User-centered Development Research Articles

Understanding User Behavior for Enhancing Cybersecurity Training with Immersive Gamified Platforms

In modern digital infrastructure, cyber systems are foundational, making resilience against sophisticated attacks essential. Traditional cybersecurity defenses primarily address technical vulnerabilities; however, the human element, particularly decision-making during cyber attacks, adds complexities that current behavioral studies fail to capture adequately. Existing approaches, including theoretical models, game theory, and simulators, rely on retrospective data and static scenarios. These methods often miss the real-time, context-specific nature of user responses during cyber threats. To address these limitations, this work introduces a framework that combines Extended Reality (XR) and Generative Artificial Intelligence (Gen-AI) within a gamified platform. This framework enables continuous, high-fidelity data collection on user behavior in dynamic attack scenarios. It includes three core modules: the Player Behavior Module (PBM), Gamification Module (GM), and Simulation Module (SM). Together, these modules create an immersive, responsive environment for studying user interactions. A case study in a simulated critical infrastructure environment demonstrates the framework’s effectiveness in capturing realistic user behaviors under cyber attack, with potential applications for improving response strategies and resilience across critical sectors. This work lays the foundation for adaptive cybersecurity training and user-centered development across critical infrastructure.

The work organization in teleoperated driving – a human reliability and socio-technical systems perspective

Abstract Very high levels of automation in road traffic are accompanied by the need for teleoperation. If the driverless autonomous vehicle is not able to solve a complex driving situation, then the problem should be solved by a teleoperated intervention by getting a human into the loop. Such a system is highly complex, interacting in a socio-technical system. Therefore, in addition to the empirical research of user-centered development of teleoperated driving, an analytical and systemic approach is crucial in the first place to understand the interrelationships between the subsystems and to optimize a teleoperated driving system. This work provides a base for the systemic consideration by taking two different perspectives focusing on the work organization and vehicle operation dealing with how many vehicles can be monitored and serviced by one operator. First, a brief analytical perspective of human reliability is taken, emphasizing the appropriate definition of the operational design domain and knowledge of its variability. Second, a comprehensive systemic, socio-technical perspective is applied using the functional resonance analysis method (FRAM) for a reflexive and computational purpose highlighting effects on operator workload and traffic performance. Finally, the implications of the research results are discussed and integrated into socio-technical interactions in everyday teleoperated driving between blunt- and sharp-end factors from a safety and reliability perspective to demonstrate the complex leverage of the work organization. Overall, the insights contribute to an enhanced understanding of the complex socio-technical interactions in teleoperated driving.

An Exercise-Based Precision Medicine Tool and Smartphone App for Managing Achilles Tendinopathy (the 'PhysViz' System): User-Centered Development Study.

People with Achilles tendinopathy (AT) experience persistent pain that can limit engagement with daily occupations and negatively impact mental health. Current therapeutic exercise approaches vary in success, with many people experiencing reinjury, leading to a cycle of chronic tendinopathy often lasting years. High-magnitude precision loading may help people exit this feedback cycle, but applying these principles clinically is challenging. This user-centered design case study aims to provide an overview on how the PhysViz (a prototype for a novel remote rehabilitation intervention for AT management) was developed and evaluated following the development phase of the Framework for Accelerated and Systematic Technology-Based Intervention Development and Evaluation Research (FASTER). The development process engaged a multidisciplinary team comprising people with AT experiences, clinicians, and engineers. It followed the 5 stages within the FASTER development phase: empathize, define, ideate, prototype, and test. The PhysViz development and evaluation were informed by needs assessments, surveys, literature reviews, validation studies, case studies, roundtable discussions, and usability testing (some of which have been published previously). The FASTER systematically guided the integration of evidence-based features and behavior change theory. By using the FASTER and ensuring that the PhysViz system was underpinned by diverse stakeholder needs, this work resulted in the development of a working prototype for both the PhysViz physical exercise tool and the accompanying PhysViz software package (mobile app and web application). A variety of study designs informed user-desired features that were integrated into the PhysViz prototype, including real-time biofeedback in the form of precision load monitoring, customizable exercise programs, and pain tracking. In addition, clinicians can visualize client data longitudinally and make changes to client exercise prescriptions remotely based on objective data. The identified areas for improvement, such as upgrading the user interface and user experience and expanding clinical applications, provide valuable insights for future PhysViz iterations. Further research is warranted to assess the long-term efficacy and feasibility of the PhysViz in diverse clinical settings and its potential to improve AT symptoms. Being one of the first technology development initiatives guided by the FASTER, this study exemplifies a systematic and multidisciplinary approach to creating a remote rehabilitation intervention. By incorporating stakeholder feedback and evidence-based features, the PhysViz addresses key challenges in AT rehabilitation, offering a novel solution for precision loading and therapeutic exercise engagement. Positive feedback from users and clinicians underscores the potential impact of the PhysViz in improving AT management outcomes. The PhysViz serves as a model for technology-based intervention development, with potential implications for other tendinopathies and remote rehabilitation strategies.

