluate the fidelity of a PHR in chronic care (the degree to which it was implemented as intended) in order to explain the found effects. Methods A convergent parallel mixed methods design was used, where qualitative and quantitative data were collected in parallel, analyzed separately, and finally merged. Log data of 536 users were used to gain insight into the actual long-term use of the PHR (the dose). Focus group meetings among caregivers (n = 13) were conducted to assess program differentiation (or intended use). Interviews with caregivers (n = 28) and usability tests with potential end-users (n = 13) of the PHR were used to understand the responsiveness and the differences and similarities between the intended and actual use of the PHR. Results The results of the focus groups showed that services for coaching are strongly associated with monitoring health values and education. However, the PHR was not used that way during the study period. In the interviews, caregivers indicated that they were ignorant on how to deploy the PHR in current working routines. Therefore, they find it difficult to motivate their patients in using the PHR. Participants in the usability study indicate that they would value a PHR in the future, given that the usability will be improved and that the caregivers will use it in daily practice as well. Conclusions In this study, actual use of the PHRs by patients was influenced by the responsiveness of caregivers. This responsiveness is likely to be strongly influenced by the perceived support when defining the differentiation and delivery of the PHR. A mixed-methods approach to understand intervention fidelity was of added value in providing explanations for the found effects that could not be revealed by solely focusing on the effectiveness of the technology in an experimental trial.

AIMS: We aim to assess whether a purpose-developed mobile application (app) is non-inferior regarding effectiveness and cost-effective when used to treat women with urinary incontinence (UI), as compared to care as usual in Dutch primary care. Additionally, we will explore the expectations and experiences of patients and care providers regarding app usage.METHODS: A mixed-methods study will be performed, combining a pragmatic, randomized-controlled, non-inferiority trial with an extensive process evaluation. Women aged ≥18 years, suffering from UI ≥ 2 times per week and with access to a smartphone or tablet are eligible to participate. The primary outcome will be the change in UI symptom scores at 4 months after randomization, as assessed by the International Consultation on Incontinence Modular Questionnaire UI Short Form. Secondary outcomes will be the change in UI symptom scores at 12 months, as well as the patient-reported global impression of improvement, quality of life, change in sexual functioning, UI episodes per day, and costs at 4 and 12 months. In parallel, we will perform an extensive process evaluation to assess the expectations and experiences of patients and care providers regarding app usage, making use of interviews, focus group sessions, and log data analysis.CONCLUSION: This study will assess both the effectiveness and cost-effectiveness of app-based treatment for UI. The combination with the process evaluation, which will be performed in parallel, should also give valuable insights into the contextual factors that influence the effectiveness of such a treatment.

As research on Health Behavior Change Support Systems (HBCSS) proliferates, meaningful management of the different findings is becoming a challenge. We argue that for the field to evolve, it is important to establish the study of HBCSSs as an independent research area, which means that instead of only applying theories from related disciplines to HBCSSs, we need to significantly extend and adapt these theories, or develop new theories, to explain the phenomena that are encountered. Current research in HBCSSs is carried out in different disciplines, with a different approach in each of these disciplines. However, both the CeHRes roadmap and the Persuasive System Design Model show that HBCSSs are complex and the development and evaluation of these systems need to deal with this complexity to be successful. Therefore, an integrative approach is needed to study the combination of content, system, and context. Although research into the separate areas has yielded important findings that are discussed in this paper, we argue that an integrated approach of HBCSSs is useful. We discuss two examples to show how a truly integrative approach can be utilized to enhance the field involving tailoring, personalization, and support. In conclusion we present three practical and relatively easy-to-implement recommendations for researchers who want to contribute to this discipline: Avoid the black box, be specific about the terms used, and look past the borders of one's own discipline.

Prior research has shown that the more patients know about their disease, health, and lifestyle the better the health outcomes are. Patients who are suffering from either a physical disease with mental consequences or from mental illnesses can contribute to their own feeling of mental well-being by following evidence-based online, self-guided therapeutic interventions. These self-guided therapeutic interventions during which there is no contact with a care provider have shown high effectiveness. However, users (patients) of self-guided eHealth interventions have difficulties fulfilling the entire trajectory as is mirrored in high non-adherence rates. Users have reported a need for support, that is traditionally provided by human care providers. This study investigates the opportunities from within the technology to increase its support level toward the user. We deployed a pedagogical agent acting as an adjunct to a self-guided positive psychology psycho-education intervention. This agent provided instructions and user support in between and explicitly not during the online learning modules as to mitigate the risk of distraction. By setting up a between-subjects design and deploying three versions of a pedagogical agent (also known as Embodied Conversational Agent), varying the features of animation, speech, and visibility we investigated whether users felt more supported than by a fourth text-only control condition. All four conditions provided similar task-related support and emotion-related support to the user. Our results showed that our pedagogical agent made users feel guided and supported with respect to fulfilling their tasks. However, no effects were found of emotion-related support resulting in higher user motivation and an improved learning experience. Significant effects of visibility and voice were found, but animation of our pedagogical agent had no effect. On the feedback outcome variable, we found a gender effect. Male participants graded the visible Embodied Conversational Agent (ECA) higher than female participants and graded the non-visible ECA lower than female participants. In our view, ECA’s should not necessarily be deployed with the ambition to compete with the profound human potential to deliver support and guidance. Exploring ECA capabilities merits further attention, from the stance that the technology itself can support users and potentially make them adhere.

Background: Maintaining weight after weight loss is a major health challenge, and eHealth (electronic health) solutions may be a way to meet this challenge. Application of behavior change techniques (BCTs) and persuasive system design (PSD) principles in eHealth development may contribute to the design of technologies that positively influence behavior and motivation to support the sustainable health behavior change needed. Objective: This review aimed to identify BCTs and PSD principles applied in eHealth interventions to support weight loss and weight loss maintenance, as well as techniques and principles applied to stimulate motivation and adherence for long-term weight loss maintenance. Methods: A systematic literature search was conducted in PsycINFO, Ovid MEDLINE (including PubMed), EMBASE, Scopus, Web of Science, and AMED, from January 1, 2007 to June 30, 2018. Arksey and O'Malley's scoping review methodology was applied. Publications on eHealth interventions were included if focusing on weight loss or weight loss maintenance, in combination with motivation or adherence and behavior change. Results: The search identified 317 publications, of which 45 met the inclusion criteria. Of the 45 publications, 11 (24%) focused on weight loss maintenance, and 34 (76%) focused on weight loss. Mobile phones were the most frequently used technology (28/45, 62%). Frequently used wearables were activity trackers (14/45, 31%), as well as other monitoring technologies such as wireless or digital scales (8/45, 18%). All included publications were anchored in behavior change theories. Feedback and monitoring and goals and planning were core behavior change technique clusters applied in the majority of included publications. Social support and associations through prompts and cues to support and maintain new habits were more frequently used in weight loss maintenance than weight loss interventions. In both types of interventions, frequently applied persuasive principles were self-monitoring, goal setting, and feedback. Tailoring, reminders, personalization, and rewards were additional principles frequently applied in weight loss maintenance interventions. Results did not reveal an ideal combination of techniques or principles to stimulate motivation, adherence, and weight loss maintenance. However, the most frequently mentioned individual techniques and principles applied to stimulate motivation were, personalization, simulation, praise, and feedback, whereas associations were frequently mentioned to stimulate adherence. eHealth interventions that found significant effects for weight loss maintenance all applied self-monitoring, feedback, goal setting, and shaping knowledge, combined with a human social support component to support healthy behaviors. Conclusions: To our knowledge, this is the first review examining key BCTs and PSD principles applied in weight loss maintenance interventions compared with those of weight loss interventions. This review identified several techniques and principles applied to stimulate motivation and adherence. Future research should aim to examine which eHealth design combinations can be the most effective in support of long-term behavior change and weight loss maintenance.

