IDEAS (Integrate, Design, Assess, and Share): A Framework and Toolkit of Strategies for the Development of More Effective Digital Interventions to Change Health Behavior

Recommendations for Methodology of Virtual Reality Clinical Trials in Health Care by an International Working Group: Iterative Study

BACKGROUND

Therapeutic virtual reality (VR) has emerged as an efficacious treatment modality for a wide range of health conditions. However, despite encouraging outcomes from early stage research, a consensus for the best way to develop and evaluate VR treatments within a scientific framework is needed.

OBJECTIVE

We aimed to develop a methodological framework with input from an international working group in order to guide the design, implementation, analysis, interpretation, and communication of trials that develop and test VR treatments.

METHODS

A group of 21 international experts was recruited based on their contributions to the VR literature. The resulting Virtual Reality Clinical Outcomes Research Experts held iterative meetings to seek consensus on best practices for the development and testing of VR treatments.

RESULTS

The interactions were transcribed, and key themes were identified to develop a scientific framework in order to support best practices in methodology of clinical VR trials. Using the Food and Drug Administration Phase I-III pharmacotherapy model as guidance, a framework emerged to support three phases of VR clinical study designs-VR1, VR2, and VR3. VR1 studies focus on content development by working with patients and providers through the principles of human-centered design. VR2 trials conduct early testing with a focus on feasibility, acceptability, tolerability, and initial clinical efficacy. VR3 trials are randomized, controlled studies that evaluate efficacy against a control condition. Best practice recommendations for each trial were provided.

CONCLUSIONS

Patients, providers, payers, and regulators should consider this best practice framework when assessing the validity of VR treatments.

Design Thinking to Improve Implementation of Public Health Interventions: An Exploratory Case Study on Enhancing Park Use

Design thinking, a human-centred, iterative process to innovate solutions aligned with communities' tacit knowledge, has the potential to augment public health interventions. This paper presents a case study of a design thinking workshop to illustrate the process and methods to train public health researchers. A workshop was conducted to engage participants in a systematic, non-linear process of design thinking to design possible interventions to enhance use of renovated New York City parks. Participants engaged in exercises to rapidly craft proposals for park re-design. The process involved learning about design methods to overcome limitations of linear thinking and how design thinking can be applied to public health problems that require community input. The case study demonstrated the feasibility of training public health researchers in design thinking methods that can be applied to public health problems. With increased capacity, public health researchers could apply design thinking to community collaborations to develop solutions embedded in the unique contexts of the community.

Integrating Taxonomies Into Theory-Based Digital Health Interventions for Behavior Change: A Holistic Framework

Digital health interventions (DHIs) have been emerging in the last decade. Due to their interdisciplinary nature, DHIs are guided and influenced by theories (eg, behavioral theories, behavior change technologies, and persuasive technology) from different research communities. However, DHIs are always coded using various taxonomies and reported in insufficient perspectives. This inconsistency and incomprehensiveness will cause difficulty in conducting systematic reviews and sharing contributions among communities. Therefore, based on existing related work, we propose a holistic framework that embeds behavioral theories, behavior change technique taxonomy, and persuasive system design principles. Including four development steps, two toolboxes, and one workflow, our framework aims to guide DHI developers to design, evaluate, and report their work in a formative and comprehensive way.

Parents' Perspectives on the Theoretical Domains Framework Elements Needed in a Pediatric Health Behavior App: A Crowdsourced Social Validity Study

Background

Most pediatric studies do not include parent stakeholders in the design of the intervention itself and many pediatric mobile health (mHealth) interventions are not meaningfully disseminated after the trial period ends. Consequently, the consumer desire for mobile apps targeting pediatric health behavior is likely to be met by commercial products that are not based in theory or evidence and may not take stakeholder preferences into account.

Objective

The aim was to assess parent preference for mobile app features that map onto specific Theoretical Domains Framework (TDF) elements.

Methods

This study was a crowdsourced social validity study of 183 parents who were asked to rate their preferences for mobile app features that correspond to elements of the TDF. The TDF organizes a large number of theoretical models and constructs into three components: (1) capability, (2) motivation, and (3) opportunity. Parents of children were recruited through Amazon Mechanical Turk.

