Creating Gameful Design in mHealth: A Participatory Co-Design Approach

Influencing Factors and Implementation Pathways of Adherence Behavior in Intelligent Personalized Exercise Prescription: Qualitative Study

BACKGROUND

Personalized intelligent exercise prescriptions have demonstrated significant benefits in increasing physical activity and improving individual health. However, the health benefits of these prescriptions depend on long-term adherence. Therefore, it is essential to analyze the factors influencing adherence to personalized intelligent exercise prescriptions and explore the intrinsic relationship between individual behavioral motivation and adherence. This understanding can help improve adherence and maximize the effectiveness of such prescriptions.

OBJECTIVE

This study aims to identify the factors influencing adherence behavior among middle-aged and older community residents who have been prescribed personalized exercise regimens through an electronic health promotion system. It also explores how these factors affect the initiation and maintenance of adherence behavior.

METHODS

We used purposive sampling to conduct individual, face-to-face semistructured interviews based on the Transtheoretical Model (TTM) with 12 middle-aged and older community residents who had been following personalized exercise regimens for 8 months. These residents had received detailed exercise health education and guidance from staff. The interviews were recorded, transcribed verbatim, and analyzed using NVivo software through grounded theory. We then applied the TTM and multibehavioral motivation theory to analyze the factors influencing adherence. Additionally, the relationship between behavioral motivations and adherence was explored.

RESULTS

Using the behavior change stages of the TTM, open coding yielded 21 initial categories, which were then organized into 8 main categories through axial coding: intrinsic motivation, extrinsic motivation, benefit motivation, pleasure motivation, achievement motivation, perceived barriers, self-regulation, and optimization strategies. Selective coding further condensed these 8 main categories into 3 core categories: "multitheory motivation," "obstacle factors," and "solution strategies." Using the coding results, a 3-level model of factors influencing adherence to intelligent personalized exercise prescriptions was developed. Based on this, an implementation path for promoting adherence to intelligent personalized exercise prescriptions was proposed by integrating the model with the TTM.

CONCLUSIONS

Adherence to personalized exercise prescriptions is influenced by both facilitating factors (eg, multibehavioral motivation, optimization strategies) and obstructive factors (eg, perceived barriers). Achieving and maintaining adherence is a gradual process, shaped by a range of motivations and factors. Personalized solutions, long-term support, feedback mechanisms, and social support networks are essential for promoting adherence. Future efforts should focus on enhancing adherence by strengthening multibehavioral motivation, optimizing solutions, and addressing barriers to improve overall adherence.

Enhancing Digital Health Awareness and mHealth Competencies in Medical Education: Proof-of-Concept Study and Summative Process Evaluation of a Quality Improvement Project

BACKGROUND

Currently, there is a need to optimize knowledge on digital transformation in mental health care, including digital therapeutics (eg, prescription apps), in medical education. However, in Germany, digital health has not yet been systematically integrated into medical curricula and is taught in a relatively small number of electives. Challenges for lecturers include the dynamic field as well as lacking guidance on how to efficiently apply innovative teaching formats for these new digital competencies. Quality improvement projects provide options to pilot-test novel educational offerings, as little is known about the acceptability of participatory approaches in conventional medical education.

OBJECTIVE

This quality improvement project addressed the gap in medical school electives on digital health literacy by introducing and evaluating an elective scoping study on the systematic development of different health app concepts designed by students to cultivate essential skills for future health care professionals (ie, mobile health [mHealth] competencies).

METHODS

This proof-of-concept study describes the development, optimization, implementation, and evaluation of a web-based elective on digital (mental) health competencies in medical education. Implemented as part of a quality improvement project, the elective aimed to guide medical students in developing app concepts applying a design thinking approach at a German medical school from January 2021 to January 2024. Topics included defining digital (mental) health, quality criteria for health apps, user perspective, persuasive design, and critical reflection on digitization in medical practice. The elective was offered 6 times within 36 months, with continuous evaluation and iterative optimization using both process and outcome measures, such as web-based questionnaires. We present examples of app concepts designed by students and summarize the quantitative and qualitative evaluation results.

RESULTS

In total, 60 students completed the elective and developed 25 health app concepts, most commonly targeting stress management and depression. In addition, disease management and prevention apps were designed for various somatic conditions such as diabetes and chronic pain. The results indicated high overall satisfaction across the 6 courses according to the evaluation questionnaire, with lower scores indicating higher satisfaction on a scale ranging from 1 to 6 (mean 1.70, SD 0.68). Students particularly valued the content, flexibility, support, and structure. While improvements in group work, submissions, and information transfer were suggested, the results underscore the usefulness of the web-based elective.

CONCLUSIONS

This quality improvement project provides insights into relevant features for the successful user-centered and creative integration of mHealth competencies into medical education. Key factors for the satisfaction of students involved the participatory mindset, focus on competencies, discussions with app providers, and flexibility. Future efforts should define important learning objectives for digital health literacy and provide recommendations for integration rather than debating the need for digital health integration.

Citizen involvement in research on technological innovations for health, care or well-being: a scoping review

Citizen science can be a powerful approach to foster the successful implementation of technological innovations in health, care or well-being. Involving experience experts as co-researchers or co-designers of technological innovations facilitates mutual learning, community building, and empowerment. By utilizing the expert knowledge of the intended users, innovations have a better chance to get adopted and solve complex health-related problems. As citizen science is still a relatively new practice for health and well-being, little is known about effective methods and guidelines for successful collaboration. This scoping review aims to provide insight in (1) the levels of citizen involvement in current research on technological innovations for health, care or well-being, (2) the used participatory methodologies, and (3) lesson's learned by the researchers.A scoping review was conducted and reported in accordance with the PRISMA-ScR guidelines. The search was performed in SCOPUS in January 2021 and included peer-reviewed journal and conference papers published between 2016 and 2020. The final selection (N = 83) was limited to empirical studies that had a clear focus on technological innovations for health, care or well-being and involved citizens at the level of collaboration or higher. Our results show a growing interest in citizens science as an inclusive research approach. Citizens are predominantly involved in the design phase of innovations and less in the preparation, data-analyses or reporting phase. Eight records had citizens in the lead in one of the research phases.Researcher use different terms to describe their methodological approach including participatory design, co-design, community based participatory research, co-creation, public and patient involvement, partcipatory action research, user-centred design and citizen science. Our selection of cases shows that succesful citizen science projects develop a structural and longitudinal partnership with their collaborators, use a situated and adaptive research approach, and have researchers that are willing to abandon traditional power dynamics and engage in a mutual learning experience.

A pilot study of a new app based on self-compassion for the prevention and promotion of mental health among Brazilian college students

Introduction

Epidemiological data suggest substantial issues on the mental health of university students worldwide. Self-compassion is associated with lower rates of psychological distress and better positive mental health. Thus, we have developed a app-based intervention based on self-compassion principles targeting the prevention and promotion of mental health in college students. The current pilot study assessed adherence to intervention, preliminary mental health benefits, and satisfaction and acceptability with the app among Brazilian college students.

Methods

The study employed a pre-experimental single-group design along with pre-test and post-test assessments (n = 23). A mixed methods approach was utilized to comprehensively assess the outcomes of the intervention.

Results

The overall adherence rate for the intervention was 37.87%, with 26.26% of participants successfully completing all modules. Among the 21 outcomes assessed, 15 exhibited statistically significant results. Notably, there was a substantial increase in self-compassion, demonstrating a large effect size (d = 1.15), and a moderate effect size reduction in stress (d = 0.62) and anxiety (d = 0.52). All satisfaction indicators for the intervention received scores above 7. The intervention was well-received by participants who completed it, although a potential barrier identified was the volume of text within the app and the need to adopt a more playful and concise format for the intervention.

Discussion

Despite a notable participant dropout, the adherence to intervention aligns with patterns observed in other online interventions conducted in real-world settings. The observed mental health benefits, high satisfaction levels, and positive acceptance underscore the rationale for pursuing a subsequent randomized clinical trial.

How to design equitable digital health tools: A narrative review of design tactics, case studies, and opportunities

With a renewed focus on health equity in the United States driven by national crises and legislation to improve digital healthcare innovation, there is a need for the designers of digital health tools to take deliberate steps to design for equity in their work. A concrete toolkit of methods to design for health equity is needed to support digital health practitioners in this aim. This narrative review summarizes several health equity frameworks to help digital health practitioners conceptualize the equity dimensions of importance for their work, and then provides design approaches that accommodate an equity focus. Specifically, the Double Diamond Model, the IDEAS framework and toolkit, and community collaboration techniques such as participatory design are explored as mechanisms for practitioners to solicit input from members of underserved groups and better design digital health tools that serve their needs. Each of these design methods requires a deliberate effort by practitioners to infuse health equity into the approach. A series of case studies that use different methods to build in equity considerations are offered to provide examples of how this can be accomplished and demonstrate the range of applications available depending on resources, budget, product maturity, and other factors. We conclude with a call for shared rigor around designing digital health tools that deliver equitable outcomes for members of underserved populations.

MyHospitalVoice - a digital tool co-created with children and adolescents that captures patient-reported experience measures: a study protocol

BACKGROUND

Children and adolescents have the right to participate in decisions concerning their health and express their views, also regarding hospital experiences. Patient-reported experience measures (PREMs) are valuable tools for systematically incorporating patient voices into healthcare systems. New developments have focused on PREMs for children and adolescents, though they are more commonly used in adults. A recent systematic review mapping their use for children and adolescents indicates a growing interest in this area. However, most PREMs are completed by proxy, in this case parents, so they do not necessarily reflect children's experiences or align with their rights. Innovation is required to support and engage children and adolescents in responding to these types of questionnaires.

METHODS

Collaborating with children and adolescents (4-17 years), the primary aim of this study is to develop and validate the tool MyHospitalVoice containing digital and developmentally appropriate PREMs. The secondary aim is to document and evaluate the approaches used to involve children and adolescents and to assess the impact of their involvement. Based on the European Organisation for Research and Treatment of Cancer framework, we will divide its development and validation into four phases. First, we will discuss PREM items with children and adolescents, who will select and prioritise what they perceive as most important. Second, we will create items targeting different age groups (4-7, 8-12, and 13-17 years) and design a responsive digital interface with child and youth friendly ways of responding to the questionnaires. Third, we will explore how children and adolescents perceive MyHospitalVoice using cognitive interviewing techniques and other age-appropriate methods. Last, we will pilot test MyHospitalVoice to explore patient experiences and response rates. In each phase, children and adolescents will play an active role. We will involve young adults as peer researchers in the project group to ensure that their perspectives are part of the decision-making process.