Background Research has shown that web-based interventions concerning mental health can be effective, although there is a broad range in effect sizes. Why some interventions are more effective than others is not clear. Persuasive technology is one of the aspects which has a positive influence on changing attitude and/or behavior, and can contribute to better outcomes. According to the Persuasive Systems Design Model there are various principles that can be deployed. It is unknown whether the number and combinations of principles used in a web-based intervention affect the effectiveness. Another issue in web-based interventions is adherence. Little is known about the relationship of adherence on the effectiveness of web-based interventions. Objective This study examines whether there is a relationship between the number and combinations of persuasive technology principles used in web-based interventions and the effectiveness. Also the influence of adherence on effectiveness of web-based interventions is investigated. Methods This study elaborates on the systematic review by [37] and therefore the articles were derived from that study. Only web-based interventions were included that were intended to be used on more than one occasion and studies were excluded when no information on adherence was provided. 48 interventions targeted at mental health were selected for the current study. A within-group (WG) and between-group (BG) meta-analysis were performed and subsequently subgroup analyses regarding the relationship between the number and combinations of persuasive technology principles and effectiveness. The influence of adherence on the effectiveness was examined through a meta-regression analysis. Results For the WG meta-analysis 40 treatment groups were included. The BG meta-analysis included 19 studies. The mean pooled effect size in the WG meta-analysis was large and significant (Hedges’ g = 0.94), while for the BG meta-analysis this was moderate to large and significant (Hedges’ g = 0.78) in favor of the web-based interventions. With regard to the number of persuasive technology principles, the differences between the effect sizes in the subgroups were significant in the WG subgroup analyses for the total number of principles and for the number of principles in the three categories Primary Task Support, Dialogue Support, and Social Support. In the BG subgroup analyses only the difference in Primary Task Support was significant. An increase in the total number of principles and Dialogue Support principles yielded larger effect sizes in the WG subgroup analysis, indicating that more principles lead to better outcomes. The number of principles in the Primary Task Support (WG and BG) and Social Support (WG) did not show an upward trend but had varying effect sizes. We identified a number of combinations of principles that were more effective, but only in the WG analyses. The association between adherence and effectiveness was not significant. Conclusions There is a relationship between the number of persuasive technology principles and the effectiveness of web-based interventions concerning mental health, however this does not always mean that implementing more principles leads to better outcomes. Regarding the combinations of principles, specific principles seemed to work well together (e.g. tunneling and tailoring; reminders and similarity; social learning and comparison), but adding another principle can diminish the effectiveness (e.g. tunneling, tailoring and reduction). In this study, an increase in adherence was not associated with larger effect sizes. The findings of this study can help developers to decide which persuasive principles to include to make web-based interventions more persuasive.

Background: In electronic health (eHealth) evaluations, there is increasing attention for studying the actual usage of a technology in relation to the outcomes found, often by studying the adherence to the technology. On the basis of the definition of adherence, we suggest that the following three elements are necessary to determine adherence to eHealth technology: (1) the ability to measure the usage behavior of individuals; (2) an operationalization of intended use; and (3) an empirical, theoretical, or rational justification of the intended use. However, to date, little is known on how to operationalize the intended usage of and the adherence to different types of eHealth technology. Objective: The study aimed to improve eHealth evaluations by gaining insight into when, how, and by whom the concept of adherence has been used in previous eHealth evaluations and finding a concise way to operationalize adherence to and intended use of different eHealth technologies. Methods: A systematic review of eHealth evaluations was conducted to gain insight into how the use of the technology was measured, how adherence to different types of technologies was operationalized, and if and how the intended use of the technology was justified. Differences in variables between the use of the technology and the operationalization of adherence were calculated using a chi-square test of independence. Results: In total, 62 studies were included in this review. In 34 studies, adherence was operationalized as “the more use, the better,” whereas 28 studies described a threshold for intended use of the technology as well. Out of these 28, only 6 reported a justification for the intended use. The proportion of evaluations of mental health technologies reporting a justified operationalization of intended use is lagging behind compared with evaluations of lifestyle and chronic care technologies. The results indicated that a justification of intended use does not require extra measurements to determine adherence to the technology. Conclusions: The results of this review showed that to date, justifications for intended use are often missing in evaluations of adherence. Evidently, it is not always possible to estimate the intended use of a technology. However, such measures do not meet the definition of adherence and should therefore be referred to as the actual usage of the technology. Therefore, it can be concluded that adherence to eHealth technology is an underdeveloped and often improperly used concept in the existing body of literature. When defining the intended use of a technology and selecting valid measures for adherence, the goal or the assumed working mechanisms should be leading. Adherence can then be standardized, which will improve the comparison of adherence rates to different technologies with the same goal and will provide insight into how adherence to different elements contributed to the outcomes.

Background: Web-based mental health interventions have evolved from innovative prototypes to evidence-based and clinically applied solutions for mental diseases such as depression and anxiety. Open-access, self-guided types of these solutions hold the promise of reaching and treating a large population at a reasonable cost. However, a considerable factor that currently hinders the effectiveness of these self-guided Web-based interventions is the high level of nonadherence. The absence of a human caregiver apparently has a negative effect on user adherence. It is unknown to what extent this human support can be handed over to the technology of the intervention to mitigate this negative effect. Objective: The first objective of this paper was to explore what is known in literature about what support a user needs to stay motivated and engaged in an electronic health (eHealth) intervention that requires repeated use. The second objective was to explore the current potential of embodied conversational agents (ECAs) to provide this support. Methods: This study reviews and interprets the available literature on (1) support within eHealth interventions that require repeated use and (2) the potential of ECAs by means of a scoping review. The rationale for choosing a scoping review is that the subject is broad, diverse, and largely unexplored. Themes for (1) and (2) were proposed based on grounded theory and mapped on each other to find relationships. Results: The results of the first part of this study suggest the presence of user needs that largely remain implicit and unaddressed. These support needs can be categorized as task-related support and emotion-related support. The results of the second part of this study suggest that ECAs are capable of engaging and motivating users of information technology applications in the domains of learning and behavioral change. Longitudinal studies must be conducted to determine under what circumstances ECAs can create and maintain a productive user relationship. Mapping the user needs on the ECAs’ capabilities suggests that different kinds of ECAs may provide different solutions for improving the adherence levels. Conclusions: Autonomous ECAs that do not respond to a user’s expressed emotion in real time but take on empathic roles may be sufficient to motivate users to some extent. It is unclear whether those types of ECAs are competent enough and create sufficient believability among users to address the user’s deeper needs for support and empathy. Responsive ECAs may offer a better solution. However, at present, most of these ECAs have difficulties to assess a user’s emotional state in real time during an open dialogue. By conducting future research with relationship theory–based ECAs, the added value of ECAs toward user needs can be better understood.

