Resultados

The last main code ‘implementation on the work floor’ is predefined into four subcategories: (1) barriers for implementation; (2) type of employees who can benefit from Gezondeboel; (3) way of providing Gezondeboel; and (4) moment of use.

To start with, when participants were asked if they thought Gezondeboel could be useful for the organisation they work for, five participants answered positive. For example: “Ja zeker, want ik zie dat

heel veel collega’s worstelen met overbelasting.” (P3). One participant mentioned Gezondeboel is not useful for her organisation, because of the mentality and gender of the company: “Ik werk bij een ICT-

praten dat doen we niet.” (P6). The same five participants mentioned Gezondeboel could help to improve the mental wellbeing of employees in general. The last participant mentioned it could only improve mental wellbeing if the programs suit the new generation better, as illustrated in the following quote: “Als jullie inderdaad wat meer dingen ontwikkelen voor mijn leeftijdsgroep denk ik het wel ja,

maar op dit moment denk ik het nog niet, met hoe het platform is opgebouwd […] Zoals ik al zei: ga meer voor de Social Media en webcare.” (P6).

4.5.1 Barriers for implementation

The first category is about ‘barriers for implementation’. Supporting quotes for these results are visible in Table 18. In general, the participants were positive about implementing Gezondeboel on the work floor. However, some barriers were mentioned. Two participants reported a lack of intrinsic motivation as barrier. The absence of intrinsic motivation could make it difficult continue working on the programs. Also, acceptation of Gezondeboel within an organization could be difficult if people are not open to changes. Moreover, age or gender could be a barrier according to two participants. They pointed out, that despite of the user-friendly programs, the older generation might experience difficulties in using the programs, because the absence of basic computer knowledge. Besides, the older generation could be less open for changes. One participant mentioned males might be less interested in improving mental health and talking about feelings. Four participants reported ‘forgetting about the program’ as barrier. To implement the intervention people need to remember it. Four out of six participants mentioned they (temporarily) forgot about the program. As a consequence, one participant mentioned she did not completed the program as far as hoped. The next barrier pointed out by two participants, was the mentality or sector of the organisation. One participant mentioned the organisation she works for was based in Heerenveen. Those employees have a down-to-earth mentality and are therefore more interested in physical health instead of mental health. This could make implementation difficult. Another participant reported to work in a technical organisation. The employees who worked there might not want to talk about feelings. ‘Privacy’ was mentioned twice by the participants. One participant pointed out she would not make use of the intervention if her employer had insight into the themes of the programs she followed. Somebody else made clear, she would not make use of the intervention if the authors and colleagues of Gezondeboel had insight into her data (e.g. filled out assignments). The last barrier mentioned by two participants was ‘costs’. One participant reported the intervention as useful enough to pay for, but would still search for a free intervention. The other mentioned she never had paid for eMental Health before, so the threshold to pay for this intervention would be high.

Table 18.

Barriers for Implementing Gezondeboel on the work floor (n=6)

Code: Implementation Barriers for implementation No. of participants Example quote

Forgetting about the program

4 “Ik vind het jammer dat ik me er niet meer bewust van ben geweest dat het programma er nog

was en dat ik er niet mee bezig ben geweest zoveel als dat ik had willen zijn.” (P1)

Lack of intrinsic motivation

2 “Vanuit mijn eigen werk ervaar ik dat het accepteren van dit soort voorzieningen, zoals

eMental Health en innovatieve oplossingen, samenhangt met hoe je zelf in je hoofd zit; je eigen mindset: of je open staat voor nieuwe dingen, opzoek bent naar oplossingen en dingen wil proberen.” (P5)

Age or gender 2 “Ik denk dat het voor jonge mensen wel heel makkelijk zal zijn en voor de wat oudere generatie

wat lastiger. Ik bedoel, op zich is het allemaal heel simpel en duidelijk, maar als je al niet de basiskennis van een computer heb dan…”(P4)

Mentality or sector of the organization

2 “Eigenlijk zijn ze vooral bezig met fysiek gezond bezig zijn in plaats van mentaal. Dat komt

waarschijnlijk ook doordat het een organisatie is die in Heerenveen staat, dus ja… een beetje nuchtere, Noord-Hollandse mentaliteit.” (P1)

“Ik werk bij een ICT-bedrijf […], dus dan wordt het wel lastig, dan denken ze doe maar gewoon normaal en over gevoelens praten dat doen we niet.” (P6)

Privacy 2 “Wat ik heel belangrijk vind is het stukje privacy. Ik denk dat je vanuit de werkgever wel de

mogelijkheid moet krijgen om Gezondeboel te gaan doen, maar dat het niet zo moet zijn dat managers dan op de hoogte zijn van: oké, die gaat dat doen en die gaat dat doen […] Dat je dat als werknemer zonder ruggespraak moet kunnen doen.”(P2)

Costs 2 “Aan de ene kant denk ik dat het zeker nuttig genoeg is om geld waard te zijn, maar ik denk

zelf altijd als ik zoiets tegen komt: Nou ik kijk wel verder of ik iets anders kan vinden.” (P4)

4.5.2 Type of employees who can benefit from Gezondeboel

The second category is about what type of employees can benefit from Gezondeboel. An overview of supporting quotes is shown in Table 19. First, three participants pointed out that people, in particular employees, need to be open to change and have the ability to reflect on themselves. Besides, employees need to be intrinsically motivated and have time to invest in the intervention, otherwise it would be difficult to continue with the programs. One participant mentioned that prevention for people who do not struggle with their mental health yet, are not the right target group. She thought that users, before they start with Gezondeboel, need to be interested in developing themselves, and probably experience some troubles with their mental wellbeing. Otherwise the motivation to proceed with the programs is too low. This is in contrast to the variation ‘prevention for employees’ mentioned by four other participants. For example, one participant reported that Gezondeboel absolutely could be used as prevention for employees before they experience any mental complaints. Also another participant pointed out Gezondeboel could be used as prevention, before employees really get stuck with their mental complaints. Most participants mentioned employees who are at risk could benefit from Gezondeboel most, these people have little complaints so they are motivated to continue with the programs and do not have complaints which are so large they need to see a real professional (e.g. a psychologist). Two participants reported ‘dropped-out employees’ as third variation. This correlates with the fact that the two participants who currently dropped out of work, were the ones who reported

Table 19.