DISCUSSION

This project will contribute to research on co-creating with children and adolescents and enhance our understanding of their patient experiences. A validated tool like MyHospitalVoice can help improve quality of care by translating the needs and preferences of children and adolescents into clinical practice.

Evaluating the Usability of an mHealth App for Empowering Cancer Survivors With Disabilities: Heuristic Evaluation and Usability Testing

BACKGROUND

More than 18 million cancer survivors are living in the United States. The effects of cancer and its treatments can have cognitive, psychological, physical, and social consequences that many survivors find incredibly disabling. Posttreatment support is often unavailable or underused, especially for survivors living with disabilities. This leaves them to deal with new obstacles and struggles on their own, oftentimes feeling lost during this transition. Mobile health (mHealth) interventions have been shown to effectively aid cancer survivors in dealing with many of the aftereffects of cancer and its treatments; these interventions hold immense potential for survivors living with disabilities. We developed a prototype for WeCanManage, an mHealth-delivered self-management intervention to empower cancer survivors living with disabilities through problem-solving, mindfulness, and self-advocacy training.

OBJECTIVE

Our study conducted a heuristic evaluation of the WeCanManage high-fidelity prototype and assessed its usability among cancer survivors with known disabilities.

METHODS

We evaluated the prototype using Nielsen's 10 principles of heuristic evaluation with 22 human-computer interaction university students. On the basis of the heuristic evaluation findings, we modified the prototype and conducted usability testing on 10 cancer survivors with a variety of known disabilities, examining effectiveness, efficiency, usability, and satisfaction, including a completion of the modified System Usability Scale (SUS).

RESULTS

The findings from the heuristic evaluation were mostly favorable, highlighting the need for a help guide, addressing accessibility concerns, and enhancing the navigation experience. After usability testing, the average SUS score was 81, indicating a good-excellent design. The participants in the usability testing sample expressed positive reactions toward the app's design, educational content and videos, and the available means of connecting with others. They identified areas for improvement, such as improving accessibility, simplifying navigation within the community forums, and providing a more convenient method to access the help guide.

CONCLUSIONS

Overall, usability testing showed positive results for the design of WeCanManage. The course content and features helped participants feel heard, understood, and less alone.

An Escape Game on University Students' Mental Health During the COVID-19 Pandemic: Cocreation Study

BACKGROUND

The COVID-19 pandemic has had a severe impact on students' mental health. Interventions are needed to promote their psychological well-being and prevent mental illnesses in the aftermath of this unprecedented situation. Digital escape games can be an effective tool to support students' mental health. A cocreation approach can improve the acceptability of these interventions by involving different stakeholders (eg, end users, game designers, and health professionals) to obtain audience-specific games.

OBJECTIVE

This study aims to describe the process of testing and optimizing the game "EscapeCovid" on students' mental health, to serve as a model for the cocreation of future similar interventions.

METHODS

The PRODUCES (Problem, Objective, Design, End Users, Cocreators, Evaluation, Scalability) framework was used. Cocreation steps (test and optimization) were detailed for replicability. A total of 45 students tested a pilot version of the game, with 10 undergoing a semistructured interview. Meetings with a group of stakeholders and brainwriting were organized to optimize the game.

RESULTS

We produced a new version of the game incorporating the suggestions provided by student testers and following the stakeholders' guidelines. Improvements were made to both the content and the form of the new version of the pilot game. The storyline, including the protagonist and the scenes, was adapted to the student population.

CONCLUSIONS

Our results suggested that cocreation can contribute to the design of more widely accepted interventions aimed at promoting mental health and preventing psychological disorders. Results also suggest that an end user-centered approach can facilitate intervention tailoring. When conceiving a health-related escape game for students, we recommend using the cocreation approach to enhance players' experience, thus positively influencing their learning process and overall well-being.

Personalized online intervention based on a risk algorithm for the universal prevention of anxiety disorders: Design and development of the prevANS intervention

Objective

To describe the design and development of prevANS, a personalized online intervention for the universal prevention of anxiety disorders based on a predictive risk algorithm. A user-centered approach was followed, considering the feedback of potential users and mental health professionals.

Methods

The study had three phases: (a) designing the intervention based on existing scientific literature; (b) piloting and evaluating the beta version involving potential users and health professionals; and (c) refining the intervention based on participants' suggestions. This iterative process aimed to refine the prevANS intervention before testing in a randomized controlled trial.

Results

The prevANS intervention provides personalized anxiety risk reports and components tailored to individuals' needs. Participants at low risk receive psychoeducation had access to a set of tools enhance protective factors. Moderate/high-risk individuals also receive cognitive-behavioral training. Both groups have access to a reward system and forum. Results from the design evaluation indicate that the prevANS interface is attractive and user-friendly and the psychoeducational materials helpful and engaging. The cognitive-behavioral training module received positive feedback. Participants suggested changes related to usability, content clarity, attractiveness, and engagement, which were implemented afterwards.

Conclusions

This article describes the development of a personalized intervention for preventing anxiety disorders using a validated risk prediction algorithm. The prevANS intervention was designed based on current scientific literature by a team of experts employing a user-centered approach. Research on the effectiveness of information and communication technologies in mental health prevention interventions considering user needs and preferences is warranted.

The Use of Gamification in the Self-Management of Patients With Chronic Diseases: Scoping Review

BACKGROUND

Chronic disease self-management is a public health issue of worldwide concern, and gamification is an emerging strategy to improve patients' participation in chronic disease self-management. Some studies have summarized designs for the gamification of chronic disease self-management from the perspective of eHealth technology, but they have not mentioned differences in design methods, functions, and evaluation methods of gamified designs for self-management in different chronic diseases.

OBJECTIVE

This scoping review aims to synthesize the characteristics of realization forms, functions, and evaluation methods in chronic disease self-management gamification to improve self-management among the chronic disease population.

METHODS

We applied a methodological framework for scoping reviews and the PRISMA-ScR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews) checklist. As of January 7, 2023, we systematically searched 9 databases for relevant studies from January 2012 to December 2022. Related data were extracted based on the research questions. We calculated the frequencies, charted the quantitative data, and coded the extracted material for qualitative content analysis.

RESULTS

We retrieved 16,221 records, of which 70 (0.43%) met the eligibility criteria. In the included research, the target populations for gamified designs for self-management of chronic diseases included patients with stroke, cancer, diabetes, chronic obstructive pulmonary disease, coronary heart disease, obesity, and hypertension. Almost all studies mentioned technical support for gamification (68/70, 97%), mainly in the form of active video games (58/70, 83%); however, less than half of the studies mentioned the theoretical basis for gamification (31/70, 44%). There were 37 concepts or theories relevant to gamification design, most of which were in the field of psychology or were cross-disciplinary (n=33, 89%). Gamification for the self-management of chronic diseases has been widely recognized, including for promoting physical exercise and rehabilitation training (48/99, 48%), increasing initiative for symptom management (18/99, 18%), providing psychological support (14/99, 14%), improving cognitive function (12/99, 12%), and improving medication adherence (7/99, 7%). A total of 39 studies mentioned the gamification effect; however, we did not find a unified evaluation standard.

CONCLUSIONS

This scoping review focuses on gamification designs for chronic disease self-management and summarizes the realization forms and functions of gamification in self-management for different patient populations. With practice in a gamified internet-based environment, patients can not only master the knowledge and skills of self-management in fascinating scenarios but also benefit from gaming experience and make better health-related decisions in real life. It is worth noting that a comprehensive evaluation of the users as well as a personalized and targeted intervention should be developed before gamification.

Women's experience of the health information process involving a digital information tool before commencing radiation therapy for breast cancer: a deductive interview study

BACKGROUND

Individuals undergoing radiation therapy for breast cancer frequently request information before, throughout and after the treatment as a means to reduce distress. Nevertheless, the provision of information to meet individuals needs from their level of health literacy is often overlooked. Thus, individuals information needs are often unmet, leading to reports of discontent. Internet and digital information technology has significantly augmented the available information and changed the way in which persons accesses and comprehends information. As health information is no longer explicitly obtained from healthcare professionals, it is essential to examine the sequences of the health information process in general, and in relation to health literacy. This paper reports on qualitative interviews, targeting women diagnosed with breast cancer who were given access to a health information technology tool, Digi-Do, before commencing radiation therapy, during, and after treatment.

METHODS

A qualitative research design, inspired by the integrated health literacy model, was chosen to enable critical reflection by the participating women. Semi-structured interviews were conducted with 15 women with access to a digital information tool, named Digi-Do, in addition to receiving standard information (oral and written) before commencing radiation therapy, during, and after treatment. A deductive thematic analysis process was conducted.

RESULTS

The results demonstrate how knowledge, competence, and motivation influence women's experience of the health information process. Three main themes were found: Meeting interactive and personal needs by engaging with health information; Critical recognition of sources of information; and Capability to communicate comprehended health information. The findings reflect the women's experience of the four competencies: to access, understand, appraise, and apply, essential elements of the health information process.

CONCLUSIONS

We can conclude that there is a need for tailored digital information tools, such as the Digi-Do, to enable iterative access and use of reliable health information before, during and after the radiation therapy process. The Digi-Do can be seen as a valuable complement to the interpersonal communication with health care professionals, facilitating a better understanding, and enabling iterative access and use of reliable health information before, during and after the radiotherapy treatment. This enhances a sense of preparedness before treatment starts.

Co-design and prototype development of the 'Ayzot App': A mobile phone based remote monitoring system for palliative care

BACKGROUND

Palliative care, a recognised component of care by the World Health Organization is poorly developed in low- and middle-income countries. Mobile phone technology, an effective way to increase access and sustainability of healthcare systems globally, has demonstrated benefits within palliative care service delivery, but is yet to be utilised in Ethiopia.

AIM

To co-design, develop and evaluate a mobile phone based remote monitoring system for use by palliative care patients in Ethiopia.

