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

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

Mapping twenty years of antimicrobial resistance research trends

OBJECTIVE: Antimicrobial resistance (AMR) is a global threat to health and healthcare. In response to the growing AMR burden, research funding also increased. However, a comprehensive overview of the research output, including conceptual, temporal, and geographical trends, is missing. Therefore, this study uses topic modelling, a machine learning approach, to reveal the scientific evolution of AMR research and its trends, and provides an interactive user interface for further analyses. METHODS: Structural topic modelling (STM) was applied on a text corpus resulting from a PubMed query comprising AMR articles (1999-2018). A topic network was established and topic trends were analysed by frequency, proportion, and importance over time and space. RESULTS: In total, 88 topics were identified in 158,616 articles from 166 countries. AMR publications increased by 450% between 1999 and 2018, emphasizing the vibrancy of the field. Prominent topics in 2018 were Strategies for emerging resistances and diseases, Nanoparticles, and Stewardship. Emerging topics included Water and environment, and Sequencing. Geographical trends showed prominence of Multidrug-resistant tuberculosis (MDR-TB) in the WHO African Region, corresponding with the MDR-TB burden. China and India were growing contributors in recent years, following the United States of America as overall lead contributor. CONCLUSION: This study provides a comprehensive overview of the AMR research output thereby revealing the AMR research response to the increased AMR burden. Both the results and the publicly available interactive database serve as a base to inform and optimise future research

Objectively assessed long-term wearing patterns and predictors of wearing orthopaedic footwear in people with diabetes at moderate-to-high risk of foot ulceration: a 12 months observational study

Background: Orthopaedic footwear can only be effective in preventing diabetic foot ulcers if worn by the patient. Robust data on long-term wearing time of orthopaedic footwear are not available, and needed to gain more insights into wearing patterns and associated factors (i.e. participants’ demographic, disease-related characteristics, and footwear usability). We aimed to objectively assess long-term wearing patterns and identify factors associated with wearing orthopaedic footwear in people with diabetes at moderate-to-high risk of ulceration. Methods: People diagnosed with diabetes mellitus type 1 and 2 with loss of protective sensation and/or peripheral artery disease and prescribed with orthopaedic footwear were included and followed for 12 months. The primary outcome was mean daily wearing time, continuously measured using a temperature sensor inside the footwear (Orthotimer®). Adherence to wearing orthopaedic footwear was calculated as percentage of wearing time of a total assumed 16 h out-of-bed daytime, where adherence < 60% was a pre-determined non-adherent threshold. Wearing time patterns were assessed by calculating participants’ wearing (in)consistency. One-way analyses of variance tested for wearing time differences between subgroups, weekdays, and weekend days. Factors potentially associated with wearing time were collected by questionnaires and medical files. Univariately associated factors were included in multivariate linear regression analysis. Results: Sixty one participants were included (mean (SD) age: 68.0 (7.4) years; females: n = 17; type 2 diabetes mellitus: n = 54). Mean (SD) overall daily wearing time was 8.3 (6.1) hours/day. A total of 40 (66%) participants were non-adherent. Participants with a consistent wearing pattern showed higher daily wearing times than participants with an inconsistent pattern. Mean (SD) wearing times were 12.7 (4.3) vs 3.6 (4.8) hours/day, respectively (P < 0.001). Mean (SD) wearing time was significantly higher (P < 0.010) during weekdays (8.7 (6.0) hours/day) compared to Saturday (8.0 (6.1) hours/day) and Sunday (6.9 (6.2) hours/day). In the multivariate model (R2 = 0.28), “satisfaction with my wear of orthopaedic footwear” was positively associated (P < 0.001) with wearing time. The other seven multivariate model factors (four demographic variables and three footwear usability variables) were not associated with wearing time. Conclusions: Only one out of three people at moderate to high risk of foot ulceration were sufficiently adherent to wearing their orthopaedic footwear. Changing people’s wearing behaviour to a more stable pattern seems a potential avenue to improve long-term adherence to wearing orthopaedic footwear. Investigated factors are not associated with daily wearing time. Based on these factors the daily wearing time cannot be estimated in daily practice. Trial registration: Netherlands Trial Register NL7710. Registered: 6 May 2019

