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J.J. Kraal

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A 12-week cardiac telerehabilitation programme does not prevent relapse of physical activity levels

Long-term results of the FIT@Home trial

Journal article (2022) - Rutger W.M. Brouwers, Hareld M.C. Kemps, Hareld M.C. Kemps, Cyrille Herkert, Niels Peek, J.J. Kraal

Adherence to a Multidisciplinary Lifestyle Program for Patients With Atrial Fibrillation and Obesity

Feasibility Study

Journal article (2022) - Nicole Tenbult, J.J. Kraal, J.J. Kraal, Rutger W.M. Brouwers, Ruud Spee, Sabine Eijsbouts, Hareld M.C. Kemps, Hareld M.C. Kemps

Background: Atrial fibrillation is commonly associated with obesity. Observational studies have shown that weight loss is associated with improved prognosis and a decrease in atrial fibrillation frequency and severity. However, despite these benefits, nonadherence to lifestyle programs is common. Objective: In this study, we evaluated adherence to and feasibility of a multidisciplinary lifestyle program focusing on behavior change in patients with atrial fibrillation and obesity. Methods: Patients with atrial fibrillation and obesity participated in a 1-year goal-oriented cardiac rehabilitation program. After baseline assessment, the first 3 months included a cardiac rehabilitation intervention with 4 fixed modules: lifestyle counseling (with an advanced nurse practitioner), exercise training, dietary consultation, and psychosocial therapy; relaxation sessions were an additional optional treatment module. An advanced nurse practitioner monitored the personal lifestyle of each individual patient, with assessments and consultations at 3 months (ie, immediately after the intervention) and at the end of the year (ie, 9 months after the intervention). At each timepoint, level of physical activity, personal goals and progress, atrial fibrillation symptoms and frequency (Atrial Fibrillation Severity Scale), psychosocial stress (Generalized Anxiety Disorder-7), and depression (Patient Health Questionnaire-9) were assessed. The primary endpoints were adherence (defined as the number of visits attended as percentage of the number of planned visits) and completion rates of the cardiac rehabilitation intervention (defined as performing at least of 80% of the prescribed sessions). In addition, we performed an exploratory analysis of effects of the cardiac rehabilitation program on weight and atrial fibrillation symptom frequency and severity. Results: Patients with atrial fibrillation and obesity (male: n=8; female: n=2; age: mean 57.2 years, SD 9.0; baseline weight: mean 107.2 kg, SD 11.8; baseline BMI: mean 32.4 kg/m2, SD 3.5) were recruited. Of the 10 participants, 8 participants completed the 3-month cardiac rehabilitation intervention, and 2 participants did not complete the cardiac rehabilitation intervention (both because of personal issues). Adherence to the fixed treatment modules was 95% (mean 3.8 sessions attended out of mean 4 planned) for lifestyle counseling, 86% (mean 15.2 sessions attended out of mean 17.6 planned) for physiotherapy sessions, 88% (mean 3.7 sessions attended out of mean 4.1 planned) for dietician consultations, and 60% (mean 0.6 sessions attended out of mean 1.0 planned) for psychosocial therapy; 70% of participants (7/10) were referred to the optional relaxation sessions, for which adherence was 86% (mean 2 sessions attended out of mean 2.4 planned). The frequency of atrial fibrillation symptoms was reduced immediately after the intervention (before: mean 35.6, SD 3.8; after: mean 31.2, SD 3.3), and this was sustained at 12 months (mean 24.8, SD 3.2). The severity of atrial fibrillation complaints immediately after the intervention (mean 20.0, SD 3.7) and at 12 months (mean 9.3, SD 3.6) were comparable to that at baseline (mean 16.6, SD 3.3). Conclusions: A 1-year multidisciplinary lifestyle program for obese patients with atrial fibrillation was found to be feasible, with high adherence and completion rates. Exploratory analysis revealed a sustained reduction in atrial fibrillation symptoms; however, these results remain to be confirmed in large-scale studies.@en

Finding what fits: Explorative self-experimentation for health behaviour change

Journal article (2022) - A. Fedlmeier, M. Bruijnes, M. Bruijnes, M. Bos-de Vos, M. Lemke, J.J. Kraal

Changing a specific health behaviour can be highly com- plex and is often influenced by many personal, social, and environmental factors. Therefore, interventions that aim at behaviour change cannot be one-size-fits-all solutions, and no behaviour change technique is effective fo ...

Effectiveness of Cardiac Telerehabilitation With Relapse Prevention: SmartCare-CAD Randomized Controlled Trial

Journal article (2021) - R. W. M. Brouwers, J.J. Kraal, M Regis, R Spee, HMC Kemps

BackgroundMost studies failed to show superiority of cardiac telerehabilitation (CTR) over traditional, centre-based cardiac rehabilitation (CR).PurposeTo evaluate the effectiveness of a novel CTR intervention on the adherence to a physically active lifestyle in patients with cor ...

