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This dissertation focused on the added value of personalized gamification as a factor to enhance implementation potential of eHealth interventions in youth mental healthcare. Mental health disorders are the leading cause of disability in adolescents. It is important for these adolescents to go into therapy, as adolescence is a period in live in which essential developments occur on which mental health disorders have a negative impact. Although psychosocial therapies are effective in reducing psychiatric symptoms in adolescents with mental disorders, there is still room for improvement. For example, because of premature termination of treatment, poor attendance of treatment‐sessions and a low or non‐adherence to homework assignments.

One way of improving psychological treatment is the use of the use of Information and Communication Technologies combined with face‐to‐face therapy (also called “blended eHealth”). It can extend the reach of psychological therapy beyond the clinical setting, as technologies can be used anytime and anywhere. It is especially suitable for adolescents, as a majority owns a smartphone.

Current eHealth interventions in mental healthcare are often focused on the therapeutic content and provide limited interaction motivation for the users, causing a high drop‐out rate. Users of therapeutic eHealth should thus be motivated to start and continue to use the online modules for therapy‐related activities, especially when they have to perform these online modules in their own environment and time.

Gamification seems a suitable design technique to enhance this motivation within eHealth interventions. It aims to change the behavior of a user in the real world (this change is also called the (health related) transfer effect) by creating a game world experience that is more engaging, free and enjoyable compared to a real world experience, by using game‐elements in a non‐game context. However, some game‐elements can be more motivating for specific individuals than others and should therefore be personalized.

We first conducted a literature study that focused on how personalization is applied in game design for healthcare and how these games influenced health related outcomes (Chapter 2). This was followed by a focus group study that focused on the therapeutic practice of personalization in youth mental healthcare (Chapter 3) and experiments that focused on the game design relevance of personalization in youth mental healthcare (Chapter 4). Based on this information, we designed an eHealth application for youth mental healthcare and implemented gamification and personalization in the design and explain this process in Chapter 5. Concluding, the aim of the study in this dissertation was to study the added value of personalized gamification to enhance implementation potential of eHealth interventions in youth mental healthcare.

Since personalization in gamification had never been systematically studied, I executed a literature study and developed a model to study the effects of personalization in game design for healthcare (Chapter 2). Based on the literature we proposed a model for different types of personalization in eHealth development and design. We defined ‘personalization’ as the involvement of stakeholders across Problem Definition, Product Design and Tailoring (the Personalized Design Process (PDP) phases). In the first phase, information is generated to identify, establish and analyze the problem and generate related ideas. In the next Product Design phase, possible solutions are produced, resulting in product ideas or design proposal(s) that are tested and evaluated by users, and further improved through iterations. In the last Tailoring phase, the final product can be tailored to the needs of individual end‐users. The studies generally found positive effects on interaction experience, interaction behavior and health related transfer effects. However, since a majority of the studies were of low methodological quality, we could only suggest that it is important to involve stakeholders across the PDP‐phases. It will limit the amount of iterations needed, as the chance is increased that the eHealth intervention is aligned to the users. Consequently, the users will potentially use the product to its full extend which will positively influence the health related transfer effect.

Personalization is not only often applied in game design for healthcare, but also in a therapeutic process. Therapists and patients often adapt therapy protocols, to align it to their personal preferences and situation. If designers of eHealth for mental healthcare do not take this into account it is more likely that the final eHealth design does not suit the therapeutic practice. This will in turn negatively influence the implementation. We conducted focus‐group discussions with patients and therapists in youth addiction care on therapy protocol application and personalization (Chapter 3) and generated recommendations for eHealth designers to enhance alignment of eHealth to the therapeutic practice and implementation: a) study and copy at least the actual applied parts of a therapy protocol in eHealth, b) co‐design eHealth in such a way that both therapists and patients can personalize specific parts of the final eHealth design, and c) investigate if parts of the therapy protocol that are not presently applied by therapists or patients should be part of the eHealth application.

Even when an eHealth product is aligned to therapeutic practice, it is important to enhance the motivation of patients to use eHealth and to facilitate the achievement of aimed‐for real‐world goals such as behavioral change. This can be done by making it more appealing by applying gamification design. We first used a design method with the often used PLEX cards that represent 22 playful experiences that can motivate users to (continue) to play a game. We wanted to examine whether the input of playful experiences was also experienced by other end‐users from the same context in the actual design itself (Chapter 4A). However the experiences that were used in the design of the prototype did not correspond one‐on‐one with the experiences that were reported by other users who played the prototype. To ensure that the product is still aligned to preferred experiences and limit possible individual preferences of stakeholder types that cannot be generalizable to the specific stakeholder type, it is important to involve stakeholders in multiple moments and phases of a PDP, and not only in one. Next to the specific design method, we also wanted to study the effect of a specific design element in a youth mental healthcare context. Rewards are the most typically used game‐elements to foster motivation in entertainment gaming. However, it is unclear whether game‐rewards are also effective in a healthcare context. For example, patients with substance‐related disorders may be less sensitive to non‐drug‐related rewards compared to patients without a substance use disorder. Results of our study (Chapter 4B) showed that, in contrast to our expectations, substance dependent participants were more motivated by the types of rewards compared to non‐substance dependent participants.

The previous chapters provided argumentation for personalization to enhance implementation of gamified eHealth. This was taken into account in the design process of an eHealth application for youth mental healthcare (Chapter 5). We wanted to test the general effect of the gamification, by conducting a non‐randomized pre‐post (eight weeks) study. In this study we contrasted two conditions: one eHealth intervention that was gamified and one that was not gamified. However, the inflow of patients in the Luca study was low, and at the time of writing it was uncertain whether the study could be finalized as planned according to our protocol. The main reason was that the study set‐up was not in line with the current therapeutic practice, which was a reason for therapists and patients to not be fully willing to participate in the experiment. Thus, even when eHealth is personalized and gamified, implementation can still be influenced by negative expectations about the effect, a limited integration within current therapy.

Concluding, when stakeholders are more actively involved in the design phases of a gamification, the motivational effect of the gamification can be enhanced. It is important to align an eHealth product to the context of application and to align the design to the preferred experience, capacity and context of a user, to enhance the implementation potential. Secondly, the set‐up of effect‐studies should be adapted to the context of application to limit invasiveness in therapeutic practice and to enhance the feasibility of the study. If a study set‐up is not in line with the current therapeutic practice, therapists and patients may thus not be fully willing to participate in an experiment. This would make it difficult or impossible to test the effect of personalized gamification in eHealth, which is useful information for future eHealth designs and studies to enhance implementation potential.