DESIGN

Two-phase co-design approach comprising multiple methods that is stakeholder interviews, focus groups, user-co-creation activities and healthcare worker prioritisation discussions 2019-2020. Phase-1 interviews (n = 40), Phase-2 focus groups (n = 3) and interviews (n = 10).

SETTING/PARTICIPANTS

Hospice Ethiopia and Yekatit 12 Medical College Hospital: healthcare workers, palliative care patients, family carers & software-developers.

RESULTS

Co-design activities lead to development of the prototype 'Ayzot' application, which was well received and reported to be easy to use. Patients, and family caregivers saw provision of self-care information and symptom management as a key function of the App and expressed very positive attitudes towards such information being included. Healthcare workers found the App offered service benefits, in terms of time and cost-savings.

CONCLUSION

This paper provides a detailed example of the development and design of a prototype remote monitoring system using mobile phone technology for palliative care use in Ethiopia. Further development and real-world testing are required, to not only understand how it acts within usual care to deliver anticipated benefits but also to explore its effectiveness and provide cost estimates for wider implementation.

Evaluation of an Electronic Care and Rehabilitation Planning Tool With Stroke Survivors With Aphasia: Usability Study

BACKGROUND

Patients with chronic illnesses with physical and cognitive disabilities, particularly stroke survivors with aphasia, are often not involved in design and evaluation processes. As a consequence, existing eHealth services often do not meet the needs of this group of patients, which has resulted in a digital divide.

OBJECTIVE

The aim of this study was to examine the effectiveness and user satisfaction of an electronic care and rehabilitation planning tool from the perspective of stroke survivors with aphasia. This would help us gain knowledge on how such a tool would need to be adapted for these patients for further development.

METHODS

Usability tests were conducted with 9 postdischarge stroke survivors with aphasia. Effectiveness was measured using task-based tests, and user satisfaction was studied through qualitative interviews at the end of each test. All tests were audio recorded, and each test lasted approximately 1 hour. The data were analyzed using qualitative content analysis. As the tool can be used by stroke survivors either independently or with some support from their next of kin or care professionals, the research group decided to divide the participants into 2 groups. Group 1 did not receive any support during the tests, and group 2 received some minor support from the moderator.

RESULTS

The results showed that the care and rehabilitation planning tool was not effective for stroke survivors with aphasia, as many participants in group 1 did not accomplish the tasks successfully. Despite several usability problems and challenges in using the tool because of patients' disabilities, the participants were positive toward using the tool and found it useful for their care and rehabilitation journey.

CONCLUSIONS

There is a need to involve patients with chronic illnesses more in the design and evaluation processes of health information systems and eHealth services. eHealth services and health information systems designed for this group of patients should be more adaptable and flexible to provide them with appropriate functionalities and features, meet their needs, and be useful and easy to use. In addition, the design and evaluation processes should be adapted, considering the challenges of this patient group.

A Mobile Application to Improve Diabetes Self-Management Using Rapid Prototyping: Iterative Co-Design Approach in Asian Settings

BACKGROUND

Diabetes is a global public health issue, causing burden on healthcare system and increasing risk of mortality. Mobile applications (apps) can be a promising approach to facilitate diabetes self-management. An increasingly utilized approach to facilitate engagement with mobile health (mHealth) technology is to involve potential users in the creation of the technology.

OBJECTIVE

The aim of this study was to use co-design for type 2 diabetes mellitus (T2DM) self-management mHealth development.

METHODS

Three rounds of iterative rapid prototyping panel sessions were conducted with a total of 9 T2DM participants in an Asian setting between Oct 2020 and April 2021. The participants were recruited through convenience sampling. For each round, feedback was gathered through qualitative interviews, and the feedback was used as a reference by the development team to develop and test a more refined version of the app in the next round. Transcribed semi-structured interview data was analyzed thematically using an inductive approach.

RESULTS

Participants' ages ranged from 40 to 69 years. Data saturation was reached, with no new themes emerging from the data. During the sessions, the participants expressed a variety of concerns and feedback on T2DM self-management using EMPOWER app and raised suggestions on the features of ideal T2DM self-management app. Important features include 1) reminders and notifications for medications, 2) Bluetooth integration with glucometers and blood pressure machines to minimize manual entry, 3) enlarged local food database including information on sugar content and recommendations for healthier options, 4) one touch for logging of routine medications and favorite foods, 5) export function for data sharing with physicians. Overall inputs concerned aspects such as user-friendliness of the app, customization possibilities, and educational content for the features in the mobile app.

CONCLUSION

In this study, we explored users' opinions on a T2DM self-management mobile app using co-design approach. This study adds to the growing body of literature on co-designing behavioral mHealth interventions and can potentially guide researchers in mobile app design for other chronic conditions.

The Challenges Toward Real-world Implementation of Digital Health Design Approaches: Narrative Review

BACKGROUND

Digital health represents an important strategy in the future of health care delivery. Over the past decade, mobile health has accelerated the agency of health care users. Despite prevailing excitement about the potential of digital health, questions remain on efficacy, uptake, usability, and patient outcome. This challenge is confounded by 2 industries, digital and health, which have vastly different approaches to research, design, testing, and implementation. In this regard, there is a need to examine prevailing design approaches, weigh their benefits and challenges toward implementation, and recommend a path forward that synthesizes the needs of this complex stakeholder group.

OBJECTIVE

In this review, we aimed to study prominent digital health intervention design approaches that mediate the digital health space. In doing so, we sought to examine the origins, perceived benefits, contrasting nuances, challenges, and typical use-case scenarios of each methodology.

METHODS

A narrative review of digital health design approaches was performed between September 2020 and April 2021 by referencing keywords such as "digital health design," "mHealth design," "e-Health design," "agile health," and "agile healthcare." The studies selected after screening were those that discussed the design and implementation of digital health design approaches. A total of 120 studies were selected for full-text review, of which 62 (51.6%) were selected for inclusion in this review.

RESULTS

A review identifying the 5 overarching digital health design approaches was compiled: user-centered design, person-based design, human-centered design, patient-centered design, and patient-led design. The findings were synthesized in a narrative structure discussing the origins, advantages, disadvantages, challenges, and potential use-case scenarios.

CONCLUSIONS

Digital health is experiencing the growing pains of rapid expansion. Currently, numerous design approaches are being implemented to harmonize the needs of a complex stakeholder group. Whether the end user is positioned as a person, patient, or user, the challenge to synthesize the constraints and affordances of both digital design and health care, built equally around user satisfaction and clinical efficacy, remains paramount. Further research that works toward a transdisciplinarity in digital health may help break down friction in this field. Until digital health is viewed as a hybridized industry with unique requirements rather than one with competing interests, the nuances that each design approach posits will be difficult to realize in a real-world context. We encourage the collaboration of digital and health experts within hybrid design teams, through all stages of intervention design, to create a better digital health culture and design ethos.

Developing an mHealth App for Empowering Cancer Survivors With Disabilities: Co-design Study

BACKGROUND

The transition from active treatment to long-term cancer survivorship leaves the needs of many cancer survivors unaddressed as they struggle with physical, cognitive, psychological, and social consequences of cancer and its treatment. The lack of guidance after treatment has forced cancer survivors to manage long-term effects on their own, which has an impact on their overall health, quality of life, and social participation. Mobile health (mHealth) interventions can be used to promote self-management and evidence-informed education.

OBJECTIVE

This study aims to design an mHealth app for cancer survivors with disabilities that will offer interventions to improve their quality of life and increase their self-efficacy to manage cancer as a chronic condition.

METHODS

We organized 3 co-design workshops with cancer survivors (n=5). These workshops included persona development based on data from 25 interviews with cancer survivors with disabilities; prototype ideation, where we sketched ideas for the prototype; and prototype development, where participants critiqued, and suggested improvements for, the wireframes.

RESULTS

These workshops helped us to define the challenges that cancer survivors with disabilities face as well as important considerations when designing an mHealth app for cancer survivors with disabilities, such as the need for including flexibility, engagement, socialization, and a minimalistic design. We also outline guidelines for other researchers to follow when planning their own co-design workshops, which include allowing more time for discussion among participants, having small participant groups, keeping workshops engaging and inclusive, and letting participants dream big.

CONCLUSIONS

Using a co-design process aided us in developing a prototype of an mHealth app for cancer survivors with disabilities as well as a list of guidelines that other researchers can use to develop their own co-design workshops and design their app. Furthermore, working together with cancer survivors ensured that the design team had a deeper sense of empathy toward the target users and kept the focus on our ultimate goal: creating something that cancer survivors would want to use and benefit from. Future work will include usability testing of a high-fidelity prototype based on the results of these workshops.

Using Distance Communication for the User-Centered Development of a Smartphone-Based Serious Game for Children With Type 1 Diabetes: Participatory Design Approach

Background

The complications of type 1 diabetes (T1D) can be delayed or prevented in children with T1D who receive proper self-management education. Smartphone-based serious games are increasingly being used as an effective tool for teaching self-management. When developing a serious game, it is important that the development process be user-centered. Traditionally, different face-to-face methods have been used when children participate in the development process. However, face-to-face data collection is not always feasible. In such situations, distance communication can be used when developing a serious game.

Objective

The objective of this study is to develop a user-centered smartphone-based serious game that teaches self-management focused on carbohydrate intake in children aged 8-14 years with T1D using distance communication in both the development and evaluation of the game.

Methods

The development and evaluation of a smartphone-based serious game prototype was inspired by the Lean principles, and a user-centered approach was applied. The development process included 1 expert interview and design workshops with children with T1D. On the basis of the interview and design workshop results, a serious game prototype was developed using Microsoft PowerPoint. The evaluation of the serious game prototype included an interview with a dietitian and a playtest with children with T1D. All data were collected using distance communication.

Results

A user-centered smartphone-based serious game prototype was developed and evaluated. The expert interview with the dietitian formed the basis for the learning outcomes in the game. Four children and their parents contributed to the preferences, needs, requirements, and ideas for selected parts of the game design. The dietitian evaluated the prototype positively and validated its content and accuracy. The serious game prototype was well-received by the children and their parents during the playtest. The serious game prototype was perceived as a useful and engaging way to learn. However, the difficulty level was not appropriate, and the information was too basic for participants who had been diagnosed over a year ago. The use of digital communication platforms did not cause any problems.