Background: The electronic personal health record (PHR) is a promising technology for improving the quality of chronic disease management. Until now, evaluations of such systems have provided only little insight into why a particular outcome occurred. The aim of this study is to gain insight into the navigation process (what functionalities are used, and in what sequence) of e-Vita, a PHR for patients with type 2 diabetes mellitus (T2DM), to increase the efficiency of the system and improve the long-term adherence. Method: Log data of the first visits in the first 6 weeks after the release of a renewed version of e-Vita were analyzed to identify the usage patterns that emerge when users explore a new application. Results: After receiving the invitation, 28% of all registered users visited e-Vita. In total, 70 unique usage patterns could be identified. When users visited the education service first, 93% of all users ended their session. Most users visited either 1 or 5 or more services during their first session, but the distribution of the routes was diffuse. Conclusions: In conclusion, log file analyses can provide valuable prompts for improving the system design of a PHR. In this way, the match between the system and its users and the long-term adherence has the potential to increase.

Background: Infection prevention and control can be seen as a wicked public health problem as there is no consensus regarding problem definition and solution, multiple stakeholders with different needs and values are involved, and there is no clear end-point of the problem-solving process. Co-creation with stakeholders has been proposed as a suitable strategy to tackle wicked problems, yet little information and no clear step-by-step guide exist on how to do this. The objectives of this study were to develop a guideline to assist developers in tackling wicked problems using co-creation with stakeholders, and to apply this guideline to practice with an example case in the field of infection prevention and control.Methods: A mixed-method approach consisting of the integration of both quantitative and qualitative research was used. Relevant stakeholders from the veterinary, human health, and public health sectors were identified using a literature scan, expert recommendations, and snowball sampling. The stakeholder salience approach was used to select key stakeholders based on 3 attributes: power, legitimacy, and urgency. Key values of stakeholders (N = 20) were derived by qualitative semi-structured interviews and quantitatively weighted and prioritized using an online survey.Results: Our method showed that stakeholder identification and analysis are prerequisites for understanding the complex stakeholder network that characterizes wicked problems. A total of 73 stakeholders were identified of which 36 were selected as potential key stakeholders, and only one was seen as a definite stakeholder. In addition, deriving key stakeholder values is a necessity to gain insights into different problem definitions, solutions and needs stakeholders have regarding the wicked problem. Based on the methods used, we developed a step-by-step guideline for co-creation with stakeholders when tackling wicked problems.Conclusions: The mixed-methods guideline presented here provides a systematic, transparent method to identify, analyze, and co-create with stakeholders, and to recognize and prioritize their values, problem definitions, and solutions in the context of wicked problems. This guideline consists of a general framework and although it was applied in an eHealth context, may be relevant outside of eHealth as well.

Blended care, a combination of online and face-to-face therapy, is increasingly being applied in mental health care to obtain optimal benefit from the advantages these two treatment modalities have. Promising results have been reported, but a variety in descriptions and ways of operationalizing blended care exists. Currently, what type of “blend” works for whom, and why, is unclear. Furthermore, a rationale for setting up blended care is often lacking. In this viewpoint paper, we describe postulates for blended care and provide an instrument (Fit for Blended Care) that aims to assist therapists and patients whether and how to set up blended care treatment. A review of the literature, two focus groups (n=5 and n=5), interviews with therapists (n=14), and interviews with clients (n=2) were conducted to develop postulates of eHealth and blended care and an instrument to assist therapists and clients in setting up optimal blended care. Important postulates for blended care are the notion that both treatment modalities should complement each other and that set up of blended treatment should be based on shared decision making between patient and therapist. The “Fit for Blended Care” instrument is presented which addresses the following relevant themes: possible barriers to receiving blended treatment such as the risk of crisis, issues in communication (at a distance), as well as possible facilitators such as social support. More research into the reasons why and for whom blended care works is needed. To benefit from blended care, face-to-face and online care should be combined in such way that the potentials of both treatment modalities are used optimally, depending on patient abilities, needs, and preferences. To facilitate the process of setting up a personalized blended treatment, the Fit for Blended Care instrument can be used. By applying this approach in research and practice, more insight into the working mechanisms and optimal (personal) “blends” of online and face-to-face therapy becomes within reach.

BackgroundAlthough web-based interventions for promoting health and health-related behavior can be effective, poor adherence is a common issue that needs to be addressed. Technology as a means to communicate the content in web-based interventions has been neglected in research. Indeed, technology is often seen as a black-box, a mere tool that has no effect or value and serves only as a vehicle to deliver intervention content. In this paper we examine technology from a holistic perspective. We see it as a vital and inseparable aspect of web-based interventions to help explain and understand adherence. ObjectiveThis study aims to review the literature on web-based health interventions to investigate whether intervention characteristics and persuasive design affect adherence to a web-based intervention. MethodsWe conducted a systematic review of studies into web-based health interventions. Per intervention, intervention characteristics, persuasive technology elements and adherence were coded. We performed a multiple regression analysis to investigate whether these variables could predict adherence. ResultsWe included 101 articles on 83 interventions. The typical web-based intervention is meant to be used once a week, is modular in set-up, is updated once a week, lasts for 10 weeks, includes interaction with the system and a counselor and peers on the web, includes some persuasive technology elements, and about 50% of the participants adhere to the intervention. Regarding persuasive technology, we see that primary task support elements are most commonly employed (mean 2.9 out of a possible 7.0). Dialogue support and social support are less commonly employed (mean 1.5 and 1.2 out of a possible 7.0, respectively). When comparing the interventions of the different health care areas, we find significant differences in intended usage (p = .004), setup (p < .001), updates (p < .001), frequency of interaction with a counselor (p < .001), the system (p = .003) and peers (p = .017), duration (F = 6.068, p = .004), adherence (F = 4.833, p = .010) and the number of primary task support elements (F = 5.631, p = .005). Our final regression model explained 55% of the variance in adherence. In this model, a RCT study as opposed to an observational study, increased interaction with a counselor, more frequent intended usage, more frequent updates and more extensive employment of dialogue support significantly predicted better adherence. ConclusionsUsing intervention characteristics and persuasive technology elements, a substantial amount of variance in adherence can be explained. Although there are differences between health care areas on intervention characteristics, health care area per se does not predict adherence. Rather, the differences in technology and interaction predict adherence. The results of this study can be used to make an informed decision about how to design a web-based intervention to which patients are more likely to adhere.