Results

The majority of participants were Caucasian and mean age was 36.9 (SD 8.0) years. Results revealed broad acceptability of communication, motivation, and opportunity domains. However, the degree to which each domain was valued varied within behavioral category. Parents demonstrated a preference for increasing procedural knowledge for physical activity and diet behaviors over sleep (F_2,545=5.18, P=.006). Similarly, parents valued self-monitoring as more important for physical activity than sleep (F_2,546=4.04, P=.02). When asked about the value of features to help children develop skills, parents preferred those features for dietary behavior over sleep (F_2,546=3.57, P=.03). Parents perceived that goal-setting features would be most useful for physical activity over sleep and diet (F_2,545=5.30, P=.005). Incentive features within the app were seen as most useful for physical activity over sleep (F_2,546=4.34, P=.01).

Conclusions

This study presents a low-cost strategy for involving a large number of stakeholders in the discussion of how health behavior theory should be applied in a mHealth intervention. Our approach is innovative in that it took a scientific framework (ie, TDF) and made it digestible to parents so that they could then provide their opinions about features that might appear in a future app. Our survey items discriminated between various health behaviors allowing stakeholders to communicate the different health behaviors that they would like a TDF feature to change. Moreover, we were able to develop a set of consumer opinions about features that were directly linked to elements of the TDF.

Innovating From Within: A Process Model for User-Centered Digital Development in Academic Medical Centers

Background

Design thinking and human-centered design approaches have become increasingly common in health care literature, particularly in relation to health information technology (HIT), as a pathway toward the development of usable, diffusible tools and processes. There is a need in academic medical centers tasked with digital innovation for a comprehensive process model to guide development that incorporates current industry trends, including design thinking and lean and agile approaches to digital development.

Objective

This study aims to describe the foundations and phases of our model for user-centered HIT development.

Methods

Based on our experience, we established an integrated approach and rigorous process for HIT development that leverages design thinking and lean and agile strategies in a pragmatic way while preserving methodological integrity in support of academic research goals.

Results

A four-phased pragmatic process model was developed for user-centered digital development in HIT.

Conclusions

The model for user-centered HIT development that we developed is the culmination of diverse innovation projects and represents a multiphased, high-fidelity process for making more creative, flexible, efficient, and effective tools. This model is a critical step in building a rigorous approach to HIT design that incorporates a multidisciplinary, pragmatic perspective combined with academic research practices and state-of-the-art approaches to digital product development to meet the unique needs of health care.

Development of a self-guided web-based intervention to promote physical activity using the multi-process action control framework

PURPOSE

Physical activity promotion has mostly focused on theories of intention-formation, with the assumption that positive intentions will lead to behaviour. Though necessary, exercise intentions alone are often not sufficient to improve physical activity behaviour. The Multi-Process Action Control (M-PAC) framework builds on previous intention-based theories by including both determinants of intention formation and its translation into behaviour. The purpose of this study was to describe the process of developing a self-guided web-based intervention to promote physical activity among adults using the M-PAC model.

PROCEDURES

The development process consisted of the following three phases: 1) Intervention planning: determine intervention needs and requirements; 2) Intervention development: use an iterative process to design a web-based physical activity intervention based on the M-PAC framework; 3) Pilot testing: conduct usability and acceptability assessment on the web-based intervention to further enhance user experience.

PRINCIPAL RESULTS

The intervention planning phase suggested that there is a need for web-based physical activity interventions and there is currently no web-based intervention designed using the M-PAC model. In phase two, we adopted an iterative process to develop a 10-week self-guided web-based intervention to help adults (>18 years of age) to meet 150 min of moderate to vigorous physical activity per week. The pilot testing phase yielded valuable feedback on usability, content, and design of the web-based intervention.

MAJOR CONCLUSIONS

The development of a web-based physical activity intervention using the M-PAC model could further enhance the effectiveness of web-based interventions and have a significant impact on extending the reach of existing physical activity promotion programs. This study has reinforced the importance of an iterative development process that involves a multi-disciplinary team to design a web-based intervention to promote physical activity. The process enabled the team to clarify the needs for an intervention for our target users, and provided valuable feedback on the design and content of the web-based intervention. Future studies are now needed to evaluate the effectiveness of our web-based intervention.

Creating a Theoretically Grounded, Gamified Health App: Lessons From Developing the Cigbreak Smoking Cessation Mobile Phone Game

Background

Gaming techniques are increasingly recognized as effective methods for changing behavior and increasing user engagement with mobile phone apps. The rapid uptake of mobile phone games provides an unprecedented opportunity to reach large numbers of people and to influence a wide range of health-related behaviors. However, digital interventions are still nascent in the field of health care, and optimum gamified methods of achieving health behavior change are still being investigated. There is currently a lack of worked methodologies that app developers and health care professionals can follow to facilitate theoretically informed design of gamified health apps.

