Marcia Nissen
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Item type:Publication, Sensor-Augmented Conversational Agent for Personalized Lifestyle Support in Older Adults with Mild Cognitive Impairment: Two-Week Feasibility Study (Preprint)(JMIR Publications Inc., 2026-06-25); Klöppel, StefanBackground: Early lifestyle interventions may reduce dementia-related cognitive decline, but individuals with cognitive impairment often face barriers to accessing and maintaining such interventions. Smartphone applications and wearables may offer low-burden, real-time support. Objective: This study examined the feasibility and acceptability of a two-week sensor-augmented just-in-time adaptive intervention (JITAI) delivered via smartphone-based conversational agents (CAs) and a wearable fitness tracker in older adults with mild cognitive impairment (MCI). Methods: In this single-arm, feasibility study, 24 MCI participants (mean age: 75.9 years) used the intervention with a rule-based CA delivering two daily JITAI interventions: (1) a sensor-informed primary physical-activity component, in which continuously collected step-count data from a wrist-worn fitness tracker (Garmin Vivoactive 6) were used to assess vulnerability against a personalized step goal and deliver tailored walking prompts; and (2) an ecological momentary assessment-based secondary health-promoting component targeting one of six additional health domains (hydration, nutrition, cognitive exercise, sleep, social engagement, movement), assessed via momentary self-report. Both components followed the same JITAI decision logic: vulnerability assessment in the afternoon, receptivity evaluation if vulnerable, tailored prompt delivery if receptive, and adherence assessment at an evening check-in. Post-intervention questionnaires assessed technology acceptance, usability, working alliances and qualitative feedback. Results: Across the study period, engagement with the CA was high for both components. Afternoon response rates were 86.6% for the primary physical-activity component and 84.2% for the secondary health-promoting-activities component. Evening check-in response rates were 85.6% and 79.3%. Among all responses classified as vulnerable (38.7% and 32.1% of afternoon interactions on the physical-activity and secondary-activity components, respectively), 85.4% and 75.9% were receptive, of which 76.6% and 70.7% resulted in adherence at the evening check-in. On days satisfying the full JITAI chain for physical activity, participants exceeded their personalized step goal, reaching a mean of 170% of goal (SD ± 95) and a mean evening step count of 7,718 steps (SD ± 3,453). The wearable-based data acquisition pipeline was feasible and largely reliable under study conditions, with the Garmin device supplying step-count data in 80.8% of decision points, the smartphone in 17.4%, and manual self-report required in only 1.8% of cases. Participants rated the CA favorably across all technology acceptance and usability domains, with all mean scores above the neutral midpoint on seven-point Likert scales. Qualitative analysis described an intervention experienced as accessible and structuring. Conclusions: This pilot study supports the short-term feasibility and acceptability of integrating wearable-derived step data into a smartphone-based CA-delivered JITAI for older adults with MCI. Passive sensing may support personalized intervention delivery while reducing reliance on self-report. However, as a feasibility study, it was not designed to provide evidence of efficacy. Controlled studies with adaptive decision times, sensor-derived baselines, and more diverse samples are needed to evaluate efficacy and sustained behavioral benefits. Clinical Trial: NAType:working paperJournal:JMIR - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Design tensions in a two-sided marketplace for reusable digital therapeutics software components: a qualitative interview studyObjectives To identify stakeholder-perceived design tensions in a two-sided marketplace for reusable digital therapeutics (DTx) software components and to use these tensions to propose alternative marketplace concepts. Methods We conducted 24 semi-structured interviews with digital health researchers and professionals. Data were analysed using hybrid deductive-inductive codebook thematic analysis. The Magic Triangle provided the initial deductive structure. One researcher coded all transcripts; a second independently applied the developing codebook to five transcripts to refine definitions and consistency. Seventeen parent themes were synthesized into 12 design tensions, which informed three author-generated marketplace concepts. Results Participants described trade-offs concerning target users and host, component scope and customization, quality labels, verification, geographic scope, pricing, interoperability, platform launch, risks and market niche. The resulting concepts emphasized a regional startup ecosystem, a research-oriented hybrid marketplace or a global marketplace with stricter entry requirements. Discussion The concepts combine the tensions in different ways and highlight competing priorities in governance, openness, assurance, scalability and early platform growth. Conclusion Stakeholders identified recurring design choices for a DTx software-component