A mobile app could be a powerful medium for providing individual support for cognitive behavioral therapy (CBT), as well as facilitating therapy adherence. Little is known about factors that may explain the acceptance and uptake of such applications. This study, therefore, examines factors from an extended version of the Unified Theory of Acceptance and Use of Technology (UTAUT2) model to explain variation between people’s behavioral intention to use a CBT for insomnia (CBT-I) app and their use-behavior. The model includes eight aspects of behavioral intention: performance expectancy, effort expectancy, social influence, self-efficacy, trust, hedonic motivation, anxiety, and facilitating conditions, and investigates further the influence of the behavioral intention and facilitating conditions on app-usage behavior. Data were gathered from a field trial involving people ( n = 89) with relatively mild insomnia using a CBT-I app. The analysis applied the Partial Least Squares-Structural Equation Modeling method. The results found that performance expectancy, effort expectancy, social influence, self-efficacy, trust, and facilitating conditions all explained part of the variation in behavioral intention, but not beyond the explanation provided by hedonic motivation, which accounted for R 2 = 0.61. Both behavioral intention and facilitating conditions could explain the use-behavior ( R 2 = 0.32). We anticipate that the findings will help researchers and developers to focus on: (1) users’ positive feelings about the app as this was an indicator of their acceptance of the mobile app and usage; and (2) the availability of resources and support as this also correlated with the technology use.

The design and implementation of applications for behavior change should be preceded by careful analysis of the behavior change process and the target population. We, therefore, present on the basis of a blended research approach a rationale, opportunities and basic requirements for an application that offers a program for reducing intake of sugar sweetened beverages (SSB) by adolescents. This paper discusses the role of e-coaching and gamification as two high-touch design patterns in the behavior change process. Both design patterns aim at supporting the individual in a transformational journey from a current state toward a desired state where the detrimental behavior should be replaced by healthy alternative behavior. First, an elementary behavior scheme is introduced that frames three empirical studies. In the first study (plenary focus groups;n= 13), participants advised to include system recommendations for alternative healthy behavior, stressed the need for personalization of the e-coach and showed strong appreciation for the inclusion of gamification elements. The second study (online survey;n= 249) showed that SSB-intake is highly contextual and that reasons for (limiting) consumption SSB varies greatly between individuals, which the e-coach application should take into account. In a final small-scale pilot study (n= 27), we observed the potential of the inclusion of gamification elements, such as challenges and rewards, to increase compliance to the self-monitoring process of SSB consumption. Building upon these insights and prior studies, we argue that an e-coach mimics the collaborative practice of the program; its main task is to enrich the interaction with cooperative conversational experiences, in particular with respect to the alignment between user and system, motivational encouragement, personalized advice, and feedback about the activities. In addition, we outline that gamification not only has the potential to increase self-monitoring of the target behavior, user engagement, and commitment with the intervention program, but also enables a designer to shift long-term negative outcome of excessive intake in real life to short-term consequences in a virtual environment. In future larger follow-up studies, we advise to integrate the two design patterns within a social network of virtual and human agents that play a variety of competitive, normative and supportive roles.

In this paper, we discuss the characteristics of a smartphone system that behaves as an automated e-coach that supports behavior change. To mimic the behavior of a human coach and to build a relationship with the end-user, the system offers a conversational experience and behaves as an active virtual coach that discusses various aspects with the coachee about the therapy. For that, the system provides two types of integrated interfaces that we call the ‘Talk-and-Tools’ paradigm. Talk provides the functionality for the conversational experience, while various Tool-interfaces form a coherent structure of input and output facilities that enable the user to get access to and manipulate relevant information. Currently, the system supports cognitive behavior therapy for insomnia, but its generic design targets at a broad range of application domains. Various types of tests and user evaluations were performed, ranging from expert analysis to a randomized controlled trial with insomnia patients.

In this paper, we present the design of a negotiation protocol for behaviour change exercises that are supported by automated e-coaching systems. Negotiation is introduced as an interactive persuasive strategy with the aim to improve adherence of exercises. The protocol is implemented in a mobile application, called SleepCare, that supports cognitive behaviour therapy for insomnia. The interaction design of the application is centred around the paradigm of Talk-and-Tools. Talk represents personalized conversations with a virtual e-coach, while Tools are represented by specialized modules that form a coherent structure of input and output facilities. We focus on the technique of sleep restriction, an intensive form of behaviour change that requires strong perseverance from the user. Both user and e-coach may negotiate about the attributes of the sleep restriction technique, here the duration of the total time in bed. The algorithm that calculates the negotiation space is personalized on the basis of previous sleeping behaviour of the coachee, the stage of the program and general constraints of the insomnia therapy. The system is evaluated by means of automated simulations and data from a randomized controlled trial. More than 50% of the subjects who did sleep restriction as a behaviour changing exercise used the protocol in the first round and negotiated with the system about an agreed time in bed. We expect that negotiation includes a number of important adherence enhancing strategies in e-coaching: increase of the coachee's autonomy, a sense of shared decision making and commitment.