Aim: This paper is a report of a study conducted to assess nurses’ information-seeking strategies and problems encountered when seeking clinical guidelines on the Internet, and to investigate the criteria they apply when evaluating the guidelines and the websites communicating the guidelines. - Background: As nurses are increasingly taking on clinical responsibilities, they should be able to use the Internet to access up-to-date clinical guidelines. Currently, nurses’ information-seeking skills remain rather limited. - Method: In 2008, a convenience sample of 20 nurses solved scenario-based tasks using the Internet to seek clinical guidelines regarding methicillin-resistant Staphylococcus aureus while thinking aloud. - Results: General background information and universal precautions were successfully identified by participants, in contrast to more specific precautions. Nurses’ information-seeking skills appeared rather basic, as they employed a limited number of search terms and consulted a limited number of websites. Ineffective searches were mainly caused by a mismatch between the guidelines and nurses’ tacit knowledge. Perceived practical relevance and information completeness were the most frequently applied quality criteria. Accuracy and disclosures, which are emphasized in existing e-health literature, were considered less important. As long as information matched nurses’ practical and experiential wisdom, they were satisfied. - Conclusion: Nurses appeared to rely predominantly on tacit knowledge during the search process and while evaluating the retrieved guidelines. This is dangerous because nurses’ reliance on inaccurate information might result in inadequate behaviour. It is therefore essential to expand nurses’ current information base by tailoring both navigation structure and the guideline communication to dovetail with nurses’ tacit knowledge.

Objective To identify factors that can enhance the use of e-consultation in primary care. We investigated the barriers, demands and motivations regarding e-consultation among patients with no e-consultation experience (non-users). Methods We used an online survey to gather data. Via online banners on 26 different websites of patient organizations we recruited primary care patients with chronic complaints, an important target group for e-consultation. A regression analysis was performed to identify the main drivers for e-consultation use among patients with no e-consultation experience. Results In total, 1706 patients started to fill out the survey. Of these patients 90% had no prior e-consultation experience. The most prominent reasons for non-use of e-consultation use were: not being aware of the existence of the service, the preference to see a doctor and e-consultation not being provided by a GP. Patients were motivated to use e-consultation, because e-consultation makes it possible to contact a GP at any time and because it enabled patients to ask additional questions after a visit to the doctor. The use of a Web-based triage application for computer-generated advice was popular among patients desiring to determine the need to see a doctor and for purposes of self-care. The patients’ motivations to use e-consultation strongly depended on demands being satisfied such as getting a quick response. When looking at socio-demographic and health-related characteristics it turned out that certain patient groups – the elderly, the less-educated individuals, the chronic medication users and the frequent GP visitors – were more motivated than other patient groups to use e-consultation services, but were also more demanding. The less-educated patients, for example, more strongly demanded instructions regarding e-consultation use than the highly educated patients. Conclusion In order to foster the use of e-consultation in primary care both GPs and non-users must be informed about the possibilities and consequences of e-consultation through tailored education and instruction. We must also take into account patient profiles and their specific demands regarding e-consultation. Special attention should be paid to patients who can benefit the most from e-consultation while also facing the greatest chance of being excluded from the service. As health care continues to evolve towards a more patient-centred approach, we expect that patient expectations and demands will be a major force in driving the adoption of e-consultation.

Currently, infection control guidelines in hospitals and other health care institutions are more expert-driven than user-oriented. In order to enhance the usability of the expert-driven guideline format, we developed a website for the communication of existing guidelines that better fit the practical information needs of health care workers (HCWs). We employed a user-centered design process that involved two studies. In the initial study, 28 HCWs were asked to solve tasks using existing, paper-based infection control guidelines. In order to detect their strategies and problems, the participants were asked to think aloud. Usability problems occurred due to poorly structured information, insufficient quality of information, and a mismatch between experts' and HCWs' vocabulary. To overcome these shortcomings, three design principles were applied for communicating infection control guidelines: better navigation (the guidelines should be searchable in several ways); multimodality (the guidelines should not be presented as text only), and action-orientation (the guidelines should be presented as HCWs' behaviors). A website was developed to meet these principles. In the second study, the same 28 HCWs completed tasks identical to those of the first study while thinking aloud, but this time using the website. The percentage of correctly completed tasks increased and the mean time for task completion decreased significantly. Also, respondents were more satisfied with the website than the paper-based guidelines. The number of problems due to poor information quality and a mismatch in vocabulary declined, although the number of structural problems increased. This can probably be explained by the fact that the navigation structure was user-generated (using Card Sort), in contrast to a standardized answer format based on common usability principles. Overall, we found that involving HCWs in the development process is important to create a sense of ownership and to foster the implementation of the guidelines, which might eventually result in compliance and reduce health care-associated infections. This paper outlines concrete steps for how to involve HCWs in the design process.

To identify factors that could affect health care workers' (HCWs) adoption of a website for communicating infection control guidelines.In total, 20 semi-structured interviews were conducted with HCWs in 5 different occupational groups and 4 different hospitals in the Netherlands and Germany. A website communicating guidelines for the prevention and control of Methicillin Resistant Staphylococcus aureus served as a casus. The HCWs, the majority of whom had prior experience with the website, were asked to give their opinions about factors that hinder or facilitate adoption of the website in practice. The interviews were based on the PRECEDE (Predisposing, Reinforcing, and Enabling Causes in Educational Diagnosis and Evaluation) model complemented by quality criteria for health-related websites. This model encompasses different categories of factors relevant to technology adoption in health care.A total of 361 interview statements were relevant to the four main categories of the PRECEDE model, yielding the following observations: (1) Technological factors (72 statements): The usability, design, and relevance of the website were positively valued. The website enabled HCWs to access contextually relevant information quickly. The website's credibility was evaluated rather negatively, as respondents perceived that the website's guidelines were not in concurrence with the best available evidence and it was not clear to HCWs who created the website. (2) Individual factors (85 statements): Respondents, particular infection control professionals, showed individual resistance to the website because they preferred to use their personal knowledge and experience (and communication with colleagues) over online sources. (3) Work-related factors (53 statements): Respondents perceived high work pressure during working hours as an impediment to consulting the website. In contrast, respondents thought the website might lower work pressure for infection control professionals, as they will receive fewer questions from HCWs. (4) Organizational factors (131 statements): Interpersonal (face-to-face) communication between HCWs from different occupational groups in both a formal (training) and informal (feedback) manner was seen as the most stimulating factor behind website use. The respondents identified infection control nurses as the most important opinion leaders.Factors from multiple categories determine HCWs' adoption of web-based guidelines, but the organization appeared to be a paramount reinforcer of initiation and maintenance of technology adoption among HCWs. In order eliminate resistance and create ownership among HCWs toward the website, leading to a willingness to integrate the website into routine care, it is essential to more actively involve HCWs in the early phases of the design process.