Conclusions

The smartphone-based serious game prototype has the potential to be a useful and attractive tool for teaching disease self-management. The use of distance communication proved to be a useful approach in the development of a serious game.

Pilot implementation of a user-driven, web-based application designed to improve sexual health knowledge and communication among young Zambians: a mixed method study (Preprint)

Background

Digital health interventions show promise in improving the uptake of HIV services among adolescents and young people aged 15 to 24 years in sub-Saharan Africa.

Objective

This study aimed to pilot-test a theory-based, empirically grounded web-based application designed to increase condom-related knowledge, sexual and reproductive health (SRH) communication, and healthier choices among young Zambians.

Methods

We conducted a pre-post quasi-experimental evaluation of the user-driven Be in the Know Zambia (BITKZ) web application using web-based surveys and in-depth interviews (IDIs) on the phone. We enrolled participants using social media advertisements. Our final analysis set comprised 46.04% (749/1627) of participants in the intervention group (which received the BITKZ link) and 53.96% (878/1627) of participants in the comparison group (no intervention). We collected survey data at study enrollment (baseline) and 5 weeks after the first enrollment in each group. Approximately 85% (637/749) of BITKZ users completed a user survey, of whom 9.3% (59/637) participated in IDIs. We calculated the time interfacing with BITKZ using the application log files. We conducted descriptive analyses to describe baseline characteristics and the user experience. At the endline, we assessed association using a t test and adjusted logistic regression for binary outcomes and ordinal regression for ordered outcomes, conditioning on age, sex, marital status, and employment status. We used adjusted average treatment effects (aATE) to assess the effects of BITKZ intervention. We conducted rapid matrix analyses of IDI transcripts in Microsoft Excel, sorting the data by theme, gender, and experience rating.

Results

Users rated BITKZ highly (excellent: 352/609, 57.8%; good: 218/609, 35.8%). At the endline, the intervention group had a higher level of knowledge related to condoms (adjusted odds ratio [aOR]: 1.35, 95% CI 1.06-1.69) and on wearing condoms correctly (aOR: 1.23, 95% CI 1.02-1.49). Those who had full-time employment had increased odds of knowing how to wear condoms correctly (aOR: 1.67, 95% CI 1.06-2.63) compared with those who reported being unemployed, as did men when compared with women (aOR: 1.92, 95% CI 1.59-2.31). Those in the intervention group were more likely to score higher for intention to test for sexually transmitted infections (STIs; aATE 0.21; P=.01) and HIV (aATE 0.32; P=.05), as well as for resisting peer pressure (aATE 2.64; P=.02). IDIs corroborated increased knowledge on correct condom use among men and female condoms among women, awareness of STIs and testing, and resistance to peer pressure. Interviewees provided examples of more open SRH communication with partners and peers and of considering, adopting, and influencing others to adopt healthier behaviors.

Conclusions

Despite the high baseline awareness of SRH among Zambian adolescents and young people with internet access, BITKZ provided modest gains in condom-related knowledge, resistance to peer pressure, and intention to test for STIs and HIV.

Determining Priorities in the Aboriginal and Islander Mental Health Initiative for Youth App Second Phase Participatory Design Project: Qualitative Study and Narrative Literature Review

Background

Digital mental health tools can promote access to culturally safe early intervention mental health services for Aboriginal and Torres Strait Islander young people. Participatory design methodology facilitates user engagement in the co-design of digital resources. However, several challenges have been identified that limit the methodological rigor of this approach.

Objective

This paper aims to present an in-depth account of the second phase of participatory design in the development of the Aboriginal and Islander Mental Health Initiative for Youth (AIMhi-Y) app.

Methods

A first idea storyboard, generated from a formative phase of the AIMhi-Y project, was refined through a series of youth co-design workshops and meetings. A narrative review of the literature, 6 service provider interviews, and engagement with an expert reference group also informed the design process. Generative design activities, storyboarding, discussions, and voting strategies were used.

Results

The participatory design process identified the app features preferred by young people and service providers and assessed their alignment with current recommendations from the scientific literature. Findings from the co-design process are presented across 9 app characteristic domains. Integration of findings into app design proved complex. Although most preferred features identified by young people were included to some degree, other inclusions were restricted by budget, time, and the need to integrate best practice recommendations. A process of prioritization was required.

Conclusions

Participatory design is often cited in the development of digital mental health resources; however, methods are diverse and often lack detailed descriptions. This study reports the outcomes and strategies used to determine priorities in the second phase of the development of the AIMhi-Y app. We provide an example and the key learnings to inform others seeking to use participatory design with a similar cohort.

Co-designing a dementia-specific education and training program for home care workers: The 'Promoting Independence Through quality dementia Care at Home' project

Undertaking co-design with the end users of services has rapidly evolved as the best-practice approach to program design, development and implementation. Increased interest in using participatory co-design in dementia care has drawn attention to the need for evidence-informed methods for facilitating the meaningful involvement of people with dementia and their family carers in co-design activities. The aim of this paper is to describe the co-design framework used in the co-design of a dementia specialist training program for home care workers. The Promoting Independence Through quality dementia Care at Home program is a successful example of co-design methodology used across multiple project stages and with various stakeholder groups, including people living with dementia, family carers, home care workers, managers and researchers. Co-design methods were tailored to each stage, purpose, and stakeholder group, and to facilitate the involvement of people living with dementia. Findings provide unique insights into optimising input from co-design partners, including people living with dementia; the methodology, conditions and requirements for participants to co-design and implement ideas; and perspectives on the enablers and challenges of using co-design in this population. In this paper, we present a comprehensive approach for involving people living with dementia as active and equal contributors in inclusive and meaningful participatory co-design.

A Mobile App to Support Self-management of Chronic Kidney Disease: Development Study

Background

Chronic kidney disease (CKD) is a common and costly condition that is usually accompanied by multiple comorbidities including type 2 diabetes, hypertension, and obesity. Proper management of CKD can delay or prevent kidney failure and help mitigate cardiovascular disease risk, which increases as kidney function declines. Smart device apps hold potential to enhance patient self-management of chronic conditions including CKD.

Objective

The objective of this study was to develop a mobile app to facilitate self-management of nondialysis-dependent CKD.

Methods

Our stakeholder team included 4 patients with stage 3-4 nondialysis-dependent CKD; a kidney transplant recipient; a caretaker; CKD care providers (pharmacists, a nurse, primary care physicians, a nephrologist, and a cardiologist); 2 health services and CKD researchers; a researcher in biomedical informatics, nutrition, and obesity; a system developer; and 2 programmers. Focus groups and in-person interviews with the patients and providers were conducted using a focus group and interview guide based on existing literature on CKD self-management and the mobile app quality criteria from the Mobile App Rating Scale. Qualitative analytic methods including the constant comparative method were used to analyze the focus group and interview data.

Results

Patients and providers identified and discussed a list of requirements and preferences regarding the content, features, and technical aspects of the mobile app, which are unique for CKD self-management. Requirements and preferences centered along themes of communication between patients and caregivers, partnership in care, self-care activities, adherence to treatment regimens, and self-care self-efficacy. These identified themes informed the features and content of our mobile app. The mobile app user can enter health data including blood pressure, weight, and blood glucose levels. Symptoms and their severity can also be entered, and users are prompted to contact a physician as indicated by the symptom and its severity. Next, mobile app users can select biweekly goals from a set of predetermined goals with the option to enter customized goals. The user can also keep a list of medications and track medication use. Our app includes feedback mechanisms where in-range values for health data are depicted in green and out-of-range values are depicted in red. We ensured that data entered by patients could be downloaded into a user-friendly report, which could be emailed or uploaded to an electronic health record. The mobile app also includes a mechanism that allows either group or individualized video chat meetings with a provider to facilitate either group support, education, or even virtual clinic visits. The CKD app also includes educational material on CKD and its symptoms.

Conclusions

Patients with CKD and CKD care providers believe that a mobile app can enhance CKD self-management by facilitating patient-provider communication and enabling self-care activities including treatment adherence.

Evaluating a Strengths-Based mHealth Tool (MyStrengths): Explorative Feasibility Trial

BACKGROUND

As the number of people living with chronic illnesses increases, providing wide-reaching and easy-to-use support tools is becoming increasingly important. Supporting people in this group to recognize and use more of their personal strengths has the potential to improve their quality of life. With this in mind, we have developed the MyStrengths app prototype, a gamefully designed app aimed at aiding users in both identifying their strengths and using these strengths more actively in their daily life.

OBJECTIVE

The goal of this study was to evaluate the user-reported feasibility and usefulness of the MyStrengths app. The study additionally aimed to explore whether the use of MyStrengths could be associated with selected psychosocial outcomes.

METHODS

A 31-day explorative feasibility trial with a pretest-posttest design and an optional end of study interview was conducted. Data collection included system-use log data, demographic information, pre- and post-psychosocial measures (ie, strengths use, self-efficacy, health-related quality of life, depression), user experience measures (ie, usability, engagement, flow), and interview data.

RESULTS

In total, 34 people with at least 1 chronic condition were enrolled in the study, with 26 participants (mean age 48 years, range 29-62 years; 1 male) completing the trial. Among these individuals, 18 were also interviewed posttrial. Participants used the MyStrengths app an average of 6 days during the trial period, with 54% (14/26) using the app over a period of at least 19 days. In total, 8738 unique app actions were registered. Of the psychosocial outcome measures, only 1 subscale, general health in the RAND 36-Item Health Survey, yielded significant pre- and posttest changes. Posttrial interviews showed that the number of participants who considered the MyStrengths app to be useful, somewhat useful, or not useful was evenly distributed across 3 groups. However, every participant did voice support for the strengths approach. All participants were able to identify a multitude of personal strengths using the MyStrengths app. Most participants that reported it to be useful had little or no previous experience with the personal strengths approach. A multitude of users welcomed the gameful design choices, particularly the rolling die feature, suggesting strengths exercises, activities that use a specific strength, were well received.

CONCLUSIONS

Although the reported usefulness and feedback from use varied, most participants were favorable to the strengths-focused approach to care and support. Consequently, low-threshold and wide-reaching mobile health tools that use a strengths-focused approach, such as MyStrengths, hold the potential to support people living with chronic illness in performing self-management and achieving mastery of their life.