Use of Creative Frameworks in Health Care to Solve Data and Information Problems: Scoping Review.

Digitization is vital for data management, especially in health care. However, problems still hinder health care stakeholders in their daily work while collecting, processing, and providing health data or information. Data are missing, incorrect, cannot be collected, or information is inadequately presented. These problems can be seen as data or information problems. A proven way to elicit requirements for (software) systems is by using creative frameworks (eg, user-centered design, design thinking, lean UX [user experience], or service design) or creative methods (eg, mind mapping, storyboarding, 6 thinking hats, or interaction room). However, to what extent they are used to solve data or information-related problems in health care is unclear. The primary objective of this scoping review is to investigate the use of creative frameworks in addressing data and information problems in health care. Following JBI guidelines and the PRISMA-ScR framework, this paper analyzes selected papers, answering whether creative frameworks addressed health care data or information problems. Focusing on data problems (elicitation or collection, processing) and information problems (provision or visualization), the review examined German and English papers published between 2018 and 2022 using keywords related to "data," "design," and "user-centered." The database SCOPUS was used. Of the 898 query results, only 23 papers described a data or information problem and a creative method to solve it. These were included in the follow-up analysis and divided into different problem categories: data collection (n=7), data processing (n=1), information visualization (n=11), and mixed problems meaning data and information problem present (n=4). The analysis showed that most identified problems fall into the information visualization category. This could indicate that creative frameworks are particularly suitable for solving information or visualization problems and less for other, more abstract areas such as data problems. The results also showed that most researchers applied a creative framework after they knew what specific (data or information) problem they had (n=21). Only a minority chose a creative framework to identify a problem and realize it was a data or information problem (n=2). In response to these findings, the paper discusses the need for a new approach that addresses health care data and information challenges by promoting collaboration, iterative feedback, and user-centered development. Although the potential of creative frameworks is undisputed, applying these in solving data and information problems is a minority. To harness this potential, a suitable method needs to be developed to support health care system stakeholders. This method could be the User-Centered Data Approach.

APPROACH e-PROM system: a user-centered development and evaluation of an electronic patient-reported outcomes measurement system for management of coronary artery disease

BackgroundCoronary artery disease (CAD) confers increased risks of premature mortality, non-fatal morbidity, and significant impairment in functional status and health-related quality of life. Routine administration of electronic patient-reported outcome measures (PROMs) and its real time delivery to care providers is known to have the potential to inform routine cardiac care and to improve quality of care and patient outcomes. This study describes a user-centered development and evaluation of the Alberta Provincial Project for Outcomes Assessment (APPROACH) electronic Patient Reported Outcomes Measurement (e-PROM) system. This e-PROM system is an electronic system for the administration of PROMs to patients with CAD and the delivery of the summarized information to their care providers to facilitate patient-physician communication and shared decision-making. This electronic platform was designed to be accessible via web-based and hand-held devices. Heuristic and user acceptance evaluation were conducted with patients and attending care providers.ResultsThe APPROACH e-PROM system was co-developed with patients and care providers, research investigators, informaticians and information technology experts. Five PROMs were selected for inclusion in the online platform after consultations with patient partners, care providers, and PROMs experts: the Seattle Angina Questionnaire, Patient Health Questionnaire, EuroQOL, and Medical Outcomes Study Social Support Survey, and Self-Care of Coronary Heart Disease Inventory. The heuristic evaluation was completed by four design experts who examined the usability of the prototype interfaces. User acceptance testing was completed with 13 patients and 10 cardiologists who evaluated prototype user interfaces of the e-PROM system.ConclusionBoth patients and physicians found the APPROACH e-PROM system to be easy to use, understandable, and acceptable. The APPROACH e-PROM system provides a user-informed electronic platform designed to incorporate PROMs into the delivery of individualized cardiac care for persons with CAD.

