The added value of ehealth - Improving the development, implementation and evaluation of technology in treatment of offenders
Due to the COVID-19 crisis measures the PhD defence of Hanneke Kip will take place online (until further notice).
The PhD defence can be followed by a live stream.
Hanneke Kip is a PhD student in the research group Psychology, Health & Technology (PGT). Her supervisor is prof.dr. J.E.W.C. van Gemert-Pijnen from the faculty of Behavioural, Management and Social Sciences (BMS).
While eHealth interventions such as virtual reality, web-based interventions and mobile applications have the potential to improve treatment of offenders in forensic mental healthcare, not much is known about if and how this could be achieved. This thesis aims to provide more insight into the added value of eHealth interventions that support behaviour change in people who have committed or are on the verge of committing aggressive or sexual offenses. Its main objectives and accompanying research questions are provided below.
Goal 1: Provide insight into the added value of eHealth for forensic mental healthcare.
- What is the current state of affairs of eHealth in treatment of forensic psychiatric patients?
- Why and in what way can virtual reality be of added value for treatment in forensic mental healthcare?
- To what extent can a mobile app increase self-control and reduce reactive aggression?
Goal 2: To further improve development, implementation and evaluation of eHealth interventions.
- How can novel eHealth interventions be developed in complex settings by means of participatory development?
- How can the implementation and effectiveness of eHealth interventions be evaluated by means of a holistic approach using multiple methods?
Part 1: The current state of affairs of eHealth in forensic mental healthcare
In Chapter 2, an overview of the scientific literature on eHealth interventions is provided by means of a systematic review. This review showed that there is a pressing need for more research on different types of eHealth interventions, and that most studies so far addressed mostly language-based interventions such as videoconferencing and web-based interventions. Since web-based interventions are used relatively often in clinical practice, Chapter 3 focused on the analysis of the implementation of a web-based intervention that was used for several years in treatment of forensic psychiatric outpatients. In order to do justice to the different levels and complexity of implementation, a mixed-methods approach in which log data analysis, semi-structured interviews and desk research were integrated was applied. This study showed that the intervention was not used as much as expected, which could be partly explained by a suboptimal fit between the characteristics of the technology, the skills of its users, and the integration the intervention in existing care structures.
Part 2: The added value of virtual reality
Because first part of this thesis showed that web-based interventions are used quite often, but do not optimally fit the characteristics of forensic mental healthcare, the second part of this thesis is focused on a technology that is expected to be more suitable for this context: virtual reality (VR). In Chapter 4, the potential added value that VR can have for forensic mental healthcare according to stakeholders such as patients and therapists is identified by combining an interview with an elaborate questionnaire study, which are both inspired by methods from human-centred design. The findings of this chapter serve as the foundation of Chapter 5, in which it is shown how data from different sources can be combined into values that can be used to guide the development, implementation and evaluation process of VR interventions. In Chapter 6, a description of and critical reflection on the participatory development process of an interactive, personalized VR application are provided, guided by the contextual inquiry, value specification and design phase of the interdisciplinary CeHRes Roadmap. All of this has led to the development of the interactive, highly personalized ‘Triggers & Helpers’ VR application, which focuses on the identification and improvement of acute dynamic risk factors. In this thesis’ second part, it becomes clear that VR interventions can add something ‘new’ to treatment that cannot be achieved in in-person sessions with therapists, and can facilitate a focus on ‘doing instead of talking’. Additionally, multiple points of improvements of the development approaches were identified, as well as guidelines on how to coordinate a multi-method, participatory development process in practice with complex target groups.
Part 3: Novel methods to evaluate eHealth
Chapter 2 of this thesis showed that there are many technologies that can be used to treat forensic psychiatric patients. Consequently, this third part is focused on another type of technology that can be of added value: mobile apps. A self-control training (SCT) app was developed and evaluated with students, as a first step for its further development. In order to do justice to the iterative and holistic nature of eHealth evaluation, two research designs were combined: a pre-posttest design without control group and a full factorial design. These methods do not only offer insight into the effectiveness of the app and its added value compared to a simple e-mail based SCT, but also provide insight into the most optimal version of the app. Our work showed that an SCT app has the potential to increase self-control in a student sample, and - based on the MOST framework - recommendations for further evaluation studies are provided, amongst which evaluation of the app with forensic psychiatric patients using suitable evaluation methods such as single-case experimental designs.
Part 4: Discussion
In the fourth and final part of this thesis, a reflection on the main findings is provided. The main conclusions can be summarized as follows:
- In order for eHealth to be of actual added value, it has to offer er something new and unique that cannot be achieved in regular, in-person treatment. So-called ‘experiential’ technologies such as virtual reality and apps that target automatic processes such as self-control have the potential to transform healthcare. These experiential eHealth interventions can support behaviour change in novel ways and also require less cognitive skills, which makes them especially suitable for vulnerable target groups.
- To ensure that (experiential) eHealth actually reaches its potential, technology, people and context should all be flexible and adaptive to ensure a good fit. In order to overcome the predominant one-size-fits-all approach, the content and design of a technology should be adaptable in order to seamlessly fit the characteristics, points of improvement and values of a specific treatment setting, which shows the importance of personalization. Additionally, the context and people should also be adaptive, in order to ensure that an eHealth intervention is used in the most optimal way.
- Development, implementation and evaluation of eHealth interventions should be viewed as flexible, iterative processes instead of fixed, single-method activities. In these processes, research methods are adapted to the practical demands from the context and skills of the participants. There is a need for more knowledge on how to actively involve vulnerable patient populations in development, implementation and evaluation research.
Based on this thesis, we conclude that adaptiveness is an essential concept in eHealth: the technology, people involved, context in which it is used, and the development, implementation and evaluation processes all have to be adaptive and flexible in order for eHealth to be of added value.