Barriers and facilitators to adherence to national drug policies on antibiotic prescribing and dispensing in Bangladesh

BACKGROUND

The National Drug Policy in Bangladesh prohibits the sale and distribution of antibiotics without prescription from a registered physician. Compliance with this policy is poor; prescribing antibiotics by unqualified practitioners is common and over-the-counter dispensing widespread. In Bangladesh, unqualified practitioners such as drug shop operators are a major source of healthcare for the poor and disadvantaged. This paper reports on policy awareness among drug shop operators and their customers and identifies current dispensing practices, barriers and facilitators to policy adherence.

METHODS

We conducted a qualitative study in rural and urban Bangladesh from June 2019 to August 2020. This included co-design workshops (n = 4) and in-depth interviews (n = 24) with drug shop operators and customers/household members, key informant interviews (n = 12) with key personnel involved in aspects of the antibiotic supply chain including pharmaceutical company representatives, and model drug shop operators; and a group discussion with stakeholders representing key actors in informal market systems namely: representatives from the government, private sector, not-for-profit sector and membership organizations.

RESULTS

Barriers to policy compliance among drug shop operators included limited knowledge of government drug policies, or the government-led Bangladesh Pharmacy Model Initiative (BPMI), a national guideline piloted to regulate drug sales. Drug shop operators had no clear knowledge of different antibiotic generations, how and for what diseases antibiotics work contributing to inappropriate antibiotic dispensing. Nonetheless, drug shop operators wanted the right to prescribe antibiotics based on having completed related training. Drug shop customers cited poor healthcare facilities and inadequate numbers of attending physician as a barrier to obtaining prescriptions and they described difficulties differentiating between qualified and unqualified providers.

CONCLUSION

Awareness of the National Drug Policy and the BPMI was limited among urban and rural drug shop operators. Poor antibiotic prescribing practice is additionally hampered by a shortage of qualified physicians; cultural and economic barriers to accessing qualified physicians, and poor implementation of regulations. Increasing qualified physician access and increasing training and certification of drug shop operators could improve the alignment of practices with national policy.

Conceptual Ambiguity Surrounding Gamification and Serious Games in Health Care: Literature Review and Development of Game-Based Intervention Reporting Guidelines (GAMING)

BACKGROUND

In health care, the use of game-based interventions to increase motivation, engagement, and overall sustainability of health behaviors is steadily becoming more common. The most prevalent types of game-based interventions in health care research are gamification and serious games. Various researchers have discussed substantial conceptual differences between these 2 concepts, supported by empirical studies showing differences in the effects on specific health behaviors. However, researchers also frequently report cases in which terms related to these 2 concepts are used ambiguously or even interchangeably. It remains unclear to what extent existing health care research explicitly distinguishes between gamification and serious games and whether it draws on existing conceptual considerations to do so.

OBJECTIVE

This study aims to address this lack of knowledge by capturing the current state of conceptualizations of gamification and serious games in health care research. Furthermore, we aim to provide tools for researchers to disambiguate the reporting of game-based interventions.

METHODS

We used a 2-step research approach. First, we conducted a systematic literature review of 206 studies, published in the Journal of Medical Internet Research and its sister journals, containing terms related to gamification, serious games, or both. We analyzed their conceptualizations of gamification and serious games, as well as the distinctions between the two concepts. Second, based on the literature review findings, we developed a set of guidelines for researchers reporting on game-based interventions and evaluated them with a group of 9 experts from the field.

RESULTS

Our results show that less than half of the concept mentions are accompanied by an explicit definition. To distinguish between the 2 concepts, we identified four common approaches: implicit distinction, synonymous use of terms, serious games as a type of gamified system, and distinction based on the full game dimension. Our Game-Based Intervention Reporting Guidelines (GAMING) consist of 25 items grouped into four topics: conceptual focus, contribution, mindfulness about related concepts, and individual concept definitions.

CONCLUSIONS

Conceptualizations of gamification and serious games in health care literature are strongly heterogeneous, leading to conceptual ambiguity. Following the GAMING can support authors in rigorous reporting on study results of game-based interventions.

Mobile Health for Smoking Cessation Among Disadvantaged Young Women During and After Pregnancy: User-Centered Design and Usability Study

Background

Smoking prevalence during and after pregnancy remains high among socioeconomically disadvantaged women. Mobile health (mHealth) apps with game and social support elements seem promising to support smoking cessation.

Objective

This study aims to describe the user-centered design and usability evaluation of Kindle, an mHealth app with game and social support elements, to support disadvantaged young women during and after pregnancy through the first stages of smoking cessation.

Methods

Disadvantaged women (n=9), members of their social networks (n=4), and nurses supporting these women (n=51) were informants throughout the iterative prototype development of Kindle according to the International Organization for Standardization 9241-11:2018. Specific phases included understanding the context of use through secondary analysis of qualitative interview data (phase 1), establishing the user and organizational requirements (phase 2), production of design solutions (phase 3), and usability inspection of the prototype through a heuristic evaluation (3 experts) along with user testing by a think aloud method (5 disadvantaged women and 5 nurses; phase 4). Usability problems were categorized according to the principles of the Healthcare Information and Management Systems Society.

Results

Phase 1 resulted in an understanding of the VoorZorg program and the needs of VoorZorg nurses and clients (eg, focus on early stages of change and building new supportive networks to aid clients in smoking cessation). In phase 2, we established requirements (n=22; eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring at early stages of change in smoking cessation). Phase 3 resulted in a prototype of Kindle, combining the interface for nurses and clients, including the following functionalities: personal goal setting with earning points; secured chat function between nurses and other clients; and tips, diary, and profile creation. The heuristic evaluation and thinking aloud method in phase 4 revealed 78 usability problems in the interfaces. Most usability problems concerned simplicity (eg, unclear clickable button) and naturalness (eg, unclear icon).

Conclusions

The user-centered design and usability testing of the mHealth app Kindle yielded useful insights. The involvement of end users, specifically socioeconomically disadvantaged women during and after their pregnancy, resulted in a prototype that met their needs and requirements (eg, mHealth app, secure communication between nurses and clients, easy-to-use interfaces, inclusion of game elements, and tailoring to the early stages of change in smoking cessation) to achieve readiness for smoking cessation. Moreover, the usability evaluation by end users and experts revealed unique usability problems for this population. These insights allow for further optimization of Kindle and encourage future studies to engage disadvantaged populations in all phases of mHealth intervention design and usability testing.

The Influence of Gamification and Information Technology Identity on Postadoption Behaviors of Health and Fitness App Users: Empirical Study in the United States

BACKGROUND

The use of health and fitness apps has been on the rise to monitor personal fitness and health parameters. However, recent research discovered that many users discontinue using these apps after only a few months. Gamification has been suggested as a technique to increase users' interactions with apps. Nevertheless, it is still not clear how gamification mechanisms encourage continued use and inspire user self-management.

OBJECTIVE

The main objective of this study was to articulate how gamification mechanisms in studies of designing and using health and fitness apps can contribute to the realization of information technology (IT) identity and positive behavioral outcomes. The broader goal was to shed light on how gamification mechanisms will translate into positive use behaviors in the context of mobile health apps.

METHODS

Data were collected from 364 users of health and fitness apps through an online survey to empirically examine the proposed model.

RESULTS

Based on identity theories, this study suggests the fully mediating role of IT identity to describe how gamification elements can lead to continued intention to use health and fitness apps, and increase users' tendency for information sharing through the apps. The findings indicate that perceived gamification can increase users' IT identity. In turn, a higher IT identity would encourage users to continue using the apps and share more personal health information with others through the apps.

CONCLUSIONS

The results of this study can have practical implications for app designers to use gamification elements to increase users' dependency, relatedness, and emotional energy associated with health apps. Moreover, the findings can have theoretical contributions for researchers to help better articulate the process in which gamification can be translated into positive use behaviors.

A Systematic Review of Design Workshops for Health Information Technologies

Background: Design workshops offer effective methods in eliciting end-user participation from design inception to completion. Workshops unite stakeholders in the utilization of participatory methods, coalescing in the best possible creative solutions. Objective: This systematic review aimed to identify design approaches whilst providing guidance to health information technology designers/researchers in devising and organizing workshops. Methods: A systematic literature search was conducted in five medical/library databases identifying 568 articles. The initial duplication removal resulted in 562 articles. A criteria-based screening of the title field, abstracts, and pre-full-texts reviews resulted in 72 records for full-text review. The final review resulted in 10 article exclusions. Results: 62 publications were included in the review. These studies focused on consumer facing and clinical health information technologies. The studied technologies involved both clinician and patients and encompassed an array of health conditions. Diverse workshop activities and deliverables were reported. Only seven publications reported workshop evaluation data. Discussion: This systematic review focused on workshops as a design and research activity in the health informatics domain. Our review revealed three themes: (1) There are a variety of ways of conducting design workshops; (2) Workshops are effective design and research approaches; (3) Various levels of workshop details were reported.

Co-Design for People-Centred Care Digital Solutions: A Literature Review

Introduction:

The implementation of people-centred care requires strategies that respond to local conditions and contexts, with the participation of local stakeholders in collaborative approaches such as co-design. Within this framework, the authors performed a literature review to identify the most implemented practices in health and social care services for co-designing digital solutions.

Methods:

The literature review was conducted following five steps: (i) Definition of the Keywords and their relations; (ii) Definition of the selection criteria; (iii) Search in PubMed; (iv) Selection of papers; and (v) Analysis of the selected papers.

Results:

20 papers addressed to co-design health digital solutions with stakeholders were analysed in terms of the activities implemented and participants involved.

Discussion:

Previous studies using co-design methods for the deployment of health digital solutions employed a wide range of activities, most of them combining activities and/or mixed target groups.

Conclusion:

Co-design is the key to deliver people-centred care as it allows to involve stakeholders in the development of health digital solutions. Implementing one or more of the co-design methods identified in this literature review should be considered to better address the needs and specific projects and target groups.