Cost-effectiveness of Cardiac Telerehabilitation with Relapse Prevention for the Treatment of Patients with Coronary Artery Disease in the Netherlands

Journal article (2021) - Rutger W.M. Brouwers, Esmée K.J. Van Der Poort, Hareld M.C. Kemps, M. E. van den Akker-van Marle, J.J. Kraal

Importance: Cardiac telerehabilitation (CTR) has been found to be a safe and beneficial alternative to traditional center-based cardiac rehabilitation (CR) and might be associated with higher participation rates by reducing barriers to CR use. However, implementation of CTR interventions remains low, which may be owing to a lack of cost-effectiveness analyses of data from large-scale randomized clinical trials. Objective: To assess the cost-effectiveness of CTR with relapse prevention compared with center-based CR among patients with coronary artery disease. Design, Setting, and Participants: This economic evaluation performed a cost-utility analysis of data from the SmartCare-CAD (Effects of Cardiac Telerehabilitation in Patients With Coronary Artery Disease Using a Personalized Patient-Centred ICT Platform) randomized clinical trial. The cost-effectiveness and utility of 3 months of cardiac telerehabilitation followed by 9 months of relapse prevention were compared with the cost-effectiveness of traditional center-based cardiac rehabilitation. The analysis included 300 patients with stable coronary artery disease who received care at a CR center serving 2 general hospitals in the Netherlands between May 23, 2016, and July 26, 2018. All patients were entering phase 2 of outpatient CR and were followed up for 1 year (until August 14, 2019). Data were analyzed from September 21, 2020, to September 24, 2021. Intervention: After baseline measurements were obtained, participants were randomly assigned on a 1:1 ratio to receive CTR (intervention group) or center-based CR (control group) using computerized block randomization. After 6 supervised center-based training sessions, patients in the intervention group continued training at home using a heart rate monitor and accelerometer. Patients uploaded heart rate and physical activity data and discussed their progress during a weekly video consultation with their physical therapist. After 3 months, weekly coaching was concluded, and on-demand coaching was initiated for relapse prevention; patients were instructed to continue using their wearable sensors and were contacted in cases of nonadherence to the intervention or reduced exercise or physical activity volumes. Main Outcomes and Measures: Quality-adjusted life-years were assessed using the EuroQol 5-Dimension 5-Level survey (EQ-5D-5L) and the EuroQol Visual Analogue Scale (EQ-VAS), and cardiac-associated health care costs and non-health care costs were measured by health care consumption, productivity, and informal care questionnaires (the Medical Consumption Questionnaire, the Productivity Cost Questionnaire, and the Valuation of Informal Care Questionnaire) designed by the Institute for Medical Technology Assessment. Costs were converted to 2020 price levels (in euros) using the Dutch consumer price index (to convert to US dollars, euro values were multiplied by 1.142, which was the mean exchange rate in 2020). Results: Among 300 patients (266 men [88.7%]), the mean (SD) age was 60.7 (9.5) years. The quality of life among patients receiving CTR vs center-based CR was comparable during the study according to the results of both utility measures (mean difference on EQ-5D-5L: -0.004; P =.82; mean difference on EQ-VAS: -0.001; P =.92). Intervention costs were significantly higher for CTR (mean [SE], 224 [4] [$256 ($4)]) compared with center-based CR (mean [SE], 156 [5] [$178 ($6)]; P <.001); however, no difference in overall cardiac health care costs was observed between CTR (mean [SE], 4787 [503] [$5467 ($574)] and center-based CR (mean [SE], 5507 [659] [$6289 ($753)]; P =.36). From a societal perspective, CTR was associated with lower costs compared with center-based CR (mean [SE], 20 495 [ 2751] [$23 405 ($3142)] vs 24 381 [3613] [$27 843 ($4126)], respectively), although this difference was not statistically significant (-3887 [-$4439]; P =.34). Conclusions and Relevance: In this economic evaluation, a CTR intervention with relapse prevention was likely to be cost-effective compared with center-based CR, suggesting that CTR maybe used as an alternative intervention for the treatment of patients with coronary artery disease. These results add to the evidence base in favor of CTR and may increase the implementation of CTR interventions in clinical practice..

@en

Attitudes Toward Health, Healthcare, and eHealth of People With a Low Socioeconomic Status

A Community-Based Participatory Approach

Journal article (2021) - J.S. Faber, Isra Al-Dhahir, T. Reijnders, T. Reijnders, N.H. Chavannes, A.W.M. Evers, A.W.M. Evers, A.W.M. Evers, J.J. Kraal, H. J. G. van den Berg-Emons, H. J. G. van den Berg-Emons, V.T. Visch

Low socioeconomic status (SES) is associated with a higher prevalence of unhealthy lifestyles compared to a high SES. Health interventions that promote a healthy lifestyle, like eHealth solutions, face limited adoption in low SES groups. To improve the adoption of eHealth interventions, their alignment with the target group's attitudes is crucial. This study investigated the attitudes of people with a low SES toward health, healthcare, and eHealth. We adopted a mixed-method community-based participatory research approach with 23 members of a community center in a low SES neighborhood in the city of Rotterdam, the Netherlands. We conducted a first set of interviews and analyzed these using a grounded theory approach resulting in a group of themes. These basic themes' representative value was validated and refined by an online questionnaire involving a different sample of 43 participants from multiple community centers in the same neighborhood. We executed three focus groups to validate and contextualize the results. We identified two general attitudes based on nine profiles toward health, healthcare, and eHealth. The first general attitude, optimistically engaged, embodied approximately half our sample and involved light-heartedness toward health, loyalty toward healthcare, and eagerness to adopt eHealth. The second general attitude, doubtfully disadvantaged, represented roughly a quarter of our sample and was related to feeling encumbered toward health, feeling disadvantaged within healthcare, and hesitance toward eHealth adoption. The resulting attitudes strengthen the knowledge of the motivation and behavior of people with low SES regarding their health. Our results indicate that negative health attitudes are not as evident as often claimed. Nevertheless, intervention developers should still be mindful of differentiating life situations, motivations, healthcare needs, and eHealth expectations. Based on our findings, we recommend eHealth should fit into the person's daily life, ensure personal communication, be perceived usable and useful, adapt its communication to literacy level and life situation, allow for meaningful self-monitoring and embody self-efficacy enhancing strategies.@en