Objective

This study aimed to present a series of steps undertaken during the development of Cigbreak, a gamified smoking cessation health app.

Methods

A systematic and iterative approach was adopted by (1) forming an expert multidisciplinary design team, (2) defining the problem and establishing user preferences, (3) incorporating the evidence base, (4) integrating gamification, (5) adding behavior change techniques, (6) forming a logic model, and (7) user testing. A total of 10 focus groups were conducted with 73 smokers.

Results

Users found the app an engaging and motivating way to gain smoking cessation advice and a helpful distraction from smoking; 84% (62/73) of smokers said they would play again and recommend it to a friend.

Conclusions

A dedicated gamified app to promote smoking cessation has the potential to modify smoking behavior and to deliver effective smoking cessation advice. Iterative, collaborative development using evidence-based behavior change techniques and gamification may help to make the game engaging and potentially effective. Gamified health apps developed in this way may have the potential to provide effective and low-cost health interventions in a wide range of clinical settings.

Agile research to complement agile development: a proposal for an mHealth research lifecycle

Mobile health (mHealth) technology is increasingly being used, but academic evaluations supporting its use are not keeping pace. This is partly due to the disconnect between the traditional pharmaceutical approach to product evaluation, with its incremental approach, and the flexible way in which mHealth products are developed. An important step to addressing these problems lies in establishing agile research methods that complement the agile development methodologies used to create modern digital health applications. We describe an mHealth research model that mirrors traditional clinical research methods in its attention to safety and efficacy, while also accommodating the rapid and iterative development and evaluation required to produce effective, evidence-based, and sustainable digital products. This approach consists of a project identification stage followed by four phases of clinical evaluation: Phase 1: User Experience Design, Development, & Alpha Testing; Phase 2: Beta testing; Phase 3: Clinical Trial Evaluation; and Phase 4: Post-Market Surveillance. These phases include sample gating questions and are adapted to accommodate the unique nature of digital product development.

An Algorithm for Digital Medicine Testing: A NODE.Health Perspective Intended to Help Emerging Technology Companies and Healthcare Systems Navigate the Trial and Testing Period prior to Full-Scale Adoption

Over the last several years, there has been rapid growth of digital technologies attempting to transform healthcare. Unique features of digital medicine technology lead to both challenges and opportunities for testing and validation. Yet little guidance exists to help a health system decide whether to undertake a pilot test of new technology, move right to full-scale adoption or start somewhere in between. To navigate this complexity, this paper proposes an algorithm to help choose the best path toward validation and adoption. Special attention is paid to considering whether the needs of patients with limited digital skills, equipment (e.g., smart-phones) and connectivity (e.g., data plans) have been considered in technology development and deployment. The algorithm reflects the collective experience of 20+ health systems and academic institutions that have established the Network of Digital Evidence for Health, NODE. Health, plus insights from existing clinical research taxonomies, syntheses or frameworks for assessing technology or for reporting clinical trials.

3MD for Chronic Conditions, a Model for Motivational mHealth Design: Embedded Case Study

Background

Chronic conditions are the leading cause of death in the world. Major improvements in acute care and diagnostics have created a tendency toward the chronification of formerly terminal conditions, requiring people with these conditions to learn how to self-manage. Mobile technologies hold promise as self-management tools due to their ubiquity and cost-effectiveness. The delivery of health-related services through mobile technologies (mobile health, mHealth) has grown exponentially in recent years. However, only a fraction of these solutions take into consideration the views of relevant stakeholders such as health care professionals or even patients. The use of behavioral change models (BCMs) has proven important in developing successful health solutions, yet engaging patients remains a challenge. There is a trend in mHealth solutions called gamification that attempts to use game elements to drive user behavior and increase engagement. As it stands, designers of mHealth solutions for behavioral change in chronic conditions have no clear way of deciding what factors are relevant to consider.

Objective

The goal of this work is to discover factors for the design of mHealth solutions for chronic patients using negotiations between medical knowledge, BCMs, and gamification.

Methods

This study uses an embedded case study research methodology consisting of 4 embedded units: 1) cross-sectional studies of mHealth applications; 2) statistical analysis of gamification presence; 3) focus groups and interviews to relevant stakeholders; and 4) research through design of an mHealth solution. The data obtained was thematically analyzed to create a conceptual model for the design of mHealth solutions.