Background: This study is one of the first randomized controlled trials investigating cognitive behavioral therapy for insomnia (CBT-I) delivered by a fully automated mobile phone app. Such an app can potentially increase the accessibility of insomnia treatment for the 10% of people who have insomnia.Objective: The objective of our study was to investigate the efficacy of CBT-I delivered via the Sleepcare mobile phone app, compared with a waitlist control group, in a randomized controlled trial.Methods: We recruited participants in the Netherlands with relatively mild insomnia disorder. After answering an online pretest questionnaire, they were randomly assigned to the app (n = 74) or the waitlist condition (n = 77). The app packaged a sleep diary, a relaxation exercise, sleep restriction exercise, and sleep hygiene and education. The app was fully automated and adjusted itself to a participant's progress. Program duration was 6 to 7 weeks, after which participants received posttest measurements and a 3-month follow-up. The participants in the waitlist condition received the app after they completed the posttest questionnaire. The measurements consisted of questionnaires and 7-day online diaries. The questionnaires measured insomnia severity, dysfunctional beliefs about sleep, and anxiety and depression symptoms. The diary measured sleep variables such as sleep efficiency. We performed multilevel analyses to study the interaction effects between time and condition.Results: The results showed significant interaction effects (P< . 01) favoring the app condition on the primary outcome measures of insomnia severity (d = -0.66) and sleep efficiency (d = 0.71). Overall, these improvements were also retained in a 3-month follow-up.Conclusions: This study demonstrated the efficacy of a fully automated mobile phone app in the treatment of relatively mild insomnia. The effects were in the range of what is found for Web-based treatment in general. This supports the applicability of such technical tools in the treatment of insomnia. Future work should examine the generalizability to a more diverse population. Furthermore, the separate components of such an app should be investigated. It remains to be seen how this app can best be integrated into the current health regimens.

In this paper, a user interface paradigm, called Talk-and-Tools, is presented for automated e-coaching. The paradigm is based on the idea that people interact in two ways with their environment: symbolically and physically. The main goal is to show how the paradigm can be applied in the design of interactive systems that offer an acceptable coaching process. As a proof of concept, an e-coaching system is implemented that supports an insomnia therapy on a smartphone. A human coach was replaced by a cooperative virtual coach that is able to interact with a human coachee. In the interface of the system, we distinguish between a set of personalized conversations ("Talk") and specialized modules that form a coherent structure of input and output facilities ("Tools"). Conversations contained a minimum of variation to exclude unpredictable behavior but included the necessary mechanisms for variation to offer personalized consults and support. A variety of system and user tests was conducted to validate the use of the system. After a 6-week therapy, some users spontaneously reported the experience of building a relationship with the e-coach. It is concluded that the addition of a conversational component fills an important gap in the design of current mobile systems.

s ................................................................................................................................................... 4 Keynotes ................................................................................................................................................... 4 Oral Presentations .................................................................................................................................... 6 Poster Presentations and Demos ........................................................................................................... 11

Background: This study is one of the first randomized controlled trials investigating cognitive behavioral therapy for insomnia (CBT-I) delivered by a fully automated mobile phone app. Such an app can potentially increase the accessibility of insomnia treatment for the 10% of people who have insomnia. Objective: The objective of our study was to investigate the efficacy of CBT-I delivered via the Sleepcare mobile phone app, compared with a waitlist control group, in a randomized controlled trial. Methods: We recruited participants in the Netherlands with relatively mild insomnia disorder. After answering an online pretest questionnaire, they were randomly assigned to the app (n=74) or the waitlist condition (n=77). The app packaged a sleep diary, a relaxation exercise, sleep restriction exercise, and sleep hygiene and education. The app was fully automated and adjusted itself to a participant’s progress. Program duration was 6 to 7 weeks, after which participants received posttest measurements and a 3-month follow-up. The participants in the waitlist condition received the app after they completed the posttest questionnaire. The measurements consisted of questionnaires and 7-day online diaries. The questionnaires measured insomnia severity, dysfunctional beliefs about sleep, and anxiety and depression symptoms. The diary measured sleep variables such as sleep efficiency. We performed multilevel analyses to study the interaction effects between time and condition. Results: The results showed significant interaction effects (P<.01) favoring the app condition on the primary outcome measures of insomnia severity (d=–0.66) and sleep efficiency (d=0.71). Overall, these improvements were also retained in a 3-month follow-up. Conclusions: This study demonstrated the efficacy of a fully automated mobile phone app in the treatment of relatively mild insomnia. The effects were in the range of what is found for Web-based treatment in general. This supports the applicability of such technical tools in the treatment of insomnia. Future work should examine the generalizability to a more diverse population. Furthermore, the separate components of such an app should be investigated. It remains to be seen how this app can best be integrated into the current health regimens. Trial Registration: Netherlands Trial Register: NTR5560; http://www.trialregister.nl/trialreg/admin/rctview.asp?TC=5560 (Archived by WebCite at http://www.webcitation.org/6noLaUdJ4) (J Med Internet Res 2017;19(4):e70) doi:10.2196/jmir.6524