Quality Assessment of an Integrated Care Pathway Using Telemonitoring in Patients with Chronic Heart Failure and Chronic Obstructive Pulmonary Disease

Protocol for a Quasi-Experimental Study

Journal article (2020) - C Herkert, J.J. Kraal, R Spee, A Serier, L Graat-Verboom, HMC Kemps, HMC Kemps

Background: Chronic heart failure (CHF) and chronic obstructive pulmonary disease (COPD) often coexist and are associated with a high morbidity and reduced quality of life (QoL). Although these diseases share similarities in symptoms and clinical course, and exacerbations of both diseases often overlap, care pathways for both conditions are usually not integrated. This results in frequent outpatient consultations and suboptimal treatment during exacerbations, leading to frequent hospital admissions. Therefore, we propose an integrated care pathway for both diseases, using telemonitoring to detect deterioration at an early stage and a single case manager for both diseases.

Objective: This study aims to investigate whether an integrated care pathway using telemonitoring in patients with combined CHF and COPD results in a higher general health-related QoL (HRQoL) as compared with the traditional care pathways. Secondary end points include disease-specific HRQoL, level of self-management, patient satisfaction, compliance to the program, and cost-effectiveness.

Methods: This is a monocenter, prospective study using a quasi-experimental interrupted time series design. Thirty patients with combined CHF and COPD are included. The study period of 2.5 years per patient is divided into a preintervention phase (6 months) and a postintervention phase (2 years) in which end points are assessed. The intervention consists of an on-demand treatment strategy based on monitoring symptoms related to CHF/COPD and vital parameters (weight, blood pressure, heart rate, oxygen saturation, temperature), which are uploaded on a digital platform. The monitoring frequency and the limit values of the measurements to detect abnormalities are determined individually. Monitoring is performed by a case manager, who has the opportunity for a daily multidisciplinary meeting with both the cardiologist and the pulmonologist. Routine appointments at the outpatient clinic are cancelled and replaced by telemonitoring-guided treatment.

Results: Following ethical approval of the study protocol, the first patient was included in May 2018. Inclusion is expected to be complete in May 2021.

Conclusions: This study is the first to evaluate the effects of a novel integrated care pathway using telemonitoring for patients with combined CHF and COPD. Unique to this study is the concept of remote on-demand disease management by a single case manager for both diseases, combined with multidisciplinary meetings. Moreover, modern telemonitoring technology is used instead of, rather than as an addition to, regular care.

Trial Registration: Netherlands Trial Register NL6741; https://www.trialregister.nl/trial/6741

International Registered Report Identifier (IRRID): DERR1-10.2196/20571@en

Predictors of cardiac rehabilitation referral, enrolment and completion after acute myocardial infarction: an exploratory study

Journal article (2020) - R. W. M. Brouwers, V. J. G. Houben, J.J. Kraal, R. F. Spee, H. M. C. Kemps

Background: Despite proven clinical benefits, only a minority of patients complete outpatient cardiac rehabilitation (CR) after acute myocardial infarction (AMI). The main purpose of this study was to evaluate to what extent and at which time patients drop out of CR, and to as ...

Usefulness of Modern Activity Trackers for Monitoring Exercise Behavior in Chronic Cardiac Patients

Validation Study

Journal article (2019) - C Herkert, J.J. Kraal, EMA van Loon, M van Hooff, HMC Kemps

BACKGROUND:Improving physical activity (PA) is a core component of secondary prevention and cardiac (tele)rehabilitation. Commercially available activity trackers are frequently used to monitor and promote PA in cardiac patients. However, studies on the validity of these devices in cardiac patients are scarce. As cardiac patients are being advised and treated based on PA parameters measured by these devices, it is highly important to evaluate the accuracy of these parameters in this specific population. OBJECTIVE:The aim of this study was to determine the accuracy and responsiveness of 2 wrist-worn activity trackers, Fitbit Charge 2 (FC2) and Mio Slice (MS), for the assessment of energy expenditure (EE) in cardiac patients. METHODS:EE assessed by the activity trackers was compared with indirect calorimetry (Oxycon Mobile [OM]) during a laboratory activity protocol. Two groups were assessed: patients with stable coronary artery disease (CAD) with preserved left ventricular ejection fraction (LVEF) and patients with heart failure with reduced ejection fraction (HFrEF). RESULTS:A total of 38 patients were included: 19 with CAD and 19 with HFrEF (LVEF 31.8%, SD 7.6%). The CAD group showed no significant difference in total EE between FC2 and OM (47.5 kcal, SD 112 kcal; P=.09), in contrast to a significant difference between MS and OM (88 kcal, SD 108 kcal; P=.003). The HFrEF group showed significant differences in EE between FC2 and OM (38 kcal, SD 57 kcal; P=.01), as well as between MS and OM (106 kcal, SD 167 kcal; P=.02). Agreement of the activity trackers was low in both groups (CAD: intraclass correlation coefficient [ICC] FC2=0.10, ICC MS=0.12; HFrEF: ICC FC2=0.42, ICC MS=0.11). The responsiveness of FC2 was poor, whereas MS was able to detect changes in cycling loads only. CONCLUSIONS:Both activity trackers demonstrated low accuracy in estimating EE in cardiac patients and poor performance to detect within-patient changes in the low-to-moderate exercise intensity domain. Although the use of activity trackers in cardiac patients is promising and could enhance daily exercise behavior, these findings highlight the need for population-specific devices and algorithms.@en