Designing the Optimal Digital Health Intervention for Patients' Use Before and After Elective Orthopedic Surgery: Qualitative Study

Background

Health behavior changes made by patients during the perioperative period can impact the outcomes and success of elective surgeries. However, there remains a limited understanding of how best to support patients during this time, particularly through the use of digital health interventions. Recognizing and understanding the potential unmet needs of elective orthopedic surgery patients is central to motivating healthier behavior change, improving recovery, and optimizing overall surgical success in the short and long term.

Objective

The aim of this study is to explore patient perspectives on technology features that would help support them to change their lifestyle behaviors during the pre- and postoperative periods, and that could potentially maintain long-term healthy lifestyles following recovery.

Methods

Semistructured interviews with pre- and postoperative elective orthopedic patients were conducted between May and June 2020 using telephone and video call–based software. Patient perspectives on the use of digital technologies to complement current surgical care and support with lifestyle behavior changes were discussed. Interviews were audio recorded and transcribed verbatim. Reflexive thematic analysis enabled the development of themes from the data, with QSR NVivo software (version 12) facilitating data management. Ethical approval was obtained from the National Health Service Health Research Authority.

Results

A total of 18 participants were interviewed. Four themes were developed from the data regarding the design and functionality of digital technologies to best support the perioperative journey. These center around an intervention’s ability to incorporate interactive, user-centered features; direct a descriptive and structured recovery; enable customizable, patient-controlled settings; and deliver both general and specific surgical advice in a timely manner. Interventions that are initiated preoperatively and continued postoperatively were perceived as beneficial. Interventions designed with personalized milestones were found to better guide patients through a structured recovery. Individualized tailoring of preparatory and recovery information was desired by patients with previously high levels of physical activity before surgery. The use of personalized progression-based exercises further encouraged physical recovery; game-like rewards and incentives were regarded as motivational for making and sustaining health behavior change. In-built video calling and messaging features offered connectivity with peers and clinicians for supported care delivery.

Conclusions

Specific intervention design and functionality features can provide better, structured support for elective orthopedic patients across the entire surgical journey and beyond. This study provides much-needed evidence relating to the optimal design and timing of digital interventions for elective orthopedic surgical patients. Findings from this study suggest a desire for personalized perioperative care, in turn, supporting patients to make health behavior changes to optimize surgical success. These findings should be used to influence future co-design projects to enable the design and implementation of patient-focused, tailored, and targeted digital health technologies within modern health care settings.

Recommendations for Designing Health Information Technologies for Mental Health Drawn From Self-Determination Theory and Co-design With Culturally Diverse Populations: Template Analysis

BACKGROUND

Culturally diverse populations (including Aboriginal and Torres Strait Islander people, people of diverse genders and sexualities, and culturally and linguistically diverse people) in nonurban areas face compounded barriers to accessing mental health care. Health information technologies (HITs) show promising potential to overcome these barriers.

OBJECTIVE

This study aims to identify how best to improve a mental health and well-being HIT for culturally diverse Australians in nonurban areas.

METHODS

We conducted 10 co-design workshops (N=105 participants) in primary youth mental health services across predominantly nonurban areas of Australia and conducted template analysis on the workshop outputs. Owing to local (including service) demographics, the workshop participants naturalistically reflected culturally diverse groups.

RESULTS

We identified 4 main themes: control, usability, affirmation, and health service delivery factors. The first 3 themes overlap with the 3 basic needs postulated by self-determination theory (autonomy, competence, and relatedness) and describe participant recommendations on how to design an HIT. The final theme includes barriers to adopting HITs for mental health care and how HITs can be used to support care coordination and delivery. Hence, it describes participant recommendations on how to use an HIT.

CONCLUSIONS

Although culturally diverse groups have specific concerns, their expressed needs fall broadly within the relatively universal design principles identified in this study. The findings of this study provide further support for applying self-determination theory to the design of HITs and reflect the tension in designing technologies for complex problems that overlap multiple medical, regulatory, and social domains, such as mental health care. Finally, we synthesize the identified themes into general recommendations for designing HITs for mental health and provide concrete examples of design features recommended by participants.

The Design and Development of a Personalized Leisure Time Physical Activity Application Based on Behavior Change Theories, End-User Perceptions, and Principles From Empirical Data Mining

Introduction: Many adults do not reach the recommended physical activity (PA) guidelines, which can lead to serious health problems. A promising method to increase PA is the use of smartphone PA applications. However, despite the development and evaluation of multiple PA apps, it remains unclear how to develop and design engaging and effective PA apps. Furthermore, little is known on ways to harness the potential of artificial intelligence for developing personalized apps. In this paper, we describe the design and development of the Playful data-driven Active Urban Living (PAUL): a personalized PA application. Methods: The two-phased development process of the PAUL apps rests on principles from the behavior change model; the Integrate, Design, Assess, and Share (IDEAS) framework; and the behavioral intervention technology (BIT) model. During the first phase, we explored whether location-specific information on performing PA in the built environment is an enhancement to a PA app. During the second phase, the other modules of the app were developed. To this end, we first build the theoretical foundation for the PAUL intervention by performing a literature study. Next, a focus group study was performed to translate the theoretical foundations and the needs and wishes in a set of user requirements. Since the participants indicated the need for reminders at a for-them-relevant moment, we developed a self-learning module for the timing of the reminders. To initialize this module, a data-mining study was performed with historical running data to determine good situations for running. Results: The results of these studies informed the design of a personalized mobile health (mHealth) application for running, walking, and performing strength exercises. The app is implemented as a set of modules based on the persuasive strategies "monitoring of behavior," "feedback," "goal setting," "reminders," "rewards," and "providing instruction." An architecture was set up consisting of a smartphone app for the user, a back-end server for storage and adaptivity, and a research portal to provide access to the research team. Conclusions: The interdisciplinary research encompassing psychology, human movement sciences, computer science, and artificial intelligence has led to a theoretically and empirically driven leisure time PA application. In the current phase, the feasibility of the PAUL app is being assessed.

Recommendations for Implementing Gamification for Mental Health and Wellbeing

Gamification is increasingly being proposed as a strategy to increase engagement for mental health and wellbeing technologies. However, its implementation has been criticized as atheoretical, particularly in relation to behavior change theory and game studies theories. Definitions of the term “gamification” vary, sometimes widely, between and within academic fields and the effectiveness of gamification is yet to be empirically established. Despite this, enthusiasm for developing gamified mental health technologies, such as interventions, continues to grow. There is a need to examine how best to implement gamification in mental health and wellbeing technologies in a way that takes quick production cycles into account while still emphasizing empirical investigation and building a rigorous evidence base. With reference to game studies and the medical (eHealth/mHealth) literature, this article interrogates gamification for mental health and wellbeing by examining core properties of the game form. It then explores how gamification can best be conceptualized and implemented for mental health and wellbeing goals from conceptualization through to iterative co-development and evaluation that accommodates software development schedules. Finally, it summarizes its conceptual analysis into recommendations for researchers and designers looking to do so. These recommendations are: (1) assess suitability, (2) implement to support, (3) assess acceptability, (4) evaluate impact, and (5) document comprehensively. These recommendations aim to encourage clear language, unified terminology, the application and evaluation of theory, comprehensive and constant documentation, and transparent evaluation of outcomes.

Opportunities and Challenges of a Self-Management App to Support People With Spinal Cord Injury in the Prevention of Pressure Injuries: Qualitative Study

BACKGROUND

Mobile health applications can offer tailored self-management support to individuals living with chronic health conditions. However, there are several challenges to the adoption of these technologies in practice. Co-design is a promising approach to overcoming some of these challenges by enabling the development of solutions that meet the actual needs and preferences of the relevant stakeholder groups.

OBJECTIVE

Taking spinal cord injury as a case in point, the overall objectives of this study were to identify the perceived benefits of a co-designed self-management app that could promote its uptake and to explore the factors that may impede adoption.

METHODS

We adopted a qualitative research approach guided by the Technology Acceptance Model. Data were collected through semistructured interviews with individuals with spinal cord injury (n=15) and two focus groups with health care professionals specialized in spinal cord injury (n=7, n=5). Prior to the interviews and focus groups, study participants were given time to explore the app prototype. All interviews were transcribed verbatim and analyzed using inductive thematic analysis.

RESULTS

Findings of our analysis indicate that study participants perceived the app prototype as potentially useful for supporting individuals with spinal cord injury in preventing pressure injuries. In particular, we identified three concrete use cases highlighting the benefits of the app for different audiences: (1) a companion for newly injured individuals, (2) an emergency kit and motivational support, and 3) a guide for informal caregivers and family members. We also uncovered several challenges that might impede the adoption of the self-management app in practice, including (1) challenges in motivating individuals to use the app, (2) concerns about the misuse and abuse of the app, and (3) organizational and maintenance challenges.

CONCLUSIONS

This study adds to a growing body of research that investigates individuals' adoption and nonadoption behavior regarding mobile health solutions. Building on earlier work, we make recommendations on how to address the barriers to the adoption of mobile health solutions identified by this study. In particular, there is a need to foster trust in mobile health among prospective users, including both patients and health care professionals. Moreover, increasing personal relevance of mobile health solutions through personalization may be a promising approach to promote uptake. Last but not least, organizational support also plays an instrumental role in mobile health adoption. We conclude that even though co-design is promoted as a promising approach to develop self-management tools, co-design does not guarantee adoption. More research is needed to identify the most promising strategies to promote the adoption of evidence-based mobile health solutions in practice.

Care Me Too, a Mobile App for Engaging Chinese Immigrant Caregivers in Self-Care: Qualitative Usability Study

Background

Caregiving and self-care are challenging for Chinese immigrants in the United States due to limited accessible support and resources. Few interventions exist to assist Chinese immigrant caregivers in better performing self-care. To address this gap in the literature, our team developed the Care Me Too app to engage Chinese immigrant caregivers in self-care and conducted a user experience test to assess its usability and acceptability.

Objective

This paper aims to report the results of the app’s usability and acceptability testing with Chinese immigrant caregivers and to solicit participants’ feedback of the app design and functions.

Methods

A total of 22 Mandarin-speaking Chinese caregivers participated in the study, which consisted of 2 parts: the in-lab testing and the 1-week at-home testing. In-depth face-to-face interviews and follow-up phone interviews were used to assess user experience of the app’s usability and acceptability and to solicit feedback for app design and functions. Directed content analysis was used to analyze the qualitative data.