SIGEPS: A System for Managing the Health Internship Program.

The healthcare sector's demand for a skilled workforce necessitates effective management of internship and residency programs. This study introduces the System for Managing the Health Internship Program (SIGEPS), aimed at addressing internship and residency management challenges in Joinville's municipal health network. The method of this study focused on developing a computational solution with applied and exploratory objectives. The research adopted a User-Centered Development approach, involving seven stages from scope determination to system implementation. Key stages included selecting Google's free technological tools, developing forms for information input, integrating these into a Google Sheets spreadsheet, and creating a website for schedule display. The primary result was the successful development of SIGEPS, which automated the process from initial requests to scheduling and analysis of healthcare institutions and displayed schedules online. The system offers several advantages over previous models, such as concurrent scheduling by multiple employees, process automation, enhanced information transparency, and improved efficiency with significant time savings. Future enhancements include integrating decision support systems and enabling data analysis reports through dashboards to further reduce scheduling efforts and enhance professional efficiency. This study demonstrates the feasibility of developing and implementing a free computational solution using the Google platform for managing internships and residencies in the healthcare sector.

User-Centered Development of Explanation User Interfaces for AI-Based CDSS: Lessons Learned from Early Phases.

This paper reports lessons learned during the early phases of the user-centered design process for an explanation user interface for an AI-based clinical decision support system for the intensive care unit. This paper focuses on identifying and verifying physicians' explanation needs in a multi-center, multi-country project. The explanation needs identified through context analysis and user requirements prioritization in an initial center differed from those identified through questionnaire responses from N= 9 physicians after a multi-center project workshop. These results highlight the caution that should be taken when eliciting explanation needs during the user-centered design process.

User-Centered Development of a Mobile Application for Management of Hypertension Disorders of Pregnancy: A Study Protocol

User-Centered Development of a Mobile Application for Management of Hypertension Disorders of Pregnancy: A Study Protocol

Automatic cybersickness detection by deep learning of augmented physiological data from off-the-shelf consumer-grade sensors

Cybersickness is still a prominent risk factor potentially affecting the usability of virtual reality applications. Automated real-time detection of cybersickness promises to support a better general understanding of the phenomena and to avoid and counteract its occurrence. It could be used to facilitate application optimization, that is, to systematically link potential causes (technical development and conceptual design decisions) to cybersickness in closed-loop user-centered development cycles. In addition, it could be used to monitor, warn, and hence safeguard users against any onset of cybersickness during a virtual reality exposure, especially in healthcare applications. This article presents a novel real-time-capable cybersickness detection method by deep learning of augmented physiological data. In contrast to related preliminary work, we are exploring a unique combination of mid-immersion ground truth elicitation, an unobtrusive wireless setup, and moderate training performance requirements. We developed a proof-of-concept prototype to compare (combinations of) convolutional neural networks, long short-term memory, and support vector machines with respect to detection performance. We demonstrate that the use of a conditional generative adversarial network-based data augmentation technique increases detection performance significantly and showcase the feasibility of real-time cybersickness detection in a genuine application example. Finally, a comprehensive performance analysis demonstrates that a four-layered bidirectional long short-term memory network with the developed data augmentation delivers superior performance (91.1% F1-score) for real-time cybersickness detection. To encourage replicability and reuse in future cybersickness studies, we released the code and the dataset as publicly available.

Smartwatch-Based Interventions for People With Dementia: User-Centered Design Approach.