In this paper, the rationale and requirements are presented for an e-coaching system in the domain of intensive cardiac rehabilitation. It is argued that there is a need for a personalized program with close monitoring of the patient based on medical needs and needed lifestyle changes in a setting with other participants such as family and a human coach. Two roles are distinguished for the e-coach: support of the organizational process of the program (e.g. collecting and analyzing data) and support of the patient's process of making lifestyle changes (e.g. triggering and motivational support). Motivational interviewing is introduced as a means to minimize the discrepancy between undesired behavior and future goals of the patient. It is concluded that digital products that offer e-coaching support for these types of programs should coexist with human coaching.

Non-adherence is considered a problem that seriously undermines the outcome of behavior change therapies, in particular of self-help therapies delivered without human interference. This paper presents the design rationale behind a computer system in the domain of adherence enhancing strategies in automated e-coaching. A variety of persuasive strategies is introduced and implemented in a mobile e-coaching system in the domain of insomnia therapy. The system integrates two types of interface elements, i.e. dedicated tools and natural language conversation, to simplify therapy related activities and to include social strategies to improve motivation. We focus on the crucial role of communication and adaptation.

Evaluating interaction that spans several weeks, between a virtual coach and a human patient on a mobile behavior intervention is virtually impossible. Traditional laboratory-based user testing is too tedious and expensive, and allows only the testing of a limited amount of different scenarios. Ideally, the test results of a mobile behavior intervention application cover a clear understanding of: (i) different user models, (ii) adaptive behavior of the coach, and (iii) different levels abstraction from multiple stakeholder viewpoints. Towards this goal, we address challenges posed by the domain and devised an automated testing environment using a simulator that mimics the behavior of a patient during the process of behavior change based on scenarios. The simulation results, i.e. context sensitive user interaction (on the application) at different phases and stages of a six-week insomnia therapy, can be recorded and presented to stakeholders for the application quality assessment and analysis.

The experiment presented in this paper investigated the effects of different kinds of reminders on adherence to automated parts of a cognitive behavioural therapy for insomnia (CBT-I) delivered via a mobile device. Previous studies report that computerized health interventions can be effective. However, treatment adherence is still an issue. Reminders are a simple technique that could improve adherence. A minimal intervention prototype in the realm of sleep treatment was developed to test the effects of reminders on adherence. Two prominent ways to determine the reminder-time are: a) ask users when they want to be reminded, and b) let an algorithm decide when to remind users. The prototype consisted of a sleep diary, a relaxation exercise and reminders. A within subject design was used in which the effect of reminders and two underlying principles were tested by 45 participants that all received the following three different conditions (in random order): a) event-based reminders b) time-based reminders c) no reminders. Both types of reminders improved adherence compared to no reminders. No differences were found between the two types of reminders. Opportunity and self-empowerment could partly mediate adherence to filling out the sleep diary, but not to the number of relaxation exercises conducted. Although the study focussed on CBT-I, we expect that designers of other computerized health interventions benefit from the tested opportunity and self-empowerment principles for reminders to improve adherence, as well.

Behavioral control weaknesses are a strong predictor of problematic behaviors in adolescents, such as heavy alcohol use. Heavy alcohol use at this young age can lead to health and school-related problems and is a severe societal problem. Strengthening of cognitive control mechanisms through computerized training has been shown to have positive effects on behavior, but is often perceived as a tedious exercise. Applying novel serious gaming techniques to evidence-based training paradigms may offer a solution to this motivational problem. This paper describes the design and analysis plan that will be used to evaluate an innovative Serious Game called The Fling, aimed specifically at increasing cognitive control over impulses in adolescents. The game will be evaluated in a randomized controlled trial (RCT) among adolescents between 15–18 years in mainstream and special education.