Results

Among the 22 participants, the average age was 60.5 (SD 8.1) years, ranging from 46 to 80 years; 17 (77%) participants were women and 14 (64%) had an associate degree or higher. Participants reported uniformly positive ratings of the usability and acceptability of the app and provided detailed suggestions for app improvement. We generated guidelines for mobile health (mHealth) app designs targeting immigrant caregivers, including weighing flexibility versus majority preferences, increasing text sizes, using colors effectively, providing engaging and playful visual designs and functions, simplifying navigation, simplifying the log-in process, improving access to and the content on the help document, designing functions to cater to the population’s context, and ensuring offline access.

Conclusions

The main contribution of this study is the improved understanding of Chinese caregivers’ user experiences with a language-appropriate mHealth app for a population that lacks accessible caregiving and self-care resources and support. It is recommended that future researchers and app designers consider the proposed guidelines when developing mHealth apps for their population to enhance user experience and harness mHealth’s value.

Identifying Persuasive Design Principles and Behavior Change Techniques Supporting End User Values and Needs in eHealth Interventions for Long-Term Weight Loss Maintenance: Qualitative Study

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.

Creating a Smartphone App for Caregivers of Children With Atopic Dermatitis With Caregivers, Health Care Professionals, and Digital Health Experts: Participatory Co-Design

Background

Smartphone apps could support patients and caregivers in disease self-management. However, as patients’ experiences and needs might not always align with clinical judgments, the eliciting and engaging of perspectives of all stakeholders in the smartphone app design process is of paramount importance.

Objective

The aims of this study are to better understand the needs of and challenges facing caregivers and health care professionals (HCPs) who care for children with atopic dermatitis (AD) and to explore the desirable features and content of a smartphone app that would support AD self-management.

Methods

This study adopted a qualitative participatory co-design methodology involving 3 focus group discussions: workshop one focused on caregivers; workshop two engaged with HCPs; and in the last workshop, caregivers and digital health experts were asked to design the wireframe prototype. The participants completed a sociodemographic questionnaire, a technology acceptance questionnaire, and a workshop evaluation form.

Results

Twelve caregivers participated in the first workshop, and 10 HCPs participated in the second workshop. Eight caregivers and 4 digital health experts attended the third workshop. Three superordinate themes that reflected caregivers’ and HCPs’ challenges and needs were identified: empowerment by education, confusion over treatment, and emotional impact. Workshop participants also raised a series of suggestions on the features and contents of the AD self-management app, which informed the last co-design workshop, and described their needs and challenges. In the last workshop, the participants developed a wireframe prototype of the app following the identified requirements and recommendations.

Conclusions

The co-design approach was found to be a successful way of engaging with the participants, as it allowed them to express their creativity and helped us to articulate the root of the clinical problems. The co-design workshop was successful in creating and generating new ideas and solutions for smartphone app development.

A Novel Auditory-Cognitive Training App for Delaying or Preventing the Onset of Dementia: Participatory Design With Stakeholders

BACKGROUND

Multiple gaming apps exist under the dementia umbrella for skills such as navigation; however, an app to specifically investigate the role of hearing loss in the process of cognitive decline is yet to be designed. There is a demonstrable gap in the utilization of games to further the knowledge of the potential relationship between hearing loss and dementia.

OBJECTIVE

This study aims to identify the needs, facilitators, and barriers in designing a novel auditory-cognitive training gaming app.

METHODS

A participatory design approach was used to engage key stakeholders across audiology and cognitive disorder specialties. Two rounds, including paired semistructured interviews and focus groups, were completed and thematically analyzed.

RESULTS

A total of 18 stakeholders participated, and 6 themes were identified to inform the next stage of app development. These included congruence with hobbies, life getting in the way, motivational challenge, accessibility, addictive competition, and realism.

CONCLUSIONS

The findings can now be implemented in the development of the app. The app will be evaluated against outcome measures of speech listening in noise, cognitive and attentional tasks, quality of life, and usability.

MyStrengths, a Strengths-Focused Mobile Health Tool: Participatory Design and Development

BACKGROUND

People living with chronic illnesses are an increasingly large group. Research indicates that care and self-management should not only focus on the illness and problem-oriented aspects of these individuals' lives but also support them in recognizing and leveraging their personal strengths in daily life.

OBJECTIVE

This paper presents the design and developmental process of MyStrengths, a mobile health (mHealth) app designed to help its users (people with chronic conditions) both find and make use of their personal strengths in their daily lives. Through 4 consecutive phases, this paper presents participant- and researcher-driven activities, discussions regarding design, and development of both the MyStrengths app and its content.

METHODS

During the 4 phases, we used a range of methods and activities, including (1) an idea-generating workshop aimed at creating ideas for strengths-supporting features with different stakeholders, including patients, caregivers, relatives, and designers (N=35); (2) research seminars with an international group of experts (N=6), in which the concept, theoretical background, and design ideas for the app were discussed; (3) a series of co-design workshops with people in the user group (N=22) aiming to create ideas for how to, in an engaging manner, design the app; and (4) in 4 developmental iterations, the app was evaluated by people in the user group (N=13). Content and strengths exercises were worked on and honed by the research team, the expert groups, and our internal editorial team during the entire developmental process.

RESULTS

The first phase found a wide range of stakeholder requirements to, and ideas for, strengths-focused mHealth apps. From reviewing literature during the second phase, we found a dearth of research on personal strengths with respect to people living with chronic illnesses. Activities during the third phase creatively provided numerous ideas and suggestions for engaging and gameful ways to develop and design the MyStrengths app. The final phase saw the output from all the earlier phases come together. Through multiple increasingly complete iterations of user evaluations testing and developing, the final prototype of the MyStrengths app was created.

CONCLUSIONS

Although research supports the use of strengths-focused mHealth tools to support people living with chronic illnesses, there is little guidance as to how these tools and their content should be designed. Through all activities, we found great support among participating users for strengths-focused apps, and we can consider such apps to be both appropriate and valuable. This paper illustrates how combining a range of user-, researcher-, literature-, and designer-based methods can contribute to creating mHealth tools to support people with chronic illnesses to find and use more of their own personal strengths.

Co-designing a Self-Management App Prototype to Support People With Spinal Cord Injury in the Prevention of Pressure Injuries: Mixed Methods Study

BACKGROUND

Spinal cord injury is a complex chronic health condition that requires individuals to actively self-manage. Therefore, an evidence-based, self-management app would be of value to support individuals with spinal cord injury in the prevention of pressure injuries.

OBJECTIVE

The main objectives of this study were to (1) establish a co-design approach for developing a high-fidelity prototype app for the self-management of individuals with spinal cord injury, (2) design the prototype that resulted from this process, and (3) conduct the first usability assessment of the prototype app.

METHODS

We adopted a co-design approach to develop an evidence-based app prototype. Starting from a preliminary content model (based on clinical guidelines for the prevention of pressure injuries) and three research-based user personas, we conducted an ideation workshop involving individuals with spinal cord injury and health care professionals. The ideation workshop formed the basis for two consecutive design sprints. The result of this co-design phase was an interactive app prototype. The prototype was evaluated in two rounds of usability testing (N=4 and N=15, respectively) using a combination of qualitative and quantitative methods.

RESULTS

The co-design process resulted in a high-fidelity prototype with two key components: a self-management component and a communication component. The final prototype included a combination of features to support individuals with spinal cord injury in the prevention of pressure injuries, namely a smart camera, pressure injury diary, expert consultation, reminders, and knowledge repository. Findings of the usability testing showed that most participants navigated the app fluently with little back and forth navigation and were able to successfully complete a set of assigned tasks. These positive results are supported by the average system usability score achieved (78.5/100; range 47.5-95.0) and our qualitative analysis of the semistructured interviews. Despite an overall positive evaluation of the app prototype, we identified areas for improvement (eg, inclusion of a search function).

CONCLUSIONS

Individuals with spinal cord injury often need to navigate competing interests and priorities, paired with uncertainty about the accuracy and relevance of clinical recommendations. Understanding what matters to individuals with spinal cord injury can help guide the design of behavioral interventions that are useful and acceptable to these individuals in their daily lives. This study shows that involving individuals with spinal cord injury and health care professionals in co-designing a self-management app can foster knowledge cocreation at the intersection of lived experience, medical expertise, and technical solutions.

Patients' experiences of using an e-Health tool for self-management support after prostate cancer surgery: a deductive interview study explained through the FITT framework

OBJECTIVE

To evaluate patients' experiences of using a web-based application, especially its usability as support for self-care activities after prostate cancer surgery.

DESIGN

A deductive content analysis was used, stemming from the Fit between Individuals, Task and Technology (FITT) framework.

SETTING

One surgical department in south of Sweden between October 2015 and April 2016 and between September 2017 and July 2018.

PARTICIPANTS

Fifteen men who had undergone radical prostatectomy for prostate cancer.

RESULTS

By organising data in accordance with the FITT model, three main categories with ten subcategories were identified. Patients gave feedback on functions that suited them and their needs, as well as potential adjustments and improvements. Patients experienced that ePATH gave them easy access to reliable information regarding their rehabilitation. Directed information about ePATH at enrolment was seen as important. ePATH was perceived to have a logical structure that was easy to follow. However, when the structure was unclear, patients became less motivated to use a function.

CONCLUSIONS

Patients experienced ePATH as satisfactorily user-friendly and useful as a complementary self-management support after prostate cancer surgery, especially when the information and tasks were tailored to their preferences and the system design features supported individual autonomy.

Apps With Maps-Anxiety and Depression Mobile Apps With Evidence-Based Frameworks: Systematic Search of Major App Stores

BACKGROUND

Mobile mental health apps have become ubiquitous tools to assist people in managing symptoms of anxiety and depression. However, due to the lack of research and expert input that has accompanied the development of most apps, concerns have been raised by clinicians, researchers, and government authorities about their efficacy.

OBJECTIVE

This review aimed to estimate the proportion of mental health apps offering comprehensive therapeutic treatments for anxiety and/or depression available in the app stores that have been developed using evidence-based frameworks. It also aimed to estimate the proportions of specific frameworks being used in an effort to understand which frameworks are having the most influence on app developers in this area.

METHODS

A systematic review of the Apple App Store and Google Play store was performed to identify apps offering comprehensive therapeutic interventions that targeted anxiety and/or depression. The PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) checklist was adapted to guide this approach.