Contributed

Designing a lifestyle intervention for people with a physically demanding job

Master thesis (2022) - J. Beckmann, J.J. Kraal, N.A. Romero Herrera, Pieter Coenen

Cardiovascular diseases are a prevalent cause of death worldwide. People with physically demanding jobs tend to have poorer cardiovascular health than people with sedentary jobs. In contrast to leisure-time physical activity (PA), occupational PA (lifting, pushing, and pulling heavy loads over a long period without sufficient recovery) seems to have detrimental health effects. This phenomenon is called the ‘PA Paradox’ and requires interventions that counteract these harmful health effects.
In the current occupational health research, interventions for this population are typically narrow, focusing on limited factors in a specific environment. These kinds of interventions are not effective for people with physically demanding jobs. Instead, an intervention for this population must respond to workers‘ complex context, fit their daily activities and preferences, and be integrated into their work and home environment. Therefore, this project aimed to explore these aspects to design a promising concept for a lifestyle intervention that shifts workers’ PA behavior in a healthier direction.

At the beginning of the project, expert interviews with occupational health researchers and practitioners were executed. Moreover, literature was reviewed to comprehend the PA Paradox and current approaches to counteract it. It was found that an intervention should stimulate moderate-vigorous PA, variation, and sufficient recovery and that workers must have the capability, motivation, and opportunity to perform a healthy PA behavior. Therefore, an extensive field study was carried out to investigate workers’ PA behavior and the factors affecting it. That yielded an overview of factors influencing workers’ capability, opportunity, and motivation for a healthy PA behavior. It showed that it would be most impactful to tackle workers’ inadequate risk perception and over-exhaustion. Research through design was applied to explore how an intervention could address these factors in workers’ home and working environments and what interactions fit workers’ needs, preferences, and possibilities.

The generated insights were merged to ‘Shift it!’, a concept that makes workers feel confident about shifting their PA behavior in a healthier direction. ‘Shift it!’ consists of two parts: A health week and a digital buddy. The health week starts with a toolbox meeting to make the workers aware of the PA paradox and its consequences. Afterwards, workers can visit the company doctor to examine their current health state and future risks and monitor their heart rate for one week to get insights into the intensity of their PA and the effect of their breaks.
The digital buddy ensures that workers understand the issue and helps them to integrate recovery and PA into their daily lives. It offers them inspiration, helps them find a plan that fits their busy lives, and supports them to realize it by reminding, encouraging, and praising them.

Finally, the concept was evaluated with the workers and other stakeholders to explore its potential. Everyone was enthusiastic about the concept and showed interest in implementing its elements. The health screening and the digital buddy with all its functions were identified as the concept‘s core, but it is not yet clear which elements can be realized.

Involving older adults with an intellectual disability in the design process of the MakiMove: a modular intervention for stimulating physical activity

Master thesis (2022) - K. Adriaanse, J.J. Kraal, N.J.H. Vegt, Alyt Oppewal, Marije Bunskoek

Regular physical activity helps to improve the health, fitness and quality of life of people, and prevent or decline aging related health issues. The amount of physical activity in older adults with an intellectual disability is extremely low. Contextual research indicates that this physical inactivity stems, among other things, from previous negative experiences, the habit of being inactive, limitations related to the cognitive and physical disability, and interventions that are not taking into account these limitations. These barriers emphasize the client’s dependence on an external incentive to become physically active, but caregivers of the clients lack time to provide this stimulus. Along with an increased life expectancy of people with an intellectual disability, this increases the need for a physical activity intervention that suits the individual abilities and interests of the clients, while asking minimal time from the caregivers.

Many interventions that have been created for stimulating physical activity in people with an ID, are either not adapted to people of an older age, or not created in (creative) collaboration with the older adults. This project is therefore carried out in close collaboration with six older adults with an intellectual disability, and their caregivers.

Literature and context research showed the current barriers and motivators towards physical activity, from the perspective of the clients, the caregivers, and the physiotherapist in this context. A research through design approach, consisting of creative sessions together with clients, caregivers, and other experts, resulted in a design that is adapted and adaptable to the diverse group of older adults. The design intervention proposed in this project is called the ‘MakiMove’.

The MakiMove is a large, vertical game board that offers fun and active activities to older adults with intellectual disabilities. The product provides a positive experience to the older adults, and simultaneously increases their physical activity. The variety of activities and difficulty levels make the design adaptable to the abilities and interest of the individual client.

Although the MakiMove allows the client to move without much assistance, it is not possible to interact with the concept completely independent of a caregiver or other supervisor. With social contact and encouragement being valuable facilitators for the client, it is questioned whether independent physical activity is the road to take. On this basis, it is recommended to look into how to enable caregivers or other supervisors to play a role in increasing the physical activity of the older adults.

To create a successful experience, it is important to adapt a design to the client’s abilities and interests. To get to know the clients well, they should be involved in the design process. The experiences in this project have led to guidelines for collaborating with the target group, aiming to inspire future researchers and designers to involve this increasing population of older adults with an intellectual disability in their projects.