Assistive technologies can help people living with dementia maintain their everyday activities. Nevertheless, there is a gap between the potential and use of these materials. Involving future users may help close this gap, but the impact on people with dementia is unclear. We aimed to determine if user-centered development of smartwatch-based interventions together with people with dementia is feasible. In addition, we evaluated the extent to which user feedback is plausible and therefore helpful for technological improvements. We examined the interactions between smartwatches and people with dementia or people with mild cognitive impairment. All participants were prompted to complete 2 tasks (drinking water and a specific cognitive task). Prompts were triggered using a smartphone as a remote control and were repeated up to 3 times if participants failed to complete a task. Overall, 50% (20/40) of the participants received regular prompts, and 50% (20/40) received intensive audiovisual prompts to perform everyday tasks. Participants' reactions were observed remotely via cameras. User feedback was captured via questionnaires, which included topics like usability, design, usefulness, and concerns. The internal consistency of the subscales was calculated. Plausibility was also checked using qualitative approaches. Participants noted their preferences for particular functions and improvements. Patients struggled with rating using the Likert scale; therefore, we assisted them with completing the questionnaire. Usability (mean 78 out of 100, SD 15.22) and usefulness (mean 9 out of 12) were rated high. The smartwatch design was appealing to most participants (31/40, 76%). Only a few participants (6/40, 15%) were concerned about using the watch. Better usability was associated with better cognition. The observed success and self-rated task comprehension were in agreement for most participants (32/40, 80%). In different qualitative analyses, participants' responses were, in most cases, plausible. Only 8% (3/40) of the participants were completely unaware of their irregular task performance. People with dementia can have positive experiences with smartwatches. Most people with dementia provided valuable information. Developing assistive technologies together with people with dementia can help to prioritize the future development of functional and nonfunctional features.

User-Centered Development of a Patient Decision Aid for Choice of Early Abortion Method: Multi-Cycle Mixed Methods Study.

People seeking abortion in early pregnancy have the choice between medication and procedural options for care. The choice is preference-sensitive-there is no clinically superior option and the choice depends on what matters most to the individual patient. Patient decision aids (PtDAs) are shared decision-making tools that support people in making informed, values-aligned health care choices. We aimed to develop and evaluate the usability of a web-based PtDA for the Canadian context, where abortion care is publicly funded and available without legal restriction. We used a systematic, user-centered design approach guided by principles of integrated knowledge translation. We first developed a prototype using available evidence for abortion seekers' decisional needs and the risks, benefits, and consequences of each option. We then refined the prototype through think-aloud interviews with participants at risk of unintended pregnancy ("patient" participants). Interviews were audio-recorded and documented through field notes. Finally, we conducted a web-based survey of patients and health care professionals involved with abortion care, which included the System Usability Scale. We used content analysis to identify usability issues described in the field notes and open-ended survey questions, and descriptive statistics to summarize participant characteristics and close-ended survey responses. A total of 61 individuals participated in this study. Further, 11 patients participated in think-aloud interviews. Overall, the response to the PtDA was positive; however, the content analysis identified issues related to the design, language, and information about the process and experience of obtaining abortion care. In response, we adapted the PtDA into an interactive website and revised it to include consistent and plain language, additional information (eg, pain experience narratives), and links to additional resources on how to find an abortion health care professional. In total, 25 patients and 25 health care professionals completed the survey. The mean System Usability Scale score met the threshold for good usability among both patient and health care professional participants. Most participants felt that the PtDA was user-friendly (patients: n=25, 100%; health care professionals: n=22, 88%), was not missing information (patients: n=21, 84%; health care professionals: n=18, 72%), and that it was appropriate for patients to complete the PtDA before a consultation (patients: n=23, 92%; health care professionals: n=23, 92%). Open-ended responses focused on improving usability by reducing the length of the PtDA and making the website more mobile-friendly. We systematically designed the PtDA to address an unmet need to support informed, values-aligned decision-making about the method of abortion. The design process responded to a need identified by potential users and addressed unique sensitivities related to reproductive health decision-making.

User-Centered Development of an Online Dashboard Tool for Economic Sustainability for Small and Medium Enterprises

This study aimed to improve an existing static benchmarking tool for the economic sustainability of small and medium enterprises (SMEs) in the wine sector to develop and elevate it into a dynamic online dashboard decision support system (DSS) for economic sustainability. Development was conducted in line with a user-centered-development process in four main steps. In the first step, producers’ expectations for an optimal tool were elicited using a qualitative approach of 24 in-depth interviews with long-term users of the existing PDF reports. Among the 10 requirements, producers requested an overall summary assessment of the most important KPIs of their business (including the provision of ideal values), intuitive visual presentations, long-term time developments, flexible reference groups, and short comments. Based on the wine producers’ systemized responses, the first version of the online benchmarking tool was designed and implemented in cooperation with experienced online designers and programmers. In the third step, a usability test was conducted to elicit options for further improvements that were implemented before the fourth step, the release of the final version to the industry. The systematic development process outlined and established here and the released DSS tool that is publicly available with open access provide valuable insights for institutions planning similar future dashboards for other sectors, particularly for SMEs. This constitutes an important step toward the development of more holistic support tools for sustainability performance measurement across all pillars of sustainability moving forward. To the best of the authors’ knowledge, the DSS developed represents the first online dashboard tool for economic sustainability for SMEs globally and in the wine sector.

