The Importance of Systematically Reporting and Reflecting on eHealth Development:Participatory Development Process of a Virtual Reality Application for Forensic Mental Health Care

Background: The use of electronic health (eHealth) technologies in practice often is lower than expected, mostly because there is no optimal fit among a technology, the characteristics of prospective users, and their context. To improve this fit, a thorough systematic development process is recommended. However, more knowledge about suitable development methods is necessary to create a tool kit that guides researchers in choosing development methods that are appropriate for their context and users. In addition, there is a need for reflection on the existing frameworks for eHealth development to be able to constantly improve them. Objective: The two main objectives of this case study were to present and reflect on the (1) methods used in the development process of a virtual reality application for forensic mental health care and (2) development model that was used: the CeHRes Roadmap (the Centre for eHealth Research Roadmap). Methods: In the development process, multiple methods were used to operationalize the first 2 phases of the CeHRes Roadmap: the contextual inquiry and value specification. To summarize the most relevant information for the goals of this study, the following information was extracted per method: (1) research goal, (2) explanation of the method used, (3) main results, (4) main conclusions, and (5) lessons learned about the method. Results: Information on 10 methods used is presented in a structured manner. These 10 methods were stakeholder identification, project team composition, focus groups, literature study, semistructured interviews, idea generation with scenarios, Web-based questionnaire, value specification, idea generation with prototyping, and a second round of interviews. The lessons learned showed that although each method added new insights to the development process, not every method appeared to be the most appropriate for each research goal. Conclusions: Reflection on the methods used pointed out that brief methods with concrete examples or scenarios fit the forensic psychiatric patients the best, among other things, because of difficulties with abstract reasoning and low motivation to invest much time in participating in research. Formulating clear research questions based on a model's underlying principles and composing a multidisciplinary project team with prospective end users appeared to be important in this study. The research questions supported the project team in keeping the complex development processes structured and prevented tunnel vision. With regard to the CeHRes Roadmap, continuous stakeholder involvement and formative evaluations were evaluated as strong points. A suggestion to further improve the Roadmap is to explicitly integrate the use of domain-specific theories and models. To create a tool kit with a broad range of methods for eHealth development and further improve development models, studies that report and reflect on development processes in a consistent and structured manner are needed

Integrating People, Context, and Technology in the Implementation of a Web-Based Intervention in Forensic Mental Health Care:Mixed-Methods Study

BACKGROUND: While eMental health interventions can have many potential benefits for mental health care, implementation outcomes are often disappointing. In order to improve these outcomes, there is a need for a better understanding of complex, dynamic interactions between a broad range of implementation-related factors. These interactions and processes should be studied holistically, paying attention to factors related to context, technology, and people. OBJECTIVE: The main objective of this mixed-method study was to holistically evaluate the implementation strategies and outcomes of an eMental health intervention in an organization for forensic mental health care. METHODS: First, desk research was performed on 18 documents on the implementation process. Second, the intervention's use by 721 patients and 172 therapists was analyzed via log data. Third, semistructured interviews were conducted with all 18 therapists of one outpatient clinic to identify broad factors that influence implementation outcomes. The interviews were analyzed via a combination of deductive analysis using the nonadoption, abandonment, scale-up, spread, and sustainability framework and inductive, open coding. RESULTS: The timeline generated via desk research showed that implementation strategies focused on technical skills training of therapists. Log data analyses demonstrated that 1019 modules were started, and 18.65% (721/3865) of patients of the forensic hospital started at least one module. Of these patients, 18.0% (130/721) completed at least one module. Of the therapists using the module, 54.1% (93/172 sent at least one feedback message to a patient. The median number of feedback messages sent per therapist was 1, with a minimum of 0 and a maximum of 460. Interviews showed that therapists did not always introduce the intervention to patients and using the intervention was not part of their daily routine. Also, therapists indicated patients often did not have the required conscientiousness and literacy levels. Furthermore, they had mixed opinions about the design of the intervention. Important organization-related factors were the need for more support and better integration in organizational structures. Finally, therapists stated that despite its current low use, the intervention had the potential to improve the quality of treatment. CONCLUSIONS: Synthesis of different types of data showed that implementation outcomes were mostly disappointing. Implementation strategies focused on technical training of therapists, while little attention was paid to changes in the organization, design of the technology, and patient awareness. A more holistic approach toward implementation strategies-with more attention to the organization, patients, technology, and training therapists-might have resulted in better implementation outcomes. Overall, adaptivity appears to be an important concept in eHealth implementation: a technology should be easily adaptable to an individual patient, therapists should be trained to deal flexibly with an eMental health intervention in their treatment, and organizations should adapt their implementation strategies and structures to embed a new eHealth intervention

Care provider views on app-based treatment for female urinary incontinence:A mixed-methods study

Objective: To explore the views and preferences of care providers on app use for the treatment of UI and to identify the anticipated barriers to, and facilitators of, implementation.Patients and Methods: We performed an exploratory, two-phase, sequential mixed-methods study. In phase 1, the views of care providers were explored through five focus group sessions with care providers involved in UI: general practitioners (GPs), practice assistants (PAs), pelvic physical therapists (PPTs), and urologists and (uro)gynecologists (UGs). In phase 2, the identified themes and subthemes were quantified in an online survey distributed among different care providers matching these groups.Results: In the focus group sessions, 30 female and two male care providers participated. Survey participants included 351 PAs and 76 PPTs (all females) next to 124 GPs and 183 UGs (70% females). Caregivers generally considered UI treatment apps as having a supportive role, being less convinced about their advantages in the absence of a care provider. Whereas most PPTs (89%) and the majority of participants overall (56%) agreed that app use should be supervised, most GPs considered apps to be suitable alternatives for women who do not visit a care provider. Additionally, caregivers required that the effectiveness of an app should be proven first, and that privacy and safety should be ensured. Contrasting with other research, lack of time and financial compensation were not considered important barriers to implementation. Although care providers shared a positive view of app use for UI treatment, most never to seldom referred their patients to existing tools.Conclusion: Our results add to the existing knowledge about eHealth-related barriers and facilitators. These findings can be used to optimize implementation strategies for other apps and to enhance the uptake of app-based treatment for UI in The Netherlands