market-place. The concepts provide hypotheses for prototyping and evaluation; the study did not test technical feasibility, market demand, regulatory acceptability or effects on development cost or time. KEY MESSAGES WHAT IS ALREADY KNOWN ON THIS TOPIC DTx development can require substantial software, evidence-generation and regulatory resources. Reuse of software components could reduce duplicated work, but exchange of reusable components in DTx is not well characterized. WHAT THIS STUDY ADDS Interviews with 24 digital health experts identified 12 design tensions and informed three author-generated marketplace concepts for different contexts. HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY The findings can guide prototype specifications and policy questions concerning quality labels, software integration, maintenance and responsibility. Effects on cost, development time, adoption and patient access require empirical evaluation.Type:working paperJournal:MedRxiv - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Integrating Prevention Into Health Systems: A Prevention-first Framework for Noncommunicable DiseasesThe global healthcare system confronts a growing crisis due to the rising prevalence and escalating costs of noncommunicable diseases (NCDs). Although lifestyle intervention and targeted public health initiatives can considerably prevent NCDs, prevention efforts consistently receive inadequate funding, as healthcare budgets predominantly prioritize treatment. This article argues that healthcare systems can systematically address integration friction. We propose a multidisciplinary "Reach, Retain, Report, and Reimburse" framework, developed from existing prevention models and focus group discussions, to integrate NCD prevention effectively into current healthcare systems. This analytical lens recommends customizing the reach of prevention programs for at-risk populations, sustaining their engagement, developing relevant outcome reports, and reforming reimbursement structures to incentivize prevention. Ultimately, this multi-sector, interdisciplinary framework offers decision-makers a structure to expand access, sustain engagement, measure outcomes, and align reimbursement.Type:working paperJournal:SSRN - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Equity by Design Principles for Digital Health Interventions(Springer Science and Business Media LLC, 2025-05-30); Background Despite significant progress in the past decade, health disparities persist. Digital health interventions (DHIs) offer a transformative opportunity to advance health equity but may also exacerbate the digital divide if equity considerations are not embedded from the onset. While there is broad consensus on the importance of equity-centered design, a critical gap re-mains in the form of actionable guidance for both research and practice. Thus, this study aims to develop equity by design principles for DHIs. Methods We first synthesized existing scientific knowledge by assessing 42 articles/guidelines and formulated an initial set of 26 actionable, evidence-based design principles for DHIs (July through October 2024). We then conducted three semi-structured expert interviews to refine these principles (November 2024 through January 2025). We finally facilitated end-user workshops with two DHI providers to assess and finalize the design principles with respect to practical relevance and applicability (January through March 2025). Results We identified 25 equity by design principles, 15 targeting DHIs, and 10 the organizational context in which DHIs are developed. The DHI-specific principles were categorized according to key process stages: needs assessment, design and development, implementation, and evaluation and dissemination. The organizational context principles were grouped into four domains: strategy, people, processes and structures, and partnerships and advocacy. We further challenged the principles real-world applicability, identifying three overarching challenges that hinder their successful implementation. Conclusions The study underscores the necessity of moving beyond DHI-specific design considerations to address health inequities in digital health. By adopting these design principles, digital health companies can embed equity as a core strategic priority, actively contribute to reducing health disparities, and foster a more inclusive healthcare ecosystem.>Type:working paperJournal:Research Square - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Equity Readiness Index for Digital Health OrganizationsObjective As healthcare becomes increasingly digitalized, new challenges and opportunities arise for advancing health equity. In response, a broad range of frameworks and recommendations have emerged to guide equitable innovation. Yet despite this momentum, real world progress remains limited and many digital health organizations (DHOs) struggle to translate health equity principles into concrete, actionable strategies. One promising avenue for closing this implementation gap lies in the use of organizational readiness assessments that not only diagnose current capacity but also help to define a roadmap for improvement. In response, this study introduces the Health Equity Readiness Index and a supporting novel self-assessment tool designed to support DHOs in evaluating and