Considering the threat of antimicrobial resistance and the difficulties it entails in treating infections, it is necessary to cross borders and approach infection management in an integrated, multidisciplinary manner. We propose the antimicrobial, infection prevention and diagnostic stewardship model comprising three intertwined programs: antimicrobial, infection prevention and diagnostic stewardship, involving all stakeholders. The focus is a so-called ‘theragnostics’ approach. This leads to a personalized infection management plan, improving patient care and minimizing resistance development. Furthermore, it is important that healthcare regions nationally and internationally work together, ensuring that the patient (and microorganism) transfers will not cause problems in a neighboring institution. This antimicrobial, infection prevention and diagnostic stewardship model can serve as a blue print to implement innovative, integrative infection management.

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.

Background: Nurses can be crucial contributors to antibiotic stewardship programs (ASPs), interventions aimed at improving antibiotic use, but nurse empowerment in ASPs adds to their job complexity. Nurses work in complex settings with high cognitive loads, which ask for easily accessible information. An information application (app) was developed to support nurses in ASPs. The efficiency, effectiveness, and user satisfaction regarding this antibiotic app were tested in a pilot study.Methods: The app was introduced into 2 lung wards of a local teaching hospital. During the 8-month pilot study, the 62 nurses of the wards had access to the app. Changes in user satisfaction regarding information support, safety attitudes, and ASP behavior were assessed with a questionnaire. At baseline, 28 nurses completed the (e-mail) questionnaire; after the study, 18 nurses participated. Scenario-based tests were done to assess app efficiency and effectiveness at baseline (n = 16) and in a randomized control (without the app, n = 17) and intervention condition (with the app, n = 17).Results: Significant improvements were found regarding task support (P = .041), reliability (P = .004), unobtrusiveness (P = .000), relevance (P = .002), user friendliness (P = .000), speed, and hyperlinks (P = .001). An improvement in communication was observed regarding nurse-physician understanding (P = .034). With the app, nurses solved the scenarios faster than without it.Conclusions: The human-centered design approach and persuasive strategy of task supportwere effective in reducing time needed to find information. Stewardship-related behaviors need active education strategies. (C) 2016 Association for Professionals in Infection Control and Epidemiology, Inc. Published by Elsevier Inc. All rights reserved.

Dementia and technology, how do they go together? Technology might be a solution to support health and well-being for patients. Although promising, a lot of technologies are not used due to higher cost than expected, ineffective implementation, and technologies that do not work or help people in a positive way. To improve the adoption and use of technologies for health and well-being, we created a roadmap to guide the process of development, evaluation, and implementation (van Gemert- Pijnen et al. 2011). The roadmap is based on reviews of existing frameworks for eHealth and prior research about development, design, and implementation and applied in several research and development projects (van Gemert-Pijnen et al. 2013). In this chapter we elaborate on the use of the CeHRes roadmap for dementia care. First, we will describe the CeHRes roadmap and its principles for development, then we present a case study to demonstrate how the roadmap was used in practice, and finally we will reflect upon the case study by means of lessons learned

Over the last years, Germany has observed an increase in the prevalence of methicillin-resistant Staphylococcus (MRSA) in all S. aureus isolates from 2 % to about 25 % whereas in The Netherlands this proportion has continuously been kept below 1 % thanks to a consistent "search & destroy" policy. Both countries increasingly register so-called community-acquired (CA) MRSA which are a threat also to the healthy population without any known risk factor for MRSA carriership. The EUREGIO project "MRSA-net Twente/Munsterland" has made it its main goal to set up a German-Dutch network serving as a basis for a quality association which includes all those who are actively involved in health care provision on both sides of the border and to implement a coordinated strategy for MRSA control and prevention. The project is being carried out with the financial support of the European Union under the INTERREG-IIIA Community initiative and of the Ministry of Economics of the State of North Rhine-Westphalia. The epidemiological backbone of the MRSA-net is a genetic-based MRSA typing strategy (spa-typing) which has been developed by the Institute for Hygiene, University Hospital, Munster and which allows regional and cross-border comparability of laboratory results. The Faculty of Behavioural Sciences of the University of Twente examines MRSA hygiene protocols with regard to their acceptability and realisability with the intention of developing user-friendly, target group-oriented MRSA protocols for the EUREGIO. The health departments involved in the project play a central role in the coordination of the network partners in the municipalities. By performing their function of surveillance in accordance with Sections 23 and 36 of the Infectious Disease Control Act they provide an important contribution to enhancing MRSA control and prevention strategies. Thanks to its cross-border cooperation and exchange of knowledge and technology the EUREGIO project "MRSA-net" contributes to controlling the proliferation of MRSA in the EUREGIO and thus to removing obstacles to the free cross-border movement of patients and personnel.

Background: The combination of self-tracking and persuasive eCoaching in automated interventions is a new and promising approach for healthy lifestyle management. Objective: The aim of this study was to identify key components of self-tracking and persuasive eCoaching in automated healthy lifestyle interventions that contribute to their effectiveness on health outcomes, usability, and adherence. A secondary aim was to identify the way in which these key components should be designed to contribute to improved health outcomes, usability, and adherence. Methods: The scoping review methodology proposed by Arskey and O’Malley was applied. Scopus, EMBASE, PsycINFO, and PubMed were searched for publications dated from January 1, 2013 to January 31, 2016 that included (1) self-tracking, (2) persuasive eCoaching, and (3) healthy lifestyle intervention. Results: The search resulted in 32 publications, 17 of which provided results regarding the effect on health outcomes, 27 of which provided results regarding usability, and 13 of which provided results regarding adherence. Among the 32 publications, 27 described an intervention. The most commonly applied persuasive eCoaching components in the described interventions were personalization (n=24), suggestion (n=19), goal-setting (n=17), simulation (n=17), and reminders (n=15). As for self-tracking components, most interventions utilized an accelerometer to measure steps (n=11). Furthermore, the medium through which the user could access the intervention was usually a mobile phone (n=10). The following key components and their specific design seem to influence both health outcomes and usability in a positive way: reduction by setting short-term goals to eventually reach long-term goals, personalization of goals, praise messages, reminders to input self-tracking data into the technology, use of validity-tested devices, integration of self-tracking and persuasive eCoaching, and provision of face-to-face instructions during implementation. In addition, health outcomes or usability were not negatively affected when more effort was requested from participants to input data into the technology. The data extracted from the included publications provided limited ability to identify key components for adherence. However, one key component was identified for both usability and adherence, namely the provision of personalized content. Conclusions: This scoping review provides a first overview of the key components in automated healthy lifestyle interventions combining self-tracking and persuasive eCoaching that can be utilized during the development of such interventions. Future studies should focus on the identification of key components for effects on adherence, as adherence is a prerequisite for an intervention to be effective.