Results

The Model for Motivational Mobile-health Design (3MD) for chronic conditions guides the design of condition-oriented gamified behavioral change mHealth solutions. The main components are (1) condition specific, which describe factors that need to be adjusted and adapted for each particular chronic condition; (2) motivation related, which are factors that address how to influence behaviors in an engaging manner; and (3) technology based, which are factors that are directly connected to the technical capabilities of mobile technologies. The 3MD also provides a series of high-level illustrative design questions for designers to use and consider during the design process.

Conclusions

This work addresses a recognized gap in research and practice, and proposes a unique model that could be of use in the generation of new solutions to help chronic patients.

Health-e mums: Evaluating a smartphone app design for diabetes prevention in women with previous gestational diabetes

AIM

Women with prior gestational diabetes have increased risk for developing type 2 diabetes postpartum. While diabetes prevention programs are effective in reducing a woman's risk, the reach of traditional face-to-face programs is poor in this population and using a mHealth approach appears to be promising. We aimed to evaluate a pilot smartphone app developed from an evidence-based diabetes prevention program specifically for women with previous gestational diabetes mellitus using a series of focus groups to explore the app functionality and messaging.

METHODS

The Health-e Mums app underwent an iterative, three-phase development: initial development, wireframe development and pilot testing. Twenty-six women participated in four focus groups during the pilot-testing phase. The focus group transcripts were analysed thematically to evaluate the app functionality and user-experience.

RESULTS

Focus group participants identified diabetes screening confusion and a need for personalisation as sub-themes within the app functionality theme. The user-experience exploration found generally positive findings but participants had mixed responses to the utility of video segments and applying milestones relating to diabetes prevention guidelines.

CONCLUSIONS

A user-centred approach was taken to develop a diabetes prevention program app for women with prior gestational diabetes. Women were predominantly satisfied with the overall app design, how it functioned and what the user experience would be like when fully developed.

Communicating health-Optimising young adults' engagement with health messages using social media: Study protocol

BACKGROUND

Obesity is a global health problem. Understanding how to utilise social media (SM) as a platform for intervention and engagement with young adults (YAs) will help the practitioners to harness this media more effectively for obesity prevention.

AIM

Communicating health (CH) aims to understand the use of SM by YAs, including Aboriginal YAs, and in doing so will improve the effectiveness of SM strategies to motivate, engage and retain YAs in interventions to reduce the risk of obesity, and identify and disseminate effective ways for health professionals to deliver obesity prevention interventions via SM.

METHODS

The present study describes the theoretical framework and methodologies for the CH study, which is organised into four interrelated phases, each building on the outcomes of preceding phases. Phase 1 is a mixed methods approach to understand how YAs use SM to navigate their health issues, including healthy eating. Phase 2 utilises co-creation workshops where YAs and public health practitioners collaboratively generate healthy eating messages and communication strategies. Phase 3 evaluates these messages in a real-world setting. Phase 4 is the translation phase where public health practitioners use outcomes from CH to inform future strategies and to develop tools for SM for use by stakeholders and the research community.

DISCUSSION

The outcomes will include a rich understanding of psychosocial drivers and behaviours associated with healthy eating and will provide insight into the use of SM to reach and influence the health and eating behaviours of YAs.

Understanding the Acceptance of an eHealth Technology in the Early Stages of Development: An End-User Walkthrough Approach and Two Case Studies

Background

Studies that focus on the acceptance of an electronic health (eHealth) technology generally make use of surveys. However, results of such studies hold little value for a redesign, as they focus only on quantifying end-user appreciation of general factors (eg, perceived usefulness).

Objective

We present a method for understanding end-user acceptance of an eHealth technology, early in the development process: The eHealth End-User Walkthrough.

Methods

During a walkthrough, a participant is guided by using the technology via a scenario, a persona, and a low-fidelity protoype. A participant is questioned about factors that may affect acceptance during and after the demonstration. We show the value of the method via two case studies.

Results

During the case studies, participants commented on whether they intend to use a technology and why they would (not) use its main features. They also provided redesign advice or input for additional functions. Finally, the sessions provide guidance for the generation of business models and implementation plans.

Conclusions

The eHealth End-User Walkthrough can aid design teams in understanding the acceptance of their eHealth application in a very early stage of the design process. Consequently, it can prevent a mismatch between technology and end-users’ needs, wishes and context.