BACKGROUND:Several technologies have been proposed to support the reduction of insomnia complaints. A user-centered assessment of these technologies could provide insight into underlying factors related to treatment adherence.OBJECTIVE:Gaining insight into adherence to technology-mediated insomnia treatment as a solid base for improving those adherence rates by applying adherence-enhancing strategies.METHODS:Adherence to technology-mediated sleep products was studied in three ways. First, a meta-analysis was performed to investigate adherence rates in technology-mediated insomnia therapy. Several databases were queried for technology-mediated insomnia treatments. After inclusion and exclusion steps, data from 18 studies were retrieved and aggregated to find an average adherence rate. Next, 15 semistructured interviews about sleep-support technologies were conducted to investigate perceived adherence. Lastly, several scenarios were written about the usage of a virtual sleep coach that could support adherence rates. The scenarios were discussed in six different focus groups consisting of potential users (n=15), sleep experts (n=7), and coaches (n=9).RESULTS:From the meta-analysis, average treatment adherence appeared to be approximately 52% (95% CI 43%-61%) for technology-mediated insomnia treatments. This means that, on average, half of the treatment exercises were not executed, suggesting there is a substantial need for adherence and room for improvement in this area. However, the users in the interviews believed they adhered quite well to their sleep products. Users mentioned relying on personal commitment (ie, willpower) for therapy adherence. Participants of the focus groups reconfirmed their belief in the effectiveness of personal commitment, which they regarded as more effective than adherence-enhancing strategies.CONCLUSIONS:Although adherence rates for insomnia interventions indicate extensive room for improvement, users might not consider adherence to be a problem; they believe willpower to be an effective adherence strategy. A virtual coach should be able to cope with this "adherence bias" and persuade users to accept adherence-enhancing strategies, such as reminders, compliments, and community building.

Communication in the form of dialogues between a virtual coach and a human patient (coachee) is one of the pillars in an intervention app for smartphones. The virtual coach is considered as a cooperative partner that supports the individual with various exercises for a behavior intervention therapy. To perform its supportive behavior, the coach follows a certain interaction model and its requirements, such as alignment, mutual commitment and adaptation. In this paper, we propose E-Coach MarkUp Language (ECML), a standard XML specification for scripting discourses that define how the virtual coach maintains a dialogue with a coachee following the interaction model. The format of the language allows messages to be tailored at a fine-grained level. Each sentence is synthesized based on the inferred goals of the coaching process and the current beliefs of the user, incorporating everything that has been said previously in the conversation. The design enables inexpensive implementation on mobile devices for a flexible, seamless coaching dialogue. With expert-based evaluations, we validated the language using scenarios on implemented ECML in the field of insomnia therapy.

The present white paper presents five principles that can guide the design and implementation of effective and appropriate approaches to e-coaching and discusses both their scientific underpinnings and their (potential) applications. The paper crystallises insights that have emerged in recent and ongoing research developed in the Healthy Lifestyle Solutions programme, which is co-ordinated by the Technology Foundation STW and jointly funded by Philips Research and NWO’s National Initiative for Brain and Cognition (NIHC). Those research projects are focused on the areas of diet, exercise, sleep, and stress, but their applications are even wider.

Digital games have been used as stressors in a range of disciplines for decades. Nonetheless, the underlying characteristics of these stressors and the study in which the stressor was applied are generally not recognized for their moderating effect on the measured physiological stress responses. We have therefore conducted a meta-analysis that analyzes the effects of characteristics of digital game stressors and study design on heart rate, systolic and diastolic blood pressure, in studies carried out from 1976 to 2012. In order to assess the differing quality between study designs, a new scale is developed and presented, coined reliability of effect size. The results show specific and consistent moderating functions of both game and study characteristics, on average accounting for around 43%, and in certain cases up to 57% of the variance found in physiological stress responses. Possible cognitive and physiological processes underlying these moderating functions are discussed, and a new model integrating these processes with the moderating functions is presented. These findings indicate that a digital game stressor does not act as a stressor by virtue of being a game, but rather derives its stressor function from its characteristics and the methodology in which it is used. This finding, together with the size of the associated moderations, indicates the need for a standardization of digital game stressors.

This paper presents preliminary findings from a study of user autonomy protection (UAP) in mobile coaching applications.Autonomy refers to doing things out of one's own volition, and is an important ethical principle in the health care sector.Protecting a patient's autonomy can significantly enhance treatment adherence and can have positive motivational effects.We are developing a mobile self-help app to be used by patients undergoing cognitive behavioral therapy for insomnia (CBT-I), and aim to implement UAP in template-based dialogues.Transcripts of real CBT-I sessions are studied in order to unearth specific speech acts that therapists use to protect the patient's autonomy in practice.