Background: Antimicrobial resistance poses a threat to patient safety worldwide. To stop antimicrobial resistance, Antimicrobial Stewardship Programs (ASPs; programs for optimizing antimicrobial use), need to be implemented. Within these programs, nurses are important actors, as they put antimicrobial treatment into effect. To optimally support nurses in ASPs, they should have access to information that supports them in their preparation, administration and monitoring tasks. In addition, it should help them to detect possible risks or adverse events associated with antimicrobial therapy. In this formative study, we investigate how nurses' can be supported in ASPs by means of an eHealth intervention that targets their information needs.Methods: We applied a participatory development approach that involves iterative cycles in which health care workers, mostly nurses, participate. Focus groups, observations, prototype evaluations (via a card sort task and a scenario-based information searching task) and interviews are done with stakeholders (nurses, managers, pharmacist, and microbiologist) on two pulmonary wards of a 1000-bed teaching hospital.Results: To perform the complex antimicrobial-related tasks well, nurses need to consult various information sources on a myriad of occasions. In addition, the current information infrastructure is unsupportive of ASP-related tasks, mainly because information is not structured to match nurse tasks, is hard to find, out of date, and insufficiently supportive of awareness. Based our findings, we created a concept for a nurse information application. We attuned the application's functionality, content, and structure to nurse work practice and tasks.Conclusions: By applying a participatory development approach, we showed that task support is a basic need for nurses. Participatory development proved useful regarding several aspects. First, it allows for combining bottom-up needs (nurses') and top-down legislations (medical protocols). Second, it enabled us to fragmentise and analyse tasks and to reduce and translate extensive information into task-oriented content. Third, this facilitated a tailored application to support awareness and enhance patient safety. Finally, the involvement of stakeholders created commitment and ownership, and helped to weigh needs from multiple perspectives.

Background Antibiotic resistance is a global threat to patient safety and care. In response, hospitals start antibiotic stewardship programs to optimise antibiotic use. Expert-based guidelines recommend strategies to implement such programs, but local implementations may differ per hospital. Earlier published assessments determine maturity of antibiotic stewardship programs based on expert-based structure indicators, but they disregard that there may be valid deviations from these expert-based programs. Aim To analyse the progress and barriers of local implementations of antibiotic stewardship programs with stakeholders in nine Dutch hospitals and to develop a toolkit that guides implementing local antibiotic stewardship programs. Methods An online questionnaire based on published guidelines and recommendations, conducted with seven clinical microbiologists, seven infectious disease physicians and five clinical pharmacists at nine Dutch hospitals. Results Results show local differences in antibiotic stewardship programs and the uptake of interventions in hospitals. Antibiotic guidelines and antibiotic teams are the most extensively implemented interventions. Education, decision support and audit-feedback are deemed important interventions and they are either piloted in implementations at academic hospitals or in preparation for application in non-academic hospitals. Other interventions that are recommended in guidelines - benchmarking, restriction and antibiotic formulary - appear to have a lower priority. Automatic stop-order, pre-authorization, automatic substitution, antibiotic cycling are not deemed to be worthwhile according to respondents. Conclusion There are extensive local differences in the implementation of antibiotic stewardship interventions. These differences suggest a need to further explore the rationale behind the choice of interventions in antibiotic stewardship programs. Rather than reporting this rationale, this study reports where rationale can play a key role in the implementation of antibiotic stewardship programs. A one-size-fits-all solution is unfeasible as there may be barriers or valid reasons for local experts to deviate from expert-based guidelines. Local experts can be supported with a toolkit containing advice based on possible barriers and considerations. These parameters can be used to customise an implementation of antibiotic stewardship programs to local needs (while retaining its expert-based foundation). Electronic supplementary material The online version of this article (doi:10.1186/2047-2994-3-33) contains supplementary material, which is available to authorized users.

This article introduces the theme issue on social interaction and reflection for behaviour change. A large body of research exists on systems designed to help users in changing their behaviours, for instance, to exercise more regularly or to reduce energy consumption. Increasingly, these systems focus on multiple users, often to encourage open-ended reflection rather than prescribing a particular course of action. As background for this theme issue, this article presents a literature review on behaviour change support systems that focus on social interaction and reflection. The review highlights five key approaches amongst these systems: social traces, social support, collective use, reflection-in-action, and reflection-on-action. Each approach offers unique benefits, but also challenges for the design of behaviour change support systems. We highlight how the articles in this theme issue contribute to our current understanding of these five approaches, and beyond that, set out some broad directions for future work.

BackgroundWeb-based interventions for the early treatment of depressive symptoms can be considered effective in reducing mental complaints. However, there is a limited understanding of which elements in an intervention contribute to effectiveness. For efficiency and effectiveness of interventions, insight is needed into the use of content and persuasive features. ObjectiveThe aims of this study were (1) to illustrate how log data can be used to understand the uptake of the content of a Web-based intervention that is based on the acceptance and commitment therapy (ACT) and (2) to discover how log data can be of value for improving the incorporation of content in Web-based interventions. MethodsData from 206 participants (out of the 239) who started the first nine lessons of the Web-based intervention, Living to the Full, were used for a secondary analysis of a subset of the log data of the parent study about adherence to the intervention. The log files used in this study were per lesson: login, start mindfulness, download mindfulness, view success story, view feedback message, start multimedia, turn on text-message coach, turn off text-message coach, and view text message. Differences in usage between lessons were explored with repeated measures ANOVAs (analysis of variance). Differences between groups were explored with one-way ANOVAs. To explore the possible predictive value of the login per lesson quartiles on the outcome measures, four linear regressions were used with login quartiles as predictor and with the outcome measures (Center for Epidemiologic Studies—Depression [CES-D] and the Hospital Anxiety and Depression Scale—Anxiety [HADS-A] on post-intervention and follow-up) as dependent variables. ResultsA significant decrease in logins and in the use of content and persuasive features over time was observed. The usage of features varied significantly during the treatment process. The usage of persuasive features increased during the third part of the ACT (commitment to value-based living), which might indicate that at that stage motivational support was relevant. Higher logins over time (9 weeks) corresponded with a higher usage of features (in most cases significant); when predicting depressive symptoms at post-intervention, the linear regression yielded a significant model with login quartile as a significant predictor (explained variance is 2.7%). ConclusionsA better integration of content and persuasive features in the design of the intervention and a better intra-usability of features within the system are needed to identify which combination of features works best for whom. Pattern recognition can be used to tailor the intervention based on usage patterns from the earlier lessons and to support the uptake of content essential for therapy. An adaptable interface for a modular composition of therapy features supposes a dynamic approach for Web-based treatment; not a predefined path for all, but a flexible way to go through all features that have to be used.

