6 Design study II: Development of an ambulatory biofeedback app 195 app with patients and therapists was within the dialectical behavioral treatment (DBT) [36] unit of the clinic. Here, multidisciplinary group DBT [36] is given to a maximum of 27 inpatients at a time. All patients are diagnosed with 1 or more personality disorders—the majority of them having BPD diagnosed as main disorder. Four days a week, during working hours, patients receive multiple forms of psychological treatment. Medical treatment can be part of the treatment but serves a subsidiary role. On average, duration of treatment within the DBT program is 9 to 12 months. After that, most patients are referred for further (outpatient) care. 2.3 Data Analysis Data from interviews, questionnaires, and task scenarios were transcribed via a transcription program (F4). Additional remarks made by participants during or in between hands-on testing were also registered. Qualitative analysis consisted of a combination of content and thematic analysis [37]. Comments were categorized by applying constant comparison, comparing statements numerically and content wise. Usability problems and needs were listed and subsequently grouped, after which a central theme was allocated to each group. This was done by 2 of the authors (YD and RK), of which one has a background in psychology, and the other in computer science. Final categorization reflects consensus after comparison and discussion of the interpretation processes of both authors. The following main themes were identified: (1) technology, (2) user interface and interaction, and (3) functionality (and ethics). Next, within each set of results per group, inductive thematic analysis was used to identify whether, and if so which, specific values regarding the acceptance and adoption of the app were present. Next to the qualitative analyses, individual and overall scores of the system usability scale (SUS) [38] (used in cycles 1 and 2) and the cognitive walkthrough (used in cycle 3) were quantitatively analyzed. 2.4 Ethical considerations The study was granted approval by both a nationwide operating ethical commission and a local ethical commission associated with the university. Participation in the study was on a voluntary basis and only after informed consent. Patients undergoing clinical treatment at the treatment center and therapists working in the center were eligible if they were willing to actively participate. All participants could withdraw from the study at any time with no further obligations. In addition, therapists of the patients held the right to anytime exclude or withdraw patients from participating in the study if they judged a patient’s participation potentially detrimental for his or her well-being or unwanted or inappropriate in any other way. There was no financial reward or other incentive for participating. Cycles The cycles will be presented as separate studies. Per cycle, results will be presented in paragraphs representing the main themes that resulted from the thematic
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