Identifying the Added Value of Virtual Reality for Treatment in Forensic Mental Health: A Scenario-Based, Qualitative Approach

Background: Although literature and practice underline the potential of virtual reality (VR) for forensic mental healthcare, studies that explore why and in what way VR can be of added value for treatment of forensic psychiatric patients is lacking.Goals: This study aimed to identify (1) points of improvements in existing forensic mental health treatment of in- and outpatients, (2) possible ways of using VR that can improve current treatment, and (3) positive and negative aspects of the use of VR for the current treatment according to patients and therapists.Methods: Two scenario-based methods were used. First, semi-structured interviews were conducted with eight therapists and three patients to elicit scenarios from them. Based on these results, six scenarios about possibilities for using VR in treatment were created and presented to 89 therapists and 19 patients in an online questionnaire. The qualitative data from both methods were coded independently by two researchers, using the method of constant comparison.Results: In the interviews, six main codes with accompanying sub codes emerged. Ideas for improvement of treatment were grouped around the unique characteristics of the forensic setting, characteristics of the complex patient population, and characteristics of the type of treatment. For possibilities of VR, main codes were skills training with interaction, observation of situations or stimuli without interaction, and creating insight for others into the patient. The questionnaire resulted in a broad range of insights into potential positive and negative aspects of VR related to the current treatment, the patient, the content of a VR application, and practical matters.Conclusion: VR offers a broad range of possibilities for forensic mental health. Examples are offering training of behavioral and cognitive skills in a realistic context to bridge the gap between a therapy room and the real world, increasing treatment motivation, being able to adapt a VR application to individual patients, and providing therapists with new insights into a patient. These findings can be used to ground the development of new VR applications. Nevertheless, we should remain critical of when in the treatment process and for whom VR could be of added value

Implementation of a digital behavior change intervention (eCHANGE) for weight loss maintenance support: a service design and technology transfer approach

Obesity is a chronic disease, and while weight loss is achievable, long-term weight loss maintenance is difficult and relapse common for people living with obesity. Aiming to meet the need for innovative approaches, digital behavior change interventions show promise in supporting health behavior change to maintain weight after initial weight loss. Implementation of such interventions should however be part of the design and development processes from project initiation to facilitate uptake and impact. Based on the development and implementation process of eCHANGE, an evidence-informed application-based self-management intervention for weight loss maintenance, this manuscript provides suggestions and guidance into; (1) How a service design approach can be used from initiation to implementation of digital interventions, and (2) How a technology transfer process can accelerate implementation of research-based innovation from idea to market

Consolidated Health Economic Evaluation Reporting Standards for Interventions That Use Artificial Intelligence (CHEERS-AI)

Objectives: Economic evaluations (EEs) are commonly used by decision makers to understand the value of health interventions. The Consolidated Health Economic Evaluation Reporting Standards (CHEERS 2022) provide reporting guidelines for EEs. Healthcare systems will increasingly see new interventions that use artificial intelligence (AI) to perform their function. We developed Consolidated Health Economic Evaluation Reporting Standards for Interventions that use AI (CHEERS-AI) to ensure EEs of AI-based health interventions are reported in a transparent and reproducible manner. Methods: Potential CHEERS-AI reporting items were informed by 2 published systematic literature reviews of EEs and a contemporary update. A Delphi study was conducted using 3 survey rounds to elicit multidisciplinary expert views on 26 potential items, through a 9-point Likert rating scale and qualitative comments. An online consensus meeting was held to finalize outstanding reporting items. A digital health patient group reviewed the final checklist from a patient perspective. Results: A total of 58 participants responded to survey round 1, 42, and 31 of whom responded to rounds 2 and 3, respectively. Nine participants joined the consensus meeting. Ultimately, 38 reporting items were included in CHEERS-AI. They comprised the 28 original CHEERS 2022 items, plus 10 new AI-specific reporting items. Additionally, 8 of the original CHEERS 2022 items were elaborated on to ensure AI-specific nuance is reported. Conclusions: CHEERS-AI should be used when reporting an EE of an intervention that uses AI to perform its function. CHEERS-AI will help decision makers and reviewers to understand important AI-specific details of an intervention, and any implications for the EE methods used and cost-effectiveness conclusions