User-Centered App Adaptation of a Low-Intensity E-Mental Health Intervention for Syrian Refugees

Introduction: The aim of this study is to describe the initial stages of the iterative and user-centered mobile mental health adaptation process of Step-by-Step (SbS), a modularized and originally web-based e-mental health intervention developed by the World Health Organization (WHO). Given the great need for improving the responsiveness and accessibility of health systems in host countries, the EU-funded STRENGTHS consortium studies the adaptation, implementation and scaling-up of SbS for Syrian refugees in Germany, Sweden and Egypt. Using early prototyping, usability testing and identification of barriers to implementation, the study demonstrates a user-centered process of contextual adaptation to the needs and expectations of Syrian refugees. Materials and Methods: N = 128 adult Syrian refugees residing in Germany, Sweden and Egypt took part in qualitative assessments. Access, usage, and potential barriers regarding information and communication technologies (ICTs) were assessed in free list interviews. Interactive prototypes of the app were presented in key informant interviews and evaluated on usability, user experience and dissemination strategies. Focus groups were conducted to verify the results. The interview protocols were analyzed using inductive and deductive thematic analysis. Results: The use of digital technologies was found to be widespread among Syrian refugees. Technical literacy and problems with accessing the internet were common barriers. The majority of the respondents reacted positively to the presented app prototypes, stressing the potential health impact of the intervention (n = 28; 78%), its flexibility and customizability (n = 19; 53%) as well as the easy learnability of the app (n = 12; 33%). Aesthetic components (n = 12; 33%) and the overall length and pace of the intervention sessions (n = 9; 25%) were criticized in regard to their negative impact on user motivation. Acceptability, credibility, and technical requirements were identified as main barriers to implementation. Discussion: The study provided valuable guidance for adapting the app version of SbS and for mobile mental health adaptation in general. The findings underline the value of contextual adaptation with a focus on usability, user experience, and context specific dissemination strategies. Related factors such as access, acceptability and adherence have major implications for scaling-up digital interventions.

A Theoretically-Grounded Investigation of Perceptions About Healthy Eating and mHealth Support Among African American Men and Women in New Orleans, Louisiana

There has been a surge in diet-related mobile health (mHealth) interventions. However, diet-related mHealth research targeted toward racial/ethnic populations has been relatively limited. Focus groups with African American men and women from New Orleans, Louisiana, were conducted to (1) describe perceptions about healthy eating, (2) determine the acceptability of mHealth interventions, and (3) identify preferred mHealth intervention features. Descriptive statistics and thematic content analyses were performed. Qualitative data were organized within the context of the Theory of Planned Behavior and Social Cognitive Theory's theoretical components. Results may inform the development of mHealth research to improve eating behaviors among the target population.

Step-by-Step: a new WHO digital mental health intervention for depression

The World Health Organization is developing a range of interventions, including technology supported interventions, to help address the mental health treatment gap, particularly in low and middle-income countries. One of these, Step-by-Step, is a guided, technology supported, intervention for depression. It provides psychoeducation and training in behavioural activation through an illustrated narrative with additional therapeutic techniques such as stress management (slow breathing), identifying strengths, positive self-talk, increasing social support and relapse prevention. Step-by-Step has been designed so that it can be adapted for use in settings with different cultural contexts and resource availability and to be meaningful in communities affected by adversity. This paper describes the process of developing Step-by-Step and highlights particular design features aimed at increasing feasibility of implementation in a wide variety of settings.

REMIT: Development of a mHealth theory-based intervention to decrease heavy episodic drinking among college students

mHealth apps are an effective means of delivering health interventions, and the college-age population is particularly proficient at using apps. Informed by current theories of Ecological Momentary Interventions (EMI), Motivational Interviewing (MI), and the Transtheoretical Model (TTM) of Change, investigators have developed a self-monitoring app-Reductions through Ecological Momentary/Motivational Intervention/Transtheoretical (REMIT)-with the aim of reducing hazardous drinking among college students. The app was developed using the Integrate, Design, Assess, and Share (IDEAS) framework. This step-by-step process for developing digital behavior change interventions was conducted in five phases to: (1) understand the users, (2) determine target behavior, (3) base the intervention in behavioral theory; (4) create delivery strategies, and (5) develop the REMIT prototype. REMIT uses assessments (informed by EMI) and components of MI and TTM to guide administration of nine modules designed to engage users in reducing alcohol use and related problems. REMIT users self-monitor their alcohol consumption and develop strategies to change drinking behaviors using a range of easy-to-use features, such as the Virtual Coach, automated text messages, interactive gaming mechanisms (gamification), drink consumption tracking, and Blood Alcohol Concentration (BAC) calculators. mHealth interventions have been shown to reduce alcohol use among college students when they are applied in real-life, real-time contexts. REMIT is a theory-based app that incorporates user-friendly features to reduce hazardous drinking among college students. The next step is to conduct a pilot trial to test the efficacy of the app and enhance the REMIT prototype.