“De Klimkramen”: a co-creative journey to stimulate physical activity of children at the Dapperplein

Master thesis (2022) - L.T. Hollander, J.J. Kraal, M.A. Gielen

Since 1975, obesity has nearly tripled globally, indicating a clear trend that threatens public health. Besides changing one’s diet, the illness can be prevented by performing sufficient physical activity. In the Netherlands however, currently only 20% of the children of 11 years old meet the World Health Organisation guidelines for physical activity (Volksgezondheidenzorg.info, 2020). This is worrisome, since habits of sedentary behaviour often stick with a person from youth to adulthood (Hirvensalo & Lintunen, 2018). (World Health Organisation, 2021)

The section Child and Adolescent Public Health Research & Innovation (CAPHRI) of the Amsterdam University Medical Centre commissioned this project to address the lack of physical activity of children in Amsterdam. This project specifically targets the Dapperplein, as the section identified an interesting opportunity space here: During the day it is occupied by its daily market, but in the evening, when the market is cleared, an open space is revealed. This project aims to find ways to use that open space, and design something that stimulates children’s physical activity at the Dapperplein, after market hours.

In order to do so, children living near the Dapperplein were engaged in co-creation. Co-creation with children has the potential to create a design that fits the users’ (children’s) needs, because it creates understanding of their context for the designer (me), via close involvement and collaboration of the user and designer in the design process. The children act as co-designers. During workshops with these children, as well as expert interviews, observations and a literature study the context of the Dapperplein was explored and problems were revealed. As the project discovered, the children (and their parents) do not consider the Dapperplein to be safe during the evening. This is due to people hanging out and drinking at the square, as well as traffic that crosses at speed. Additionally, a lack of hygiene because of market leftovers is identified. Lastly, there are few stimuli present for children to play.

To address these problems, the design of “De Klimkramen’’ was created. It proposes to place playing equipment at the Dapperplein that during the day, with addition of an awning and board, functions as market stalls. This creates a safe playing area, as it forms a physical barrier for traffic, and since it is inviting towards residents, more people will be there to keep an eye out. A sense of community is fostered as it is used in harmony with the market and forms an iconic view for the Dapperplein.

During an evaluation, the design was well received by representatives of the market, police and fire brigade, although adjustments are needed to ensure a better fit with the needs of the market vendors, and to avoid creating a new spot for people to hang out and consume alcohol.

Besides contributing to the section CAPHRI and to involved stakeholders with the design of “De Klimkramen”, this project contributes to the design field with a reflection on the application of co-creation with children, and practical tips for those who (will) apply the method.

PEPSA

Optimizing the Patient Experience of patients newly diagnosed with Psoriatic Arthritis

Master thesis (2022) - E. Drost, J.J. Kraal, C. Hao, Jolanda Luime

Psoriatic arthritis is a chronic inflammation disease that affects the joints and the skin, which can manifest in many ways and various severities. Psoriatic arthritis impacts the lives of patients in both physical and mental ways. This project focussed on how the patient experience can be improved of newly diagnosed psoriatic arthritis patients. The patient experience involves multiple things, including the hospital visits and life at home. For this project it was decided to focus on the context of home. To get the necessary insights into the disease and the experience of patients with psoriatic arthritis, the co-creation method was used. In this method, a small group of stakeholders are actively part of the complete project as experts. In this project, five PsA patients were included as experts of their own experiences. The literature study and explorative research done in this project showed the following thing about the patient experience of PsA patients:

- Most of the information and help that is available focusses on the physical difficulties that psoriatic arthritis causes, even though there are a lot of mental difficulties that currently get too little attention.

- There is a lot of information available that the patients only get when they look for it themselves. But especially right after their diagnosis, they have little to no idea of what is relevant and what they have to look for.

With this knowledge, it was decided to focus on these mental difficulties that patients have. To do this, several group sessions together with the five participating patients were done. These sessions revealed that the diagnosis of psoriatic arthritis influences the perception of their identity as well as how they think others perceive them. The patients want to stay valuable and independent, where the psoriatic arthritis causes them to make changes in their daily life and become more dependable. This gives patients the idea that the psoriatic arthritis sometimes takes control over their life. This insight led to the design goal of the project, where the focus laid on empowering the patients to be in control of their own life again.

Together with the participant group, various design directions were explored and evaluated with help of various prototypes. This eventually resulted in the final design: The PEPSA journal.

The PEPSA journal is a service that provides the user with journal pages that focus on several aspects of life and psoriatic arthritis. The journal makes a distinction between standard material, which is relevant for everyone and focus topics, which allow the user to personalize their journal and make it more fitting to their life and what they think is relevant. Through positively formulated questions about each topic the users are encouraged to think about the various aspects of their life and psoriatic arthritis and how they relate to and influence each other. In this way the PEPSA journal allows the user to get more insights into their situation and get a clearer view of their life with psoriatic arthritis, putting them back in control.