Tick bites and tick-borne infections are an increasingly large problem. There is a wide range of precautions that citizens can take, but compliance is low. Mobile technology can offer a solution here, as they allow citizens to access health information in context. In this article, we discuss the development of requirements for a mobile app to support citizens in dealing with ticks and tick bites. First, we identified organizational stakeholders based on relevant protocols, and primary end-users via a systematic risk determination procedure. Then, we profiled end-users based on 25 in-depth interviews. We consulted organizational stakeholders via a focus group. The mobile app should primarily motivate citizens to check themselves for tick bites after visiting a risk area. The app should also include a tick radar, alerts to remind people to check for tick bites, and the possibility to document tick bites. Our experiences underline the necessity of thoroughly investigating the designated end-users and their context of use in order to tailor preventive health advice, and we demonstrate how this can be done. Finally, this case shows the need to create persuasive health technology in order to maximize citizen compliance.

BackgroundRequirements development is a crucial part of eHealth design. It entails all the activities devoted to requirements identification, the communication of requirements to other developers, and their evaluation. Currently, a requirements development approach geared towards the specifics of the eHealth domain is lacking. This is likely to result in a mismatch between the developed technology and end user characteristics, physical surroundings, and the organizational context of use. It also makes it hard to judge the quality of eHealth design, since it makes it difficult to gear evaluations of eHealth to the main goals it is supposed to serve. ObjectiveIn order to facilitate the creation of eHealth that matters, we present a practical, multidisciplinary requirements development approach which is embedded in a holistic design approach for eHealth (the Center for eHealth Research roadmap) that incorporates both human-centered design and business modeling. MethodsOur requirements development approach consists of five phases. In the first, preparatory, phase the project team is composed and the overall goal(s) of the eHealth intervention are decided upon. Second, primary end users and other stakeholders are identified by means of audience segmentation techniques and our stakeholder identification method. Third, the designated context of use is mapped and end users are profiled by means of requirements elicitation methods (eg, interviews, focus groups, or observations). Fourth, stakeholder values and eHealth intervention requirements are distilled from data transcripts, which leads to phase five, in which requirements are communicated to other developers using a requirements notation template we developed specifically for the context of eHealth technologies. ResultsThe end result of our requirements development approach for eHealth interventions is a design document which includes functional and non-functional requirements, a list of stakeholder values, and end user profiles in the form of personas (fictitious end users, representative of a primary end user group). ConclusionsThe requirements development approach presented in this article enables eHealth developers to apply a systematic and multi-disciplinary approach towards the creation of requirements. The cooperation between health, engineering, and social sciences creates a situation in which a mismatch between design, end users, and the organizational context can be avoided. Furthermore, we suggest to evaluate eHealth on a feature-specific level in order to learn exactly why such a technology does or does not live up to its expectations.

BackgroundAlthough Web-based interventions have been shown to be effective, they are not widely implemented in regular care. Nonadherence (ie, participants not following the intervention protocol) is an issue. By studying the way Web-based interventions are used and whether there are differences between adherers (ie, participants that started all 9 lessons) and nonadherers, more insight can be gained into the process of adherence. ObjectiveThe aims of this study were to (1) describe the characteristics of participants and investigate their relationship with adherence, (2) investigate the utilization of the different features of the intervention and possible differences between adherers and nonadherers, and (3) identify what use patterns emerge and whether there are differences between adherers and nonadherers. MethodsData were used from 206 participants that used the Web-based intervention Living to the full, a Web-based intervention for the prevention of depression employing both a fully automated and human-supported format. Demographic and baseline characteristics of participants were collected by using an online survey. Log data were collected within the Web-based intervention itself. Both quantitative and qualitative analyses were performed. ResultsIn all, 118 participants fully adhered to the intervention (ie, started all 9 lessons). Participants with an ethnicity other than Dutch were more often adherers (χ21=5.5, P=.02), and nonadherers used the Internet more hours per day on average (F1,203=3.918, P=.049). A logistic regression showed that being female (OR 2.02, 95% CI 1.01-4.04; P=.046) and having a higher need for cognition (OR 1.02; 95% CI 1.00-1.05; P=.02) increased the odds of adhering to the intervention. Overall, participants logged in an average of 4 times per lesson, but adherers logged in significantly more times per lesson than nonadherers (F1,204=20.710; P

Background: Smartphones and tablet computers have become an integral part of our lives. One of their key features is the possibility of installing third-party apps. These apps can be very helpful for improving health and healthcare. However, medical professionals and citizens are currently being overloaded with health apps. Consequently, they will have difficulty with finding the right app, and information and features are fragmented over too many apps, thereby limiting their usefulness. Discussion: In order to combat health app overload, suppliers of apps need to do three things. One, join the open source movement, so that a few apps can work as gateway to medical information by incorporating information from different sources. Two, standardize content, so that the information provided via apps is readable. And third, in order to prevent information overload from occurring within an app, content should be personalized towards an individual’s characteristics and context. Summary: Suppliers of medical information and features need to join the open source movement and must make use of standardized medical information formats, in order to allow third parties to create valuable, mobile gateway apps. This can prevent the occurrence of health app overload. By going along in these trends, we can make health apps achieve the impact on healthcare quality and citizens’ health many of us envision.

BackgroundMany public health campaigns use a one-size-fits-all strategy to achieve their desired effect. Public health campaigns for tick bites and Lyme disease (LD) in many countries convey all relevant preventive measures to all members of the public. Although preventing tick bites (eg, by wearing protective clothing or using repellants) and checking for tick bites after visiting a risk area are effective and cost-efficient methods to prevent an individual from contracting a tick-borne disease, public compliance to these methods is low. ObjectiveWe aimed to identify the group of individuals within the general Dutch population that are at high risk of being bitten by a tick or developing LD and to describe their characteristics, knowledge, and perceptions. The incidence of patients visiting their general practitioner for tick bites and erythema migrans (the first sign of LD) has increased tremendously in the last decades in the Netherlands and other European countries; therefore, our efforts can be used to counter this troubling trend. MethodsWe conducted in-depth semi-structured interviews to identify individuals belonging to the average risk group. Participants were recruited in two ways. Patients who visited two municipal health services travel health clinics (one in a high-endemic area and one in a low-endemic area) were asked to participate. This resulted in 18 interviews. Further, parents were recruited using the convenience sampling method, which resulted in 7 interviews. We discontinued interviewing when the point of data saturation was reached. We analyzed the results immediately after each interview to identify the point of data saturation. Data saturation is when the new interviews provided no new information compared to the previous interviews. The interviews were transcribed and analyzed using inductive thematic analysis. ResultsWe identified four groups at risk of being bitten by ticks and developing LD among the general Dutch population. The groups were as follows: (1) outdoor people that check for tick bites, (2) outdoor people that do not check for tick bites, (3) parents that check their children for tick bites, and (4) parents that do not check their children for tick bites. Previous experience with ticks or LD was the main denominator between the groups. Checking for tick bites is a more easily adopted measure than preventing tick bites. Therefore, for all groups, public health efforts in the future should primarily emphasize on the importance of checking for tick bites. ConclusionsThe lightweight qualitative approach presented in this paper is highly relevant in tailoring public health efforts toward specific groups. The profiles of members in each risk group and the motivations underlying the behaviors of the members in each risk group can be used to determine the features and content of a targeted communication strategy about ticks and LD.