Factors Influencing Engagement and Behavioral Determinants of Infant Feeding in an mHealth Program: Qualitative Evaluation of the Growing Healthy Program

Background

Infant feeding practices, including breastfeeding and optimal formula feeding practices, can play a role in the prevention of childhood obesity. The ubiquity of smartphone ownership among women of childbearing age provides important opportunities for the delivery of low-cost, broad reach parenting interventions delivered by mobile phone (mHealth or mobile health interventions). Little is known about how parents engage with mHealth programs targeting infant feeding and how such programs might influence infant feeding practices.

Objective

The objectives of this study were to explore participant views on (1) factors influencing engagement with the Growing healthy program, an mHealth program targeting healthy infant feeding practices from birth to 9 months of age, and (2) the ways in which the program influenced behavioral determinants of capability, opportunity, and motivation for breastfeeding and optimal formula feeding behaviors.

Methods

Semistructured, telephone interviews were conducted with a purposeful sample (n=24) of mothers participating in the Growing healthy program. Interviews explored participants’ views about engagement with the program and its features, and the ways the program influenced determinants of infant feeding behaviors related to breastfeeding and optimal formula feeding. The interview schedule was informed by the Capability, Opportunity, Motivation, and Behavior (COM-B) model.

Results

Participants reported that engagement fluctuated depending on need and the degree to which the program was perceived to fit with existing parenting beliefs and values. Participants identified that the credibility of the program source, the user friendly interface, and tailoring of content and push notifications to baby’s age and key transition points promoted engagement, whereas technical glitches were reported to reduce engagement. Participants discussed that the program increased confidence in feeding decisions. For breastfeeding mothers, this was achieved by helping them to overcome doubts about breast milk supply, whereas mothers using formula reported feeling more confident to feed to hunger and satiety cues rather than encouraging infants to finish the bottle. Participants discussed that the program provided around-the-clock, readily accessible, nonjudgmental information and support on infant feeding and helped to reinforce information received by health professionals or encouraged them to seek additional help if needed. Participants reflected that their plans for feeding were typically made before joining the program, limiting the potential for the program to influence this aspect of motivation. Rather, the program provided emotional reassurance to continue with current feeding plans.

Conclusions

Our findings suggest that engagement with the program was influenced by an interplay between the program features and needs of the user. Participants reported that the program enhanced confidence in feeding decisions by providing a 24/7 accessible, expert, nonjudgmental support for infant feeding that complemented health professional advice. It is likely that interventions need to commence during pregnancy to maximize the impact on breastfeeding intentions and plans.

Beyond Adoption: A New Framework for Theorizing and Evaluating Nonadoption, Abandonment, and Challenges to the Scale-Up, Spread, and Sustainability of Health and Care Technologies

BACKGROUND

Many promising technological innovations in health and social care are characterized by nonadoption or abandonment by individuals or by failed attempts to scale up locally, spread distantly, or sustain the innovation long term at the organization or system level.

OBJECTIVE

Our objective was to produce an evidence-based, theory-informed, and pragmatic framework to help predict and evaluate the success of a technology-supported health or social care program.

METHODS

The study had 2 parallel components: (1) secondary research (hermeneutic systematic review) to identify key domains, and (2) empirical case studies of technology implementation to explore, test, and refine these domains. We studied 6 technology-supported programs-video outpatient consultations, global positioning system tracking for cognitive impairment, pendant alarm services, remote biomarker monitoring for heart failure, care organizing software, and integrated case management via data sharing-using longitudinal ethnography and action research for up to 3 years across more than 20 organizations. Data were collected at micro level (individual technology users), meso level (organizational processes and systems), and macro level (national policy and wider context). Analysis and synthesis was aided by sociotechnically informed theories of individual, organizational, and system change. The draft framework was shared with colleagues who were introducing or evaluating other technology-supported health or care programs and refined in response to feedback.