Risk factors for surgical site infections using a data-driven approach

Objective The objective of this study was to identify risk factors for surgical site infection from digestive, thoracic and orthopaedic system surgeries using clinical and data-driven cut-off values. A second objective was to compare the identified risk factors in this study to risk factors identified in literature. Summary background data Retrospective data of 3 250 surgical procedures performed in large tertiary care hospital in The Netherlands during January 2013 to June 2014 were used. Methods Potential risk factors were identified using a literature scan and univariate analysis. A multivariate forward-step logistic regression model was used to identify risk factors. Standard medical cut-off values were compared with cut-offs determined from the data. Results For digestive, orthopaedic and thoracic system surgical procedures, the risk factors identified were preoperative temperature of �38˚C and antibiotics used at the time of surgery. Creactive protein and the duration of the surgery were identified as a risk factors for digestive surgical procedures. Being an adult (age �18) was identified as a protective effect for thoracic surgical procedures. Data-driven cut-off values were identified for temperature, age and CRP which can explain the SSI outcome up to 19.5% better than generic cut-off values. Conclusions This study identified risk factors for digestive, orthopaedic and thoracic system surgical procedures and illustrated how data-driven cut-offs can add value in the process. Future studies should investigate if data-driven cut-offs can add value to explain the outcome being modelled and not solely rely on standard medical cut-off values to identify risk factors

Barriers and Facilitators Associated With App-Based Treatment for Female Urinary Incontinence:Mixed Methods Evaluation

BACKGROUND: App-based treatment for urinary incontinence is a proven effective and cost-effective alternative to care as usual, but successful implementation requires that we identify and address the barriers and facilitators associated with app use. OBJECTIVE: The goal of the research was to explore the factors influencing app-based treatment for urinary incontinence and identify which barriers or facilitators are associated with treatment success or failure. METHODS: We used a sequential explanatory mixed methods design to connect the results of a randomized controlled trial with data from semistructured interviews. This previous RCT had shown the noninferiority of app-based treatment compared with care as usual for urinary incontinence over 4 months. Participants who reported success or failure with app-based treatment, as measured by the change in International Consultation on Incontinence Modular Questionnaire Urinary Incontinence Short Form symptom score, were selected for telephone interview by purposive sampling (n=17). This study reports mainly on the qualitative component of our mixed methods study. Qualitative analyses were conducted in two ways. First, we analyzed the qualitative data of all interviewed participants and discussed the relationships between the main themes. Second, the experiences between the success (n=9) and failure group (n=8) were compared and contrasted to explore factors that were positively or negatively associated with the quantitative effect of app-based treatment. These factors were then interpreted as barriers to and facilitators of successful app-based treatment. RESULTS: Four interrelated themes were identified as affecting the app based treatment effect: adherence, personal factors, app factors, and awareness. Qualitative analyses of the relationships between the themes showed that adherence-related factors directly influenced treatment effect in both a positive and negative matter. In turn, adherence was also positively and negatively influenced by the other 3 themes. Additionally, awareness was positively influenced by the treatment effect. Within these themes, several factors were identified that acted as barriers (eg, unrealistic expectation of time investment and interfering personal circumstances), facilitators (eg, strict integration of exercises and prior pelvic floor muscle therapy), or both (eg, personality traits and increased awareness of symptoms). CONCLUSIONS: This study shows that the effect of app-based treatment for urinary incontinence is mainly influenced by adherence, which in turn is affected by personal factors, app-based factors, and awareness. The identified factors could function as both facilitators and barriers depending on the user and interaction with other themes. Insight into these facilitators and barriers could lead to improved implementation and increased treatment effectiveness by targeting women most likely to benefit and through further development of the app. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID): RR2-10.1002/nau.2350

Design of the e-Vita diabetes mellitus study: effects and use of an interactive online care platform in patients with type 2 diabetes (e-VitaDM-1/ZODIAC-40)

Background Due to ongoing rise in need for care for people with chronic diseases and lagging increase in number of care providers, alternative forms of care provision and self-management support are needed. Empowering patients through an online care platform could help to improve patients’ self-management and reduce the burden on the healthcare system. Methods Access to laboratory results and educational modules on diabetes will be offered through a platform for subjects with type 2 diabetes mellitus treated in primary care. Differences in socio-demographic and clinical characteristics between subjects expressing interest vs. disinterest to use the platform will be explored. Platform usage will be tracked and compared. Patient satisfaction and quality of life will be measured by validated questionnaires and economic analyses will be performed. Discussion This study is designed to assess the feasibility of use of an online platform in routine primary healthcare for subjects with type 2 diabetes mellitus in the Netherlands, and to study effects of use of the platform on treatment satisfaction, quality of life and clinical parameters. Although providing access to a online platform is not a novel intervention, usage and effects have not yet been studied in this patient population