User-Centered Development of HEARTPrep, a Digital Health Psychosocial Intervention for Prenatally Diagnosed Congenital Heart Disease.

User-centered models for the development of digital health interventions are not consistently applied in healthcare settings. This study used a five-phase, user-centered approach to develop HEARTPrep©, a psychosocial intervention delivered via mobile app and telehealth to mothers expecting a baby with congenital heart disease (CHD) to promote maternal, family, and child well-being. Phases of intervention development were: (I) establishing partnerships; (II) creating content; (III) developing prototype and testable intervention; (IV) conducting think-aloud testing; and (V) completing beta testing. Partnerships with parents, clinicians, and design/technology experts were integral throughout the development of HEARTPrep©. Parents of children with CHD also served as participants in Phases II-V, contributing to the creation of content and providing feedback to inform the iterative refinement of HEARTPrep©. These five phases produced a refined digital health intervention with promising feasibility, usability, and acceptability results. This user-centered approach can be used to develop digital health interventions targeting various health outcomes.

User-centered development of an mHealth app for cardiovascular prevention

Background Mobile health (mHealth) apps can be used for cardiovascular disease (CVD) prevention. User-centered design, evidence-based content and user testing can be applied to ensure a high level of usability and adequate app access. Objective To develop and evaluate an mHealth app ( HerzFit) for CVD prevention. Methods HerzFit´s development included a user-centered design approach and guideline-based content creation based on the identified requirements of the target group. Beta testing and a preliminary usability evaluation of the HerzFit prototype were performed. For evaluation, German versions of the System Usability Scale (SUS) and the mHealth App Usability Questionnaire (GER-MAUQ) as well as free text feedback were applied. Results User-centered design thinking led to the definition of four personas. Based on their requirements, HerzFit enables users to individually assess, monitor, and optimize their cardiovascular risk profile. Users are also provided with a variety of evidence-based information on CVD and their risk factors. The user interface and system design followed the identified functional requirements. Beta-testers provided feedback on the structure and functionality and rated the usability of HerzFit´s prototype as slightly above average both in SUS and GER-MAUQ rating. Participants positively noted the variety of functions and information presented in HerzFit, while negative feedback mostly concerned wearable synchronization. Conclusions The present study demonstrates the user-centered development of a guideline-based mHealth app for CVD prevention. Beta-testing and a preliminary usability study were used to further improve the HerzFit app until its official release.

Usability and Feasibility Assessment of a Social Assistive Robot for the Older People: Results from the GUARDIAN Project.

In Italy, many people aged over 65 cannot live independently, causing an overall decrease in their quality of life and a need for social and health care. Due to the lack of both formal and informal caregivers, technological solutions become of paramount importance in this scenario. This article describes the user-centered development of the GUARDIAN ecosystem, consisting of a social robot integrated with two mobile applications which aim to monitor, coach, and keep the older user company in order to prolong his/her independence at home. In particular, the advancements from the alpha to the beta prototype of the ecosystem are described, achieved through the feedback collected from 41 end users-older people and their carers-that have tested the system for 6 weeks. By enhancing human-robot interaction, a positive improvement in terms of usability and acceptability of the system was retrieved. However, to increase the perceived usefulness and the impact on older users' lives, it is necessary to make the entire system more customizable, and more capable in providing support for daily activities.

Extending cBioPortal for Therapy Recommendation Documentation in Molecular Tumor Boards: Development and Usability Study.