RESULTS

The literature review identified 28 previous technology implementation frameworks, of which 14 had taken a dynamic systems approach (including 2 integrative reviews of previous work). Our empirical dataset consisted of over 400 hours of ethnographic observation, 165 semistructured interviews, and 200 documents. The final nonadoption, abandonment, scale-up, spread, and sustainability (NASSS) framework included questions in 7 domains: the condition or illness, the technology, the value proposition, the adopter system (comprising professional staff, patient, and lay caregivers), the organization(s), the wider (institutional and societal) context, and the interaction and mutual adaptation between all these domains over time. Our empirical case studies raised a variety of challenges across all 7 domains, each classified as simple (straightforward, predictable, few components), complicated (multiple interacting components or issues), or complex (dynamic, unpredictable, not easily disaggregated into constituent components). Programs characterized by complicatedness proved difficult but not impossible to implement. Those characterized by complexity in multiple NASSS domains rarely, if ever, became mainstreamed. The framework showed promise when applied (both prospectively and retrospectively) to other programs.

CONCLUSIONS

Subject to further empirical testing, NASSS could be applied across a range of technological innovations in health and social care. It has several potential uses: (1) to inform the design of a new technology; (2) to identify technological solutions that (perhaps despite policy or industry enthusiasm) have a limited chance of achieving large-scale, sustained adoption; (3) to plan the implementation, scale-up, or rollout of a technology program; and (4) to explain and learn from program failures.

Supportive Mental Health Self-Monitoring among Smartphone Users with Psychological Distress: Protocol for a Fully Mobile Randomized Controlled Trial

Mobile health (mHealth) could be widely used in the population to improve access to psychological treatment. In this paper, we describe the development of a mHealth intervention on the basis of supportive self-monitoring and describe the protocol for a randomized controlled trial to evaluate its effectiveness among smartphone users with psychological distress. Based on power analysis, a representative quota sample of N = 186 smartphone users will be recruited, with an over-sampling of persons with moderate to high distress. Over a 4-week period, the intervention will be compared to a self-monitoring without intervention group and a passive control group. Telephone interviews will be conducted at baseline, post-intervention (4 weeks), and 12-week follow-up to assess study outcomes. The primary outcome will be improvement of mental health. Secondary outcomes will include well-being, intentions toward help-seeking and help-seeking behavior, user activation, attitudes toward mental-health services, perceived stigmatization, smartphone app quality, user satisfaction, engagement, and adherence with the intervention. Additionally, data from the user's daily life as collected during self-monitoring will be used to investigate risk and protective factors of mental health in real-world settings. Therefore, this study will allow us to demonstrate the effectiveness of a smartphone application as a widely accessible and low-cost intervention to improve mental health on a population level. It also allows to identify new assessment approaches in the field of psychiatric epidemiology.

ListeningTime; participatory development of a web-based preparatory communication tool for elderly cancer patients and their healthcare providers

OBJECTIVE

This paper outlines the participatory development process of a web-based preparatory communication tool for elderly cancer patients and their oncological healthcare providers (HCPs). This tool aims to support them to (better) prepare their encounters. An overarching aim of the project is to develop the tool in a participatory way to increase uptake and use.

METHODS

Scrum, a participatory framework originated from software development, was applied to develop the tool. Using constant feedback loops, elderly (former) cancer patients, oncological HCPs and their representatives were, as end-users, involved.

RESULTS

During six 'sprints', the communication tool 'ListeningTime' was developed with input from end-users. The use of scrum in developing an innovative tool was challenging in this context, because of time constraints of seriously-ill patients and busy HCPs and the co-creation involving non-profit scientific researchers and a for-profit development company.

CONCLUSIONS

The collaboration with end-users facilitated the development process of ListeningTime. Early involvement of end-users and flexibility in terms of planning and setup appear to be preconditions for creating a bottom-up inspired development procedure. Several challenges emerged from using scrum as participatory framework. Nevertheless, the 'pressure cooking situation', using scrum, resulted in a quick development process and a product ready for implementation.

Exploring the acceptability and feasibility of a preconception and diabetes information app for women with pregestational diabetes: A mixed-methods study protocol

Background

Women with diabetes are at increased risk of adverse maternal and fetal outcomes. Preconception care can improve pregnancy outcomes and is paramount to minimise complications, but, current provision is sub-optimal. Mobile technology, particularly smartphones and apps have the potential to improve preconception care provision but research is lacking in this area. The need to use modern technologies to improve preconception care knowledge and awareness led to the development of a preconception and diabetes information app in Stage A of this study.

Objective

The aim of this paper, Stage B of the study, is to explore the feasibility and acceptability of the Preconception and Diabetes Information app to improve preconception care knowledge and attitudes in women with diabetes, and explore the potential for wider implementation.