RESULTS

Of the 293 apps shortlisted as offering a therapeutic treatment for anxiety and/or depression, 162 (55.3%) mentioned an evidence-based framework in their app store descriptions. Of the 293 apps, 88 (30.0%) claimed to use cognitive behavioral therapy techniques, 46 (15.7%) claimed to use mindfulness, 27 (9.2%) claimed to use positive psychology, 10 (3.4%) claimed to use dialectical behavior therapy, 5 (1.7%) claimed to use acceptance and commitment therapy, and 20 (6.8%) claimed to use other techniques. Of the 162 apps that claimed to use a theoretical framework, only 10 (6.2%) had published evidence for their efficacy.

CONCLUSIONS

The current proportion of apps developed using evidence-based frameworks is unacceptably low, and those without tested frameworks may be ineffective, or worse, pose a risk of harm to users. Future research should establish what other factors work in conjunction with evidence-based frameworks to produce efficacious mental health apps.

Codesigning discharge communication interventions with healthcare providers, youth and parents for emergency practice settings: EDUCATE study protocol

INTRODUCTION

Discharge communication is an important aspect of patient care but frequently has shortcomings in emergency departments (EDs). In a paediatric context, youth or parents with young children often leave the ED with minimal opportunity to ask questions or to ensure comprehension of important information. Strategies for improving discharge communication have primarily targeted patients and/or parents, although neither group has been engaged in intervention design or implementation. Furthermore, ED healthcare providers (HCPs), important actors in discharge communication practice, are rarely consulted regarding intervention design decisions. We will generate evidence to enhance discharge communication by engaging youth, parents and HCPs in the codesign of ED discharge communication strategies (EDUCATE) for asthma and minor head injury.

METHODS AND ANALYSIS

This mixed methods study will take place at two academic paediatric EDs in Canada. The study will occur in two phases: (A) codesign and refinement of the intervention prototypes; and (B) usability testing of the prototypes. During the first phase, two codesign teams (one for each condition) will follow a series of structured design meetings based on the Behavior Change Wheel to develop the EDUCATE interventions. Each codesign team (composed of youth, parents, HCPs and study researchers) will collaborate to identify priority target behaviours and acceptable components to include in the interventions. During the second phase, we will conduct usability testing in two EDs with a group of youth, parents and HCPs to refine the interventions. Two cycles of usability testing will be conducted with intervention refinement occurring at the end of each cycle.

ETHICS AND DISSEMINATION

Informed consent will be obtained from all participants. Ethics approval for this study has been obtained from the Research Ethics Board, IWK Health Centre. Results from this study will form the basis of a future effectiveness implementation trial. Key findings will be presented at national and international conferences and published within peer-reviewed journals.

Generative Participatory Design Methodology to Develop Electronic Health Interventions: Systematic Literature Review

BACKGROUND

Generative participatory design (PD) may help in developing electronic health (eHealth) interventions. PD is characterized by the involvement of all stakeholders in creative activities. This is different from the traditional user-centered design, where users are less involved. When looking at PD from a research through design perspective, it is important to summarize the reasons for choosing a certain form of generative PD to further develop its methodology. However, the scientific literature is currently unclear about which forms of PD are used to develop eHealth and which arguments are used to substantiate the decision to use a certain form of generative PD.

OBJECTIVE

This study aimed to explore the reporting and substantiation of generative PD methodologies in empirical eHealth studies published in scientific journals to further develop PD methodology in the field of eHealth.

METHODS

A systematic literature review following the Cochrane guidelines was conducted in several databases (EMBASE, MEDLINE Ovid, Web of Science, and CINAHL EBSCOhost). Data were extracted on the recruitment and management of stakeholders, the use of tools, and the use of outcome measures.

RESULTS

Of the 3131 studies initially identified, 69 were selected for qualitative synthesis. The reporting was very variable, depending to a large extent on whether the study stated that reporting on the PD process was a major aim. The different levels of reporting and substantiation of the choices of a recruitment strategy, stakeholder management, and tools and outcome measures are presented. Only a few authors explicitly used arguments directly related to PD guiding principles such as democratic, mutual learning, tacit and latent knowledge, and collective creativity. Even though PD principles were not always explicitly discussed in the method descriptions of the studies, they were implicitly present, mostly in the descriptions of the use of PD tools. The arguments used to substantiate the choices made in stakeholder management, PD tools, and the type of outcome measures adopted point to the involvement of PD principles.

CONCLUSIONS

Studies that have used a PD research methodology to develop eHealth primarily substantiate the choice of tools made and much less the use of stakeholders and outcome measures.

Development of a Mobile Game to Influence Behavior Determinants of HIV Service Uptake Among Key Populations in the Philippines: User-Centered Design Process

Background

Opportunities in digital distribution place mobile games as a promising platform for games for health. However, designing a game that can compete in the saturated mobile games market and deliver persuasive health messages can feel like an insurmountable challenge. Although user-centered design is widely advocated, factors such as the user’s subject domain expertise, budget constraints, and poor data collection methods can restrict the benefits of user involvement.

Objective

This study aimed to develop a playable and acceptable game for health, targeted at young key populations in the Philippines.

Methods

Authors identified a range of user-centered design methods to be used in tandem from published literature. The resulting design process involved a phased approach, with 40 primary and secondary users engaged during the initial ideation and prototype testing stages. Selected methods included participatory design workshops, playtests, playability heuristics, and focus group discussions. Subject domain experts were allocated roles in the development team. Data were analyzed using a framework approach. Conceptual frameworks in health intervention acceptability and game design guided the analysis. In-game events were captured through the Unity Analytics service to monitor uptake and game use over a 12-month period.

Results

Early user involvement revealed a strong desire for online multiplayer gameplay, yet most reported that access to this type of game was restricted because of technical and economic constraints. A role-playing game (RPG) with combat elements was identified as a very appealing gameplay style. Findings guided us to a game that could be played offline and that blended RPG elements, such as narrative and turn-based combat, with match-3 puzzles. Although the game received a positive response during playtests, gameplay was at times perceived as repetitive and predicted to only appeal to casual gamers. Knowledge transfer was predominantly achieved through interpretation of the game’s narrative, highlighting this as an important design element. Uptake of the game was positive; between December 1, 2017, and December 1, 2018, 3325 unique device installs were reported globally. Game metrics provided evidence of adoption by young key populations in the Philippines. Game uptake and use were substantially higher in regions where direct engagement with target users took place.

Conclusions

User-centered design activities supported the identification of important contextual requirements. Multiple data collection methods enabled triangulation of findings to mediate the inherent biases of the different techniques. Game acceptance is dependent on the ability of the development team to implement design solutions that address the needs and desires of target users. If target users are expected to develop design solutions, they must have adequate expertise and a significant role within the development team. Facilitating meaningful partnerships between health professionals, the games industry, and end users will support the games for health industry as it matures.

Artificial intelligence supported patient self-care in chronic heart failure: a paradigm shift from reactive to predictive, preventive and personalised care

Heart failure (HF) is one of the most complex chronic disorders with high prevalence, mainly due to the ageing population and better treatment of underlying diseases. Prevalence will continue to rise and is estimated to reach 3% of the population in Western countries by 2025. It is the most important cause of hospitalisation in subjects aged 65 years or more, resulting in high costs and major social impact. The current "one-size-fits-all" approach in the treatment of HF does not result in best outcome for all patients. These facts are an imminent threat to good quality management of patients with HF. An unorthodox approach from a new vision on care is required. We propose a novel predictive, preventive and personalised medicine approach where patients are truly leading their management, supported by an easily accessible online application that takes advantage of artificial intelligence. This strategy paper describes the needs in HF care, the needed paradigm shift and the elements that are required to achieve this shift. Through the inspiring collaboration of clinical and high-tech partners from North-West Europe combining state of the art HF care, artificial intelligence, serious gaming and patient coaching, a virtual doctor is being created. The results are expected to advance and personalise self-care, where standard care tasks are performed by the patients themselves, in principle without involvement of healthcare professionals, the latter being able to focus on complex conditions. This new vision on care will significantly reduce costs per patient while improving outcomes to enable long-term sustainability of top-level HF care.

The Influence of Physician Information on Patients' Choice of Physician in mHealth Services Using China's Chunyu Doctor App: Eye-Tracking and Questionnaire Study

BACKGROUND

Mobile health (mHealth) is becoming more popular as a way of sharing medical information. For the patient, it saves time, reduces the need for travel, reduces the cost of searching for information, and brings medical services "to your fingertips." However, it also brings information overload and makes the patient's choice of physician more difficult.

OBJECTIVE

This study aimed to identify the types of physician information that play a key role in patients' choice of physician and to explore the mechanism by which this information contributes to this choice.

METHODS

Based on the stimulus-organism-response (SOR) model and online trust theory, we proposed a research model to explain the influence of physician information on patients' choice of physician. The model was based on cognitive trust and affective trust and considered the moderating role of patient expertise. Study 1 was an eye-tracking experiment (n=42) to identify key factors affecting patients' choice of physician. Study 2 was a questionnaire study (n=272); Partial Least Squares Structural Equation Modeling was used to validate the research model.

RESULTS

The results of Study 1 revealed that seven types of physician information played a key role in patients' choice of physician. The results of Study 2 revealed that (1) physicians' profile photo information affected patients' choice of physician by positively influencing affective trust (P<.001); (2) physicians' nonprofile photo information affected patients' choice of physician by positively influencing cognitive trust (P<.001); (3) patient-generated information affected patients' choice of physician by positively affecting cognitive trust (P<.001) and affective trust (P<.001), and patient expertise played a positive moderating role on both (P=.04 and P=.01, respectively); and (4) cognitive trust and affective trust both positively affected patients' choice of physician, with affective trust playing a more significant role (P<.001 and P<.001, respectively).

CONCLUSIONS

Seven types of physician information were mainly used by patients when choosing physicians offering mHealth services; trust played an important role in this choice. In addition, the level of patient expertise was an important variable in moderating the influence of physician information and patients' trust. This paper supports the theoretical basis of information selection and processing by patients. These findings can help guide app developers in the construction of medical apps and in the management of physician information in order to facilitate patients' choice of physician.