E-health can also improve health equity by facilitating access to health information and services. However, the success of e-health is lagging behind expectations. Studies have shown health care innovation to be very complex and there is little evidence that e-health technologies can improve health care.

BackgroundMany eHealth technologies are not successful in realizing sustainable innovations in health care practices. One of the reasons for this is that the current development of eHealth technology often disregards the interdependencies between technology, human characteristics, and the socioeconomic environment, resulting in technology that has a low impact in health care practices. To overcome the hurdles with eHealth design and implementation, a new, holistic approach to the development of eHealth technologies is needed, one that takes into account the complexity of health care and the rituals and habits of patients and other stakeholders. ObjectiveThe aim of this viewpoint paper is to improve the uptake and impact of eHealth technologies by advocating a holistic approach toward their development and eventual integration in the health sector. MethodsTo identify the potential and limitations of current eHealth frameworks (1999–2009), we carried out a literature search in the following electronic databases: PubMed, ScienceDirect, Web of Knowledge, PiCarta, and Google Scholar. Of the 60 papers that were identified, 44 were selected for full review. We excluded those papers that did not describe hands-on guidelines or quality criteria for the design, implementation, and evaluation of eHealth technologies (28 papers). From the results retrieved, we identified 16 eHealth frameworks that matched the inclusion criteria. The outcomes were used to posit strategies and principles for a holistic approach toward the development of eHealth technologies; these principles underpin our holistic eHealth framework. ResultsA total of 16 frameworks qualified for a final analysis, based on their theoretical backgrounds and visions on eHealth, and the strategies and conditions for the research and development of eHealth technologies. Despite their potential, the relationship between the visions on eHealth, proposed strategies, and research methods is obscure, perhaps due to a rather conceptual approach that focuses on the rationale behind the frameworks rather than on practical guidelines. In addition, the Web 2.0 technologies that call for a more stakeholder-driven approach are beyond the scope of current frameworks. To overcome these limitations, we composed a holistic framework based on a participatory development approach, persuasive design techniques, and business modeling. ConclusionsTo demonstrate the impact of eHealth technologies more effectively, a fresh way of thinking is required about how technology can be used to innovate health care. It also requires new concepts and instruments to develop and implement technologies in practice. The proposed framework serves as an evidence-based roadmap.

BackgroundRecent studies have shown the potential of Web-based interventions for changing dietary and physical activity (PA) behavior. However, the pathways of these changes are not clear. In addition, nonusage poses a threat to these interventions. Little is known of characteristics of participants that predict usage. ObjectiveIn this study we investigated the users and effect of the Healthy Weight Assistant (HWA), a Web-based intervention aimed at healthy dietary and PA behavior. We investigated the value of a proposed framework (including social and economic factors, condition-related factors, patient-related factors, reasons for use, and satisfaction) to predict which participants are users and which participants are nonusers. Additionally, we investigated the effectiveness of the HWA on the primary outcomes, self-reported dietary and physical activity behavior. MethodsOur design was a two-armed randomized controlled trial that compared the HWA with a waiting list control condition. A total of 150 participants were allocated to the waiting list group, and 147 participants were allocated to the intervention group. Online questionnaires were filled out before the intervention period started and after the intervention period of 12 weeks. After the intervention period, respondents in the waiting list group could use the intervention. Objective usage data was obtained from the application itself. ResultsIn the intervention group, 64% (81/147) of respondents used the HWA at least once and were categorized as “users.” Of these, 49% (40/81) used the application only once. Increased age and not having a chronic condition increased the odds of having used the HWA (age: beta = 0.04, P = .02; chronic condition: beta = 2.24, P = .003). Within the intervention group, users scored better on dietary behavior and on knowledge about healthy behavior than nonusers (self-reported diet: χ22 = 8.4, P = .02; knowledge: F1,125 = 4.194, P = .04). Furthermore, users underestimated their behavior more often than nonusers, and nonusers overestimated their behavior more often than users (insight into dietary behavior: χ22 = 8.2, P = .02). Intention-to-treat analyses showed no meaningful significant effects of the intervention. Exploratory analyses of differences between pretest and posttest scores of users, nonusers, and the control group showed that on dietary behavior only the nonusers significantly improved (effect size r = −.23, P = .03), while on physical activity behavior only the users significantly improved (effect size r = −.17, P = .03). ConclusionsRespondents did not use the application as intended. From the proposed framework, a social and economic factor (age) and a condition-related factor (chronic condition) predicted usage. Moreover, users were healthier and more knowledgeable about healthy behavior than nonusers. We found no apparent effects of the intervention, although exploratory analyses showed that choosing to use or not to use the intervention led to different outcomes. Combined with the differences between groups at baseline, this seems to imply that these groups are truly different and should be treated as separate entities. Trial registrationTrial ID number: ISRCTN42687923; http://www.controlled-trials.com/ISRCTN42687923/ (Archived by WebCite at http://www.webcitation.org/5xnGmvQ9Y)

The impact and uptake of information and communication technologies that support health care are rather low. Current frameworks for eHealth development suffer from a lack of fitting infrastructures, inability to find funding, complications with scalability, and uncertainties regarding effectiveness and sustainability. These issues can be addressed by defining a better implementation strategy early in the development of eHealth technologies. A business model, and thus business modeling, help to determine such an implementation strategy by involving all important stakeholders in a value-driven dialogue on what the technology should accomplish. This idea also seems promising to eHealth, as it can contribute to the whole development of eHealth technology. We therefore suggest that business modeling can be used as an effective approach to supporting holistic development of eHealth technologies. The contribution of business modeling is elaborated in this paper through a literature review that covers the latest business model research, concepts from the latest eHealth and persuasive technology research, evaluation and insights from our prior eHealth research, as well as the review conducted in the first paper of this series. Business modeling focuses on generating a collaborative effort of value cocreation in which all stakeholders reflect on the value needs of the others. The resulting business model acts as the basis for implementation. The development of eHealth technology should focus more on the context by emphasizing what this technology should contribute in practice to the needs of all involved stakeholders. Incorporating the idea of business modeling helps to cocreate and formulate a set of critical success factors that will influence the sustainability and effectiveness of eHealth technology.