Finding what Fits

Uncovering the potential of Explorative Self-experimentation and how to facilitate it – A meta-strategy for helping individuals change and maintain personal health behaviours

Master thesis (2021) - A. Fedlmeier, J.J. Kraal, M. Bos-de Vos

We live in a world in which chronic diseases are on the rise. Yet, improving personal health behaviours is a long-term goal, that is often undermined by alluring offers that provide instant gratification and other more pressing day-to-day matters. Often it is not the intention that is missing to change personal health behaviours, but there is much evidence that highlights a gap between what individuals intend to do vs. what they actually do (Sheeran, 2002). There are many existing behaviour change tools that provide the “solution” to a problem, yet no one solution will be effective for everyone (Hekler, Burleson, & Lee, 2013). Especially when considering health behaviours, that need to be sustained over time to have significant impact, it is prudent that interventions fit our goal, our ever changing lifestyle and are enjoyable (Phatak, 2019a). An alternative approach is to give individuals the tools to self-experiment with interventions, and through this, find interventions that work for them to establish a lasting effective behaviour change. This project explores self-experimentation (SE) as a method for helping individuals change their personal health behaviours. A research through design approach was used to answer the questions: (1) What is self-experimentation and why is it needed? (2) What does self-experimentation result in and how can it contribute to individuals achieving sustainable health behaviour change? And (3) how can design facilitate individuals to self-experiment? In alignment with these questions, this project yields three significant outcomes: First, a new take on self-experimentation was discovered; one that addresses the limitation of existing approaches and caters to the needs of people trying to change their health behaviours. User research into how people go about navigating their health behaviour, and the kind of evidence they need to make decisions revealed that: (1) People generally navigate their health behaviour through intuition. (2) People who practice self-experimentation, are not seeking to answer a hypothesis, but simply want to find an intervention that works for them, explore different options and learn about themselves in the process. (3) People can determine whether or not an intervention works for them simply by trying it out. This reveals if the intervention helps them achieve their goal (i.e. is effective), whether it fits into their lives and with their personality (compatibility) and whether they enjoy it. These insights created a premise for a new approach which was labelled “Explorative Self-experimentation”. It differs fundamentally from the existing “quantitative” method in that it omits the key ingredient of a data-driven scientifically rigorous objective evaluation of the effectiveness of interventions, and instead harnesses the intuitive evaluation formed by a user’s lived experience. By observing 14 participants undergo four weeks of self-experimentation, a set of 13 phenomena were uncovered that engaging with Explorative Self-experimentation results in. These can be summarised in five statements: Explorative Self-experimentation helps people (1) take incremental steps towards a long term goal, through (2) trial and error to success. It (3) leads people to get to the heart of the issue, (4) discover new perspectives and attitudes towards their own health behaviours and (5) find support along the way. These phenomena were linked to prominent behaviour change theories in the context of health in order to establish how explorative self-experimentation can contribute to individuals changing and maintaining their health behaviours. Finally, the research through design process involved creating three sets of prototypes that explore how to facilitate individuals to self-experiment with health interventions. The design process and the testing of these prototypes revealed three lenses from which to tackle facilitating self-experimentation: (1) designing for the process, (2) designing for different scenarios or stages of change and (3) designing for the underlying needs and values of people trying to change their health behaviours. As part of this third lens, I presented seven concrete starting points for designers to facilitate self-experimentation, linking the underlying values and needs to key ingredients design can provide. The compilation of these outcomes aspire to answer the research question of how design can facilitate SE: Designers can provide guidance through the process, designers can help initiate SE, help people maintain their efforts over time to find something that fits, or help turn fitting solutions into habits. Designers can cater to needs and values by providing guidance, incentives and inspiration over time, by making room for personal growth and flexibility, fostering personal attachment and by forming a resilient mindset. In conclusion, this thesis uncovers the potential of Explorative Self-experimentation and how to facilitate it. It presents a meta-strategy for helping individuals change and maintain personal health behaviours, and through this hopes to contribute to improving health both at an individual and societal level.

Coeliac disease as social disease: design for safety during social events

Master thesis (2021) - M. Frediani, J.J. Kraal, I.A. Ruiter

The coeliac disease is an autoimmune disease caused by the ingestion of gluten affecting people with a genetic disposition. Gluten is a protein that can be found in wheat, rye and barley but it can also be used as protein filler in ice creams and soup. The only treatment for patients is to follow a strict gluten-free diet. Due to the restrictive nature of the diet, coeliac people have to develop new habits and routines to overcome uncomfortable situations at home and social situations. Different studies demonstrated that coeliac people are affected emotionally by social events. Coeliac people have to avoid food contained food, be aware of the gluten cross-contamination and find proper gluten-free options. This might lead to the development of anxiety and stress. This is a master report that gathers the research and the design activities to investigate how to create a safe environment for coeliac people during social events. The project was developed through converging and diverging design approaches involving remote user research, literature review and iterative cycles of ideations, development and testing. The project focused mainly on two areas: the perception of the gluten-free diet and the coping strategies or problem-solving skills used during social events. The research approach includes context research as base knowledge about coeliac disease, the challenges of the gluten-free diet, and coping strategies. The user research involved coeliac people to lead the development of a solution that would embrace their needs and values. At the end of the user research, a Framework was developed to describe the context of the social events for coeliac people. The design goal of the project was identified as the project aims to enhance the feeling of security for coeliac people by increasing empathy and decreasing negative emotions. Different concepts were developed according to iterative conceptualizations and evaluation tests of low fidelity prototypes with participants. The insights gathered helped to generate a final concept. The final concept is an event planner app that gives information about how to create a safe environment for coeliac people and more. The final user tests have been conducted in part in person and part remotely with participants who evaluated the possibility to create a safe environment and create empathy. The results demonstrated that by using the final concept it is possible to generate a safe environment and generate empathy. Participants had the possibility to immerse themselves in the challenges that coeliac people face daily. Coeliac people indeed felt to be secure cause people would have the correct information about the preparation of the environment and gluten-free food.

Social relations and diabetes

Creating a support system for people with diabetes

Master thesis (2021) - M.E. Kesteloo, M. Bruijnes, W.P. Brinkman, M.A. Neerincx, J.J. Kraal

People with diabetes often show symptoms heavily associated with depression, but these symptoms are often caused by the burden of daily diabetes management. The negative feelings caused by this burden are defined as "diabetes burnout''. Some of these negative feelings are caused ...