Methods

A mixed-methods study design adopting a quasi-experimental approach will assess women's knowledge and attitudes related to preconception care, and level of patient activation (knowledge and confidence for self-management of health) before and after the three-month intervention period. A log of activity will be used to determine engagement with the app and semi-structured interviews will explore women's experiences.

Conclusions

This is the first study to explore the acceptability and feasibility of a preconception and diabetes information app for women with diabetes. The app has potential to change the way preconception care is delivered, improve pregnancy outcomes and be widely implemented both in developed and developing countries. This is important given the considerable shortfalls in current preconception care services in the United Kingdom and around the world.

Accelerating Digital Mental Health Research From Early Design and Creation to Successful Implementation and Sustainment

Mental health problems are common and pose a tremendous societal burden in terms of cost, morbidity, quality of life, and mortality. The great majority of people experience barriers that prevent access to treatment, aggravated by a lack of mental health specialists. Digital mental health is potentially useful in meeting the treatment needs of large numbers of people. A growing number of efficacy trials have shown strong outcomes for digital mental health treatments. Yet despite their positive findings, there are very few examples of successful implementations and many failures. Although the research-to-practice gap is not unique to digital mental health, the inclusion of technology poses unique challenges. We outline some of the reasons for this gap and propose a collection of methods that can result in sustainable digital mental health interventions. These methods draw from human-computer interaction and implementation science and are integrated into an Accelerated Creation-to-Sustainment (ACTS) model. The ACTS model uses an iterative process that includes 2 basic functions (design and evaluate) across 3 general phases (Create, Trial, and Sustain). The ultimate goal in using the ACTS model is to produce a functioning technology-enabled service (TES) that is sustainable in a real-world treatment setting. We emphasize the importance of the service component because evidence from both research and practice has suggested that human touch is a critical ingredient in the most efficacious and used digital mental health treatments. The Create phase results in at least a minimally viable TES and an implementation blueprint. The Trial phase requires evaluation of both effectiveness and implementation while allowing optimization and continuous quality improvement of the TES and implementation plan. Finally, the Sustainment phase involves the withdrawal of research or donor support, while leaving a functioning, continuously improving TES in place. The ACTS model is a step toward bringing implementation and sustainment into the design and evaluation of TESs, public health into clinical research, research into clinics, and treatment into the lives of our patients.

Design of a Mobile App for Nutrition Education (TreC-LifeStyle) and Formative Evaluation With Families of Overweight Children

BACKGROUND

Nutrition and diet apps represent today a popular area of mobile health (mHealth), offering the possibility of delivering behavior change (BC) interventions for healthy eating and weight management in a scalable and cost-effective way. However, if commercial apps for pediatric weight management fail to retain users because of a lack of theoretical background and evidence-based content, mHealth apps that are more evidence-based are found less engaging and popular among consumers. Approaching the apps development process from a multidisciplinary and user-centered design (UCD) perspective is likely to help overcome these limitations, raising the chances for an easier adoption and integration of nutrition education apps within primary care interventions.

OBJECTIVE

The aim of this study was to describe the design and development of the TreC-LifeStyle nutrition education app and the results of a formative evaluation with families.

METHODS

The design of the nutrition education intervention was based on a multidisciplinary UCD approach, involving a team of BC experts, working with 2 nutritionists and 3 pediatricians from a primary care center. The app content was derived from evidence-based knowledge founded on the Food Pyramid and Mediterranean Diet guidelines used by pediatricians in primary care. A formative evaluation of the TreC-LifeStyle app involved 6 families of overweight children (aged 7-12 years) self-reporting daily food intake of children for 6 weeks and providing feedback on the user experience with the mHealth intervention. Analysis of the app's usage patterns during the intervention and of participants' feedback informed the refinement of the app design and a tuning of the nutrition education strategies to improve user engagement and compliance with the intervention.

RESULTS

Design sessions with the contribution of pediatricians and nutritionists helped define the nutrition education app and intervention, providing an effective human and virtual coaching approach to raise parents' awareness about children's eating behavior and lifestyle. The 6 families participating in the pilot study found the app usable and showed high compliance with the intervention over the 6 weeks, but analysis of their interaction and feedback showed the need for improving some of the app features related to the BC techniques "monitoring of the behavior" and "information provision."

CONCLUSIONS

The UCD and formative evaluation of TreC-LifeStyle show that nutrition education apps are feasible and acceptable solutions to support health promotion interventions in primary care.