In molecular tumor boards (MTBs), patients with rare or advanced cancers are discussed by a multidisciplinary team of health care professionals. Software support for MTBs is lacking; in particular, tools for preparing and documenting MTB therapy recommendations need to be developed. We aimed to implement an extension to cBioPortal to provide a tool for the documentation of therapy recommendations from MTB sessions in a secure and standardized manner. The developed extension should be embedded in the patient view of cBioPortal to enable easy documentation during MTB sessions. The resulting architecture for storing therapy recommendations should be integrable into various hospital information systems. On the basis of a requirements analysis and technology analysis for authentication techniques, a prototype was developed and iteratively refined through a user-centered development process. In conclusion, the tool was evaluated via a usability evaluation, including interviews, structured questionnaires, and the System Usability Scale. The patient view of cBioPortal was extended with a new tab that enables users to document MTB sessions and therapy recommendations. The role-based access control was expanded to allow for a finer distinction among the rights to view, edit, and delete data. The usability evaluation showed overall good usability and a System Usability Scale score of 83.57. This study demonstrates how cBioPortal can be extended to not only visualize MTB patient data but also be used as a documentation platform for therapy recommendations.

User-Centered Development of STOP (Successful Treatment for Paranoia): Material Development and Usability Testing for a Digital Therapeutic for Paranoia.

Paranoia is a highly debilitating mental health condition. One novel intervention for paranoia is cognitive bias modification for paranoia (CBM-pa). CBM-pa comes from a class of interventions that focus on manipulating interpretation bias. Here, we aimed to develop and evaluate new therapy content for CBM-pa for later use in a self-administered digital therapeutic for paranoia called STOP ("Successful Treatment of Paranoia"). This study aimed to (1) take a user-centered approach with input from living experts, clinicians, and academics to create and evaluate paranoia-relevant item content to be used in STOP and (2) engage with living experts and the design team from a digital health care solutions company to cocreate and pilot-test the STOP mobile app prototype. We invited 18 people with living or lived experiences of paranoia to create text exemplars of personal, everyday emotionally ambiguous scenarios that could provoke paranoid thoughts. Researchers then adapted 240 suitable exemplars into corresponding intervention items in the format commonly used for CBM training and created 240 control items for the purpose of testing STOP. Each item included newly developed, visually enriching graphics content to increase the engagement and realism of the basic text scenarios. All items were then evaluated for their paranoia severity and readability by living experts (n=8) and clinicians (n=7) and for their item length by the research team. Items were evenly distributed into six 40-item sessions based on these evaluations. Finalized items were presented in the STOP mobile app, which was co-designed with a digital health care solutions company, living or lived experts, and the academic team; user acceptance was evaluated across 2 pilot tests involving living or lived experts. All materials reached predefined acceptable thresholds on all rating criteria: paranoia severity (intervention items: ≥1; control items: ≤1, readability: ≥3, and length of the scenarios), and there was no systematic difference between the intervention and control group materials overall or between individual sessions within each group. For item graphics, we also found no systematic differences in users' ratings of complexity (P=.68), attractiveness (P=.15), and interest (P=.14) between intervention and control group materials. User acceptance testing of the mobile app found that it is easy to use and navigate, interactive, and helpful. Material development for any new digital therapeutic requires an iterative and rigorous process of testing involving multiple contributing groups. Appropriate user-centered development can create user-friendly mobile health apps, which may improve face validity and have a greater chance of being engaging and acceptable to the target end users.

Simulation-based development: shaping clinical procedures for extra-uterine life support technology

BackgroundResearch into Artificial Placenta and Artificial Womb (APAW) technology for extremely premature infants (born < 28 weeks of gestation) is currently being conducted in animal studies and shows promising results. Because of the unprecedented nature of a potential treatment and the high-risk and low incidence of occurrence, translation to the human condition is a complex task. Consequently, the obstetric procedure, the act of transferring the infant from the pregnant woman to the APAW system, has not yet been established for human patients. The use of simulation-based user-centered development allows for a safe environment in which protocols and devices can be conceptualized and tested. Our aim is to use participatory design principles in a simulation context, to gain and integrate the user perspectives in the early design phase of a protocol for this novel procedure.MethodsSimulation protocols and prototypes were developed using an iterative participatory design approach; usability testing, including general and task-specific feedback, was obtained from participants with clinical expertise from a range of disciplines. The procedure made use of fetal and maternal manikins and included animations and protocol task cards.ResultsPhysical simulation with the active participation of clinicians led to the diffusion of tacit knowledge and an iteratively formed shared understanding of the requirements and values that needed to be implemented in the procedure. At each sequel, participant input was translated into simulation protocols and design adjustments.ConclusionThis work demonstrates that simulation-based participatory design can aid in shaping the future of clinical procedure and product development and rehearsing future implementation with healthcare professionals.