Implementing vitality interventions

A strategy towards 'Healthy & Happy' low socioeconomic status employees

Master thesis (2020) - J.J.J. Koot, J.J. Kraal, J.S. Faber

The aim of this graduation project is to increase the effectiveness of lifestyle interventions, focused on vitality, for employees with a low socioeconomic status (SES). This project explores and maps out the organizational ecosystem of municipal reintegration company DZB Leiden to determine areas for improvement. These improvements should in-turn increase the effectiveness of lifestyle interventions at DZB Leiden. There are large differences in personal health as a consequence of different lifestyles between people with low or high socioeconomic status. By increasing the effectiveness of lifestyle interventions we might be able to decrease these differences. Low SES is often related to a poor lifestyle through poorer food choices, reduced physical activity, drinking and smoking habits. These habits have negative implications for the people with low SES as well as for the company they work for. Increased absenteeism, increased chance for non-communicable diseases, reduced productivity and a shorter life expectancy are some of the consequences that people with low SES have to cope with. DZB Leiden is a municipal reintegration company of the municipality of Leiden. DZB works with employees with a low SES in their sheltered workshops on a daily basis. They are there for anyone who has difficulty with keeping up with the daily work practices and offer them a safe environment to grow and thrive. People working in the sheltered workshops often cope with multiple disabilities. A healthy lifestyle can contribute on dealing with these disabilities and improve their way of life. Thus, increasing the effectiveness of lifestyle interventions should provide an improved quality of life as well as increasing the desirability of these employees. Multiple lifestyle interventions have been introduced at DZB Leiden, however these interventions have not always been successful. The interventions are often poorly executed, or simply forgotten, and dilute quickly due to daily issues that receive priority. Exploratory research has been performed to define two research scopes, which have the potential to contribute to increasing the effectiveness of lifestyle interventions. These research scopes reside within the interpersonal and organizational ecosystems introduced by Bronfenbrenner in 1977. This graduation thesis explores the organizational ecosystem of DZB in-depth through semi-structured interviews and a stakeholder analysis. A strategy has been devised to improve different areas of the organizational system of DZB uncovered by the performed in-depth research. The performed research resulted in multiple findings for improving the effectiveness of the lifestyle interventions. These findings have been translated into design criteria for the devised strategy. One of these findings is the potential Team Fit has within DZB to increase awareness for vitality and introduce lifestyle interventions successfully. Therefore, Team Fit is used central in the devised strategy. This strategy is substantiated by the development of a future vision for DZB to strive towards. A strategic and tactical roadmap are introduced to guide DZB towards this future vision. These roadmaps show the goals that should be worked towards, the strategy necessary to achieve these goals, the tactics on how to achieve the strategy and the operationalization of the tasks that need to be performed. The devised strategy aims to set up a vitality network with municipal reintegration companies and healthcare providers via the collaboration of DZB and SPARK. Finally, the proposed strategy was evaluated with the current interim director of DZB and Team Fit. The aim of the evaluation was to determine if the proposed strategy meets all three key attributes of feasibility, desirability and viability towards valuable design. The evaluation shows that the proposed strategy in its current state is both feasible and desirable. However, further research is needed to determine if the strategy is viable and can survive in the long run. For the strategy to be viable it is recommended that a learning cycle for the interventions is implemented and research is conducted on the interpersonal ecosystem and incorporated into the proposed strategy. The graduation project consists of a total of four deliverables. Through a stakeholder analysis a power-interest matrix and stakeholder maps have been created which shows the involved parties, their interest in vitality as well as how much power they have to help realize this. Two roadmaps have been created via design roadmapping which allows us to strategically and tactically map out what is necessary to increase the effectiveness of lifestyle interventions. Finally, recommendations for DZB are made on how to improve the strategy.

Sounds of Surgeries

Design for health behavior change in the soundscape of orthopedic operating theaters

Master thesis (2020) - Z.A. Luck, E. Ozcan Vieira, J.J. Kraal

Noise in orthopedic operating theaters The medical staff working in orthopedic operating theaters are often exposed to significant noise generated by many simultaneous sound events (e.g. powered tools, alarms) that pose a risk to their health and well-being. This thesis focuses on their health behaviors associated with the sound situation. Existing literature provides evidence that noise in some orthopedic surgeries can cause health issues ranging from increased stress levels to noise-induced hearing loss. Nevertheless, literature research also shows that the field of sound and health assessment has not been widely explored. Consequently, this thesis has two aims: Firstly, understanding the soundscape, its entailing health risks and the motivations of current health behaviors of the medical staff in relation to the soundscape. Secondly, contributing to an improved sound situation and reduced health risks for medical staff applying design. Sound perception and health behavior Applying the user research method “context mapping” (design method making people reflect on personal experiences) current health behaviors of the medical staff (e.g.surgeons, anesthesiologists) were investigated. In particular psychological consequences of noise are often underestimated. Sound levels in seven orthopedic surgeries (with varying surgical approaches) were assessed. Although the evaluation showed differences in sound levels, average sound levels did not exceed current legislation. Further investigations on sound characteristics(through psycho acoustic analysis) show that sound perceptions (e.g. pleasant or unpleasant sound experiences), causing psychological health impacts, are not sufficiently explained by loudness (i.e. especially average decibel levels). Based on the research findings, that some sound situations in operating theaters are in parts hazardous and that the behavior of the medical staff is often non-precautionary, a theoretical framework (based on Social-Ecological Model (SEM)) was developed. It showcases the stakeholders directly or indirectly involved in potential behavior change processes towards an improved sound and health situation in operating theaters.This framework formed the core guideline for the consecutive design process,aiming to explore how behavior concerning the soundscape can be improved. The key discovery: There is a lack of awareness and knowledge of health consequences posed by sound within medical staff, as well as on other social-ecological levels (e.g. hospital management). Design towards sound and health awareness The final design outcome, a website, targets a wide healthcare audience. The website initiates greater engagement concerning sound improvements through increasing awareness of the current sound situation in operating theaters. It caters to varying awareness levels: General information on sound and health in operating theaters (to increase knowledge and initiate awareness) and concrete action advice to transform awareness into action for sound improvement and risk reduction. Reflecting on the final outcome and future research This thesis showed that sound perception in operating theaters is still not sufficiently explored. The initial evaluation with medical and non-medical staff participants indicates that the website successfully improves knowledge, triggers reflection and thereby sparks awareness. By further extending the websites’ sphere of activities, it has the potential to contribute to the achievement of better sound quality in operating theaters. This thesis concludes with suggestions on future sound and health behavior research.

