In this paper, a user interface paradigm, called Talk-and-Tools, is presented for automated e-coaching. The paradigm is based on the idea that people interact in two ways with their environment: symbolically and physically. The main goal is to show how the paradigm can be applied in the design of interactive systems that offer an acceptable coaching process. As a proof of concept, an e-coaching system is implemented that supports an insomnia therapy on a smartphone. A human coach was replaced by a cooperative virtual coach that is able to interact with a human coachee. In the interface of the system, we distinguish between a set of personalized conversations (“Talk”) and specialized modules that form a coherent structure of input and output facilities (“Tools”). Conversations contained a minimum of variation to exclude unpredictable behavior but included the necessary mechanisms for variation to offer personalized consults and support. A variety of system and user tests was conducted to validate the use of the system. After a 6-week therapy, some users spontaneously reported the experience of building a relationship with the e-coach. It is concluded that the addition of a conversational component fills an important gap in the design of current mobile systems. ... Read more

The experiment presented in this paper investigated the effects of different kinds of reminders on adherence to automated parts of a cognitive behavioural therapy for insomnia (CBT-I) delivered via a mobile device. Previous studies report that computerized health interventions can be effective. However, treatment adherence is still an issue. Reminders are a simple technique that could improve adherence. A minimal intervention prototype in the realm of sleep treatment was developed to test the effects of reminders on adherence. Two prominent ways to determine the reminder-time are: a) ask users when they want to be reminded, and b) let an algorithm decide when to remind users. The prototype consisted of a sleep diary, a relaxation exercise and reminders. A within subject design was used in which the effect of reminders and two underlying principles were tested by 45 participants that all received the following three different conditions (in random order): a) event-based reminders b) time-based reminders c) no reminders. Both types of reminders improved adherence compared to no reminders. No differences were found between the two types of reminders. Opportunity and self-empowerment could partly mediate adherence to filling out the sleep diary, but not to the number of relaxation exercises conducted. Although the study focussed on CBT-I, we expect that designers of other computerized health interventions benefit from the tested opportunity and self-empowerment principles for reminders to improve adherence, as well. ... Read more

Background: This study is one of the first randomized controlled trials investigating cognitive behavioral therapy for insomnia (CBT-I) delivered by a fully automated mobile phone app. Such an app can potentially increase the accessibility of insomnia treatment for the 10% of people who have insomnia. Objective: The objective of our study was to investigate the efficacy of CBT-I delivered via the Sleepcare mobile phone app, compared with a waitlist control group, in a randomized controlled trial. Methods: We recruited participants in the Netherlands with relatively mild insomnia disorder. After answering an online pretest questionnaire, they were randomly assigned to the app (n=74) or the waitlist condition (n=77). The app packaged a sleep diary, a relaxation exercise, sleep restriction exercise, and sleep hygiene and education. The app was fully automated and adjusted itself to a participant’s progress. Program duration was 6 to 7 weeks, after which participants received posttest measurements and a 3-month follow-up. The participants in the waitlist condition received the app after they completed the posttest questionnaire. The measurements consisted of questionnaires and 7-day online diaries. The questionnaires measured insomnia severity, dysfunctional beliefs about sleep, and anxiety and depression symptoms. The diary measured sleep variables such as sleep efficiency. We performed multilevel analyses to study the interaction effects between time and condition. Results: The results showed significant interaction effects (P<.01) favoring the app condition on the primary outcome measures of insomnia severity (d=–0.66) and sleep efficiency (d=0.71). Overall, these improvements were also retained in a 3-month follow-up. Conclusions: This study demonstrated the efficacy of a fully automated mobile phone app in the treatment of relatively mild insomnia. The effects were in the range of what is found for Web-based treatment in general. This supports the applicability of such technical tools in the treatment of insomnia. Future work should examine the generalizability to a more diverse population. Furthermore, the separate components of such an app should be investigated. It remains to be seen how this app can best be integrated into the current health regimens ... Read more

Non-adherence is considered a problem that seriously undermines the outcome of behavior change therapies, in particular of self-help therapies delivered without human interference. This paper presents the design rationale behind a computer system in the domain of adherence enhancing strategies in automated e-coaching. A variety of persuasive strategies is introduced and implemented in a mobile e-coaching system in the domain of insomnia therapy. The system integrates two types of interface elements, i.e. dedicated tools and natural language conversation, to simplify therapy related activities and to include social strategies to improve motivation. We focus on the crucial role of communication and adaptation. ... Read more