User-Centered Development of Bolster, an mHealth Intervention for Early Psychosis Caregivers: Needs Assessment, Prototyping, and Field Trial.

Caregivers play a critical role in the treatment and recovery of youth and young adults at risk for psychosis. Caregivers often report feeling isolated, overwhelmed, and lacking in resources. Mobile health (mHealth) has the potential to provide scalable, accessible, and in-the-moment support to caregivers. To date, few if any mHealth resources have been developed specifically for this population. The aim of this study was to conduct user-centered design and testing of an mHealth intervention to support early psychosis caregivers. We conducted a multiphase user-centered development process to develop the Bolster mobile app. In phase 1, a total of 21 caregivers were recruited to participate in a qualitative needs assessment and respond to an initial prototype of the Bolster platform. Content analysis was used to identify key needs and design objectives, which guided the development of the Bolster mobile app. In phase 2, a total of 11 caregivers were recruited to participate in a 1-week field trial wherein they provided qualitative and quantitative feedback regarding the usability and acceptability of Bolster; in addition, they provided baseline and posttest assessments of the measures of distress, illness appraisals, and family communication. In phase 1, participants identified psychoeducation, communication coaching, a guide to seeking services, and support for coping as areas to address. Live prototype interaction sessions led to multiple design objectives, including ensuring that messages from the platform were actionable and tailored to the caregiver experience, delivering messages in multiple modalities (eg, video and text), and eliminating a messaging-style interface. These conclusions were used to develop the final version of Bolster tested in the field trial. In phase 2, of the 11 caregivers, 10 (91%) reported that they would use Bolster if they had access to it and would recommend it to another caregiver. They also reported marked changes in their appraisals of illness (Cohen d=0.55-0.68), distress (Cohen d=1.77), and expressed emotion (Cohen d=0.52). To our knowledge, this study is the first to design an mHealth intervention specifically for early psychosis caregivers. Preliminary data suggest that Bolster is usable, acceptable, and promising to improve key targets and outcomes. A future fully powered clinical trial will help determine whether mHealth can reduce caregiver burdens and increase engagement in services among individuals affected by psychosis.

User-Centered Design of a Gamified Mental Health App for Adolescents in Sub-Saharan Africa: Multicycle Usability Testing Study.

There is an urgent need for scalable psychological treatments to address adolescent depression in low-resource settings. Digital mental health interventions have many potential advantages, but few have been specifically designed for or rigorously evaluated with adolescents in sub-Saharan Africa. This study had 2 main objectives. The first was to describe the user-centered development of a smartphone app that delivers behavioral activation (BA) to treat depression among adolescents in rural South Africa and Uganda. The second was to summarize the findings from multicycle usability testing. An iterative user-centered agile design approach was used to co-design the app to ensure that it was engaging, culturally relevant, and usable for the target populations. An array of qualitative methods, including focus group discussions, in-depth individual interviews, participatory workshops, usability testing, and extensive expert consultation, was used to iteratively refine the app throughout each phase of development. A total of 160 adolescents from rural South Africa and Uganda were involved in the development process. The app was built to be consistent with the principles of BA and supported by brief weekly phone calls from peer mentors who would help users overcome barriers to engagement. Drawing on the findings of the formative work, we applied a narrative game format to develop the Kuamsha app. This approach taught the principles of BA using storytelling techniques and game design elements. The stories were developed collaboratively with adolescents from the study sites and included decision points that allowed users to shape the narrative, character personalization, in-app points, and notifications. Each story consists of 6 modules ("episodes") played in sequential order, and each covers different BA skills. Between modules, users were encouraged to work on weekly activities and report on their progress and mood as they completed these activities. The results of the multicycle usability testing showed that the Kuamsha app was acceptable in terms of usability and engagement. The Kuamsha app uniquely delivered BA for adolescent depression via an interactive narrative game format tailored to the South African and Ugandan contexts. Further studies are currently underway to examine the intervention's feasibility, acceptability, and efficacy in reducing depressive symptoms.