Overcome

Reducing ICU patients' anxiety through medical alarms feedback provision

Master thesis (2020) - S.L. Cucinella, E. Ozcan Vieira, J.J. Kraal

In the Intensive Care Units (ICU) patients are exposed to many, continuous and highly stressors, such as medical alarms, which contribute to the development of psychological issues, such as delirium, anxiety disorders and post-traumatic stress disorders (PTSD). These psychologica ...

In the Intensive Care Units (ICU) patients are exposed to many, continuous and highly stressors, such as medical alarms, which contribute to the development of psychological issues, such as delirium, anxiety disorders and post-traumatic stress disorders (PTSD). These psychological issues have a negative influence on the patients’ healing process and dramatically reduce the quality of life during and after ICU. Medical alarms are meaningful signals that inform nurses and lead them to properly act to attend patients’ basic needs and medical treatments. However, medical alarms are not meant for patients who lack resources to cope with them. Due to their ambiguity, alarms are perceived as a threat and appraised as dangerous by patients. Nurses are the main resource for patients to cope with such a threat. Nurses have the information needed by patients to reduce their uncertainty and stress provoked by such a stressor; therefore, lack of support contributes to the risks of developing psychological issues. Designing solutions that aim to reduce the risks of developing psychological disorders during the period of hospitalization in the ICU is necessary to facilitate the people healing process and to guarantee them an improved quality of life during and after such an experience. Overcome is a feedback interface designed to enable nurses to communicate by a distance with patients to reduce the risks of developing a state of anxiety when a medical alarm goes off. Through the provision of feedback, Overcome informs patients about the nurses’ decisions over medical alarms while they are approaching the room thus restoring the perceived sense of safety. Information about the decisions made by nurses over an alarm, as well as information regarding the reason for an alarm, promote medical alarms understanding and reduce the uncertainty of dying that patients can experience when exposed to ambiguous alarms and when they have to wait longer than expected before receiving the nurses' support. Feedback reassure the patients and positively influencing their state of anxiety; also, a reduced state of anxiety may also result in reduced stress levels.

Collaboration in healthcare

Building effective transdisciplinary collaborations in open innovation initiatives

Master thesis (2020) - Regina Morán Reséndiz, M.S. Kleinsmann, J.J. Kraal, Vanessa Sattele Gunther

Emerging diseases like the current pandemic, COVID-19, and the increasing number of chronic diseases around the world are putting considerable pressure on the healthcare system, demanding for more services, with higher quality and more efficient. Hence the healthcare system needs ...

Emerging diseases like the current pandemic, COVID-19, and the increasing number of chronic diseases around the world are putting considerable pressure on the healthcare system, demanding for more services, with higher quality and more efficient. Hence the healthcare system needs to transition towards sustainable healthcare. An approach to achieve a transition towards sustainable healthcare is the Quadruple Aim. It is a practical framework that focuses on improving the health of the population, improving the work-life of care providers, enhancing patients experience and reducing health cost. To implement these four aims, it is necessary the collaboration between multiple disciplines and the implementation of an innovative approach. Open innovation provides a space for transdisciplinary collaboration and innovation to occurs. Hence, this graduation project explores transdisciplinary collaborations in the healthcare sector, focusing on open innovation initiatives. The research question for this study is how to build effective transdisciplinary collaborations in healthcare? This graduation project took place in two countries, the Netherlands and Mexico. In the Netherlands, I realised interview research in eight open innovation initiatives. Later, in Mexico, I did a case study at the Research and Technological Development Unit inside the General Hospital of Mexico ‘Eduardo Liceaga’. Afterwards, I realised a comparative analysis between both studies, followed by a design phase to build effective transdisciplinary collaborations in healthcare. The results of the two studies present a future vision and a future-oriented strategy for the Research and Technological Development Unit to improve collaboration between actors. The future vision contributes to the alignment of the actors involved in the unit so that they can work in the same direction. The strategy is formed by three strategic lines: organisational and project development support, building a knowledge community, and promote and consolidate the unit. These strategic lines aim to guide the actors towards the future vision by suggesting a series of steps. The success of this initiative could contribute to boost innovation in healthcare. A suggestion for future research is on how design can facilitate the implementation of the strategy by considering the collaboration of all the actors present in the unit.