advancing their readiness to act on health equity. Methods Drawing on established frameworks from health equity, responsible AI, digital innovation, and organizational change, we created a five-dimensional Health Equity Readiness Index, encompassing strategy, governance, culture, data, and community collaboration. Each dimension was operationalized into 15 readiness indicators across four levels. A corresponding digital self-assessment tool was developed and refined through user testing and a structured online survey targeting DHOs. Results The resulting tool provides a structured, low-barrier mechanism for DHOs to assess their current equity capacity and identify priority areas for improvement. Survey results (N = 124) showed broad applicability across diverse organizational contexts, with respondents spanning regions, service types, and roles. Participants rated the tool highly across all constructs (M ≥ 4.39/5). Qualitative feedback highlighted five overarching strengths (clarity, diagnostic value, actionability, useability, awareness) and three areas for future improvement (examples, customization, additional features). Overall, respondents perceived the tool as both relevant and actionable for guiding equity-oriented strategy. Conclusion This study contributes a novel framework and diagnostic tool for advancing organizational readiness for health equity in digital health, supporting DHOs in moving from intention to implementation. It also offers potential utility for funders, regulators, and health systems seeking to institutionalize equity through incentives or benchmarking.Type:working paperJournal:medRxiv - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Leveraging Influencers to Reach and Engage Vulnerable Individuals: A Quasi-Experimental Field Study with a Digital Health Intervention (Preprint)(JMIR Publications Inc., 2025-02-10); ; Theresa SchachnerBackground: Non-communicable diseases (NCDs) are the leading cause of death, present economic challenges to healthcare systems worldwide, and disproportionally affect vulnerable individuals of low socioeconomic status (SES). While digital health interventions (DHIs) offer scalable and cost-effective solutions to promote health literacy and encourage behavior change, key challenges concern how to effectively (a) REACH and (b) ENGAGE vulnerable individuals. To this end, (a) social media influencers provide a unique opportunity to reach millions; and (b), ensure lasting engagement by designing DHIs in a manner that specifically appeals to low SES individuals through alignment with their social background. Objective: The objectives of this study are twofold: To assess the effectiveness of leveraging influencers to reach vulnerable individuals (as measured via app downloads per stream viewers) and to evaluate how the design of a DHI can improve engagement among this group (as measured via completion of intervention). Methods: This study utilized a cross-sectional, quasi-experimental field design to assess both (a) the effectiveness of influencers reaching vulnerable individuals and (b) the impact of specific design elements—such as gamification and storytelling—on user engagement with a stress-management DHI featuring a slow-paced breathing exercise. Three differently designed versions of this DHI were developed following a fractional factorial design (i.e., STRESSLESS, BREEZE, and TRAGICKINGDOM). Reach was calculated as the number of downloads per viewers per stream and influencer. Engagement with the DHI was measured via number of conversational turns, and milestone and intervention completion rates. Participants' SES and technology acceptance were evaluated through a post-intervention survey. Descriptive statistics, ꭓ2-tests, and ANOVAs were used to examine effects of the DHI design on reach and engagement metrics. Results: The recruitment via eight influencers (Total Streams = 25; Total Viewers = 12,667) generated 220 downloads. The average reach ratio across streams amounted to 16.2%, with significant differences between conditions, ꭓ2(2) = 8.04, p = .018: STRESSLESS: 8.1%; BREEZE: 14.0%; TRAGICKINGDOM: 28.4%. The intervention completion rate across all DHI versions amounted to 7.7% (17 out of 220), with no significant differences between conditions. Conclusions: This work provides first evidence that recruitment via influencers yields high reach ratios, moving far beyond the reach of traditional social media platforms. Nonetheless, based on the data collected, the ability to leverage such platforms to recruit and engage vulnerable individuals with DHIs remains unclear. Additionally, while engagement with the promoted interventions was initially high, completion rate of the full breathing exercise was comparably low, indicating that influencer promotion strategy cannot fully overcome the well-documented adherence barriers in digital health.Type:working paperJournal:Journal of Medical Internet Research - Some of the metrics are blocked by yourconsent settings
Item type:Publication, How self-tracking and engagement with personalized health content shape self-reported menstrual health experiences in a women’s health app(2025-07-08) - Some of the metrics are blocked by yourconsent settings
Item type:Publication, Success factors of growth-stage digital health companies: protocol for a systematic literature review(2024);