Employees who can benefit of Gezondeboel most (n=6)

Code: Implementation

Type of employees who can benefit of Gezondeboel

No. of participants

Example quote

Prevention for employees (who are at risk)

4 “Werknemers natuurlijk. Met name zou het mooi zijn om werknemers bij voorbaat

al te ondersteunen als ze daar zelf ook zin in hebben, zodat je het ook voorkómt. Preventief. Daar zou Gezondeboel denk ik een hele duidelijke rol in kunnen hebben.” (P2)

Employees who are open to change, who can reflect on themselves, and who are intrinsically motivated

3 “Mensen die open staan voor verandering […] in ieder geval openstaan om aan

zelfreflectie wil doen.” (P1)

“Ik denk dat het persoonlijk geen zin heeft als je het niet van binnenuit wil, ondanks dat het nog zo nodig kan zijn.” (P1)

Dropped-out employees 2 “[…] mensen die er met een burnout even uitstappen of uitgestapt zijn.” (P2)

4.5.3 Way of providing Gezondeboel

The third category is about the way Gezondeboel can be provided best according to the participants. An overview of quotes is provided in Table 20. All six participants mentioned Gezondeboel could be offered as support of another therapy. Four participants pointed out Gezondeboel could only be offered in addition to another intervention, because people need human contact to guide you in behaviour change. One participant mentioned the programs could be used as follow-up for study days. She pointed out it is important Gezondeboel becomes a priority in organizations. By the use of Gezondeboel as follow-up of study days, it could become a priority to invest in your own mental health as employee, and to invest in the mental health of the employees of your organisation if you are a supervisor/manager. Two participants reported currently to have therapy, and mentioned the program they worked on supported their therapy very well and helped them to work on their mental health independently at home.

Three participants thought Gezondeboel could be offered as isolated intervention. However, it is important to keep in mind that mental complaints could become too serious to deal with on your own. Using Gezondeboel programs to change the behaviour without external help might be difficult. One other participant thought Gezondeboel could be provided on its own, but wonders how and to whom it can be offered best.

Five participants pointed out Gezondeboel must be provided by the employer. For example, one participant regretted her employer did not provide the intervention earlier. She hopes her employer will provide it in the future, because she thinks it can prevent lots of things. According to another participant Human Resource Management or the supervisor of an organisation should inform employees about Gezondeboel. Preferably before they need to see the company doctor. If employees already see the employee doctor, this doctor should inform them about the programs. One participant agreed to this statement, but explicitly mentioned the programs of Gezondeboel should not be mandatory.

Table 20.

The way Gezondeboel could be provided (n=6)

Code: Implementation Way of providing Gezondeboel No. of participants Example quote In addition to other interventions or as follow- up

6 “[…] misschien wel in een palet van wat je nog meer wil aanbieden. Dit zou één aanbod

kúnnen zijn.“ (P5)

“Het kan ook als vervolg op studiedagen. Zodat het meer boven aan het lijstje blijft.” (P2) “Dit programma ‘Veerkracht’ sloot eigenlijk wel heel mooi aan naast de therapie om zelfstandig thuis mee aan de slag te gaan.” (P3)

Provided by the employer 5 “Ik vind het eigenlijk iets wat ik vanuit mijn werkgever aangeboden had willen krijgen of in

de toekomst dat ik daar gebruik van kan maken en in de gelegenheid wordt gesteld, want ik denk dat je een hoop dingen kunt voorkómen.” (P2)

“Het moet niet verplicht worden vanuit de werkgever, absoluut niet.” (P6)

As an isolated intervention 3 “[…] Op een gegeven moment zijn dingen zo groot en diep dat je ze niet meer, of in ieder

geval niet makkelijk meer, in je eentje overeenkomt. Maar ik denk dat het op zekere hoogte wel opzichzelfstaand nuttig kan zijn.” (P4)

4.5.4 Moment of use

The last category is about the moment participants would prefer to use Gezondeboel. This category could be divided in two variations (see Table 21). Firstly, two participants mentioned they would prefer using it at work. Despite almost all participants thought Gezondeboel should be provided by the employer, four participants pointed out working with Gezondeboel must be executed (after work) at home. For example, one participant mentioned she would not feel comfortable to do it at work or would not have a comfortable place to work on the programs. Another participant preferred doing it at home, and would spend lots of her leisure working on the program if it is a program of her interest. One participant thought working on the programs at home has more value, because then users could spend more time working on it, and could use the programs undisturbed.

Table 21.

Moments Gezondeboel could be used (n=6)

Code: Implementation

Moment of use No. of participants

Example quote

At home 4 “Ik doe dit buiten werktijd om en ik zou dit ook niet in werksetting willen doen, want het is

toch ook wel heel persoonlijk wat je aan het doen bent […] en ik zit ook niet op een werkplek waar je eens even lekker in jezelf kunt duiken, want dat is natuurlijk wel de bedoeling bij dit soort modules.” (P5)

“Ik denk ook dat het handiger is om het buiten werktijd te doen, omdat mensen dan gewoon veel meer tijd hebben om persoonlijk even na te denken, niet gestoord worden en rustig.” (P6)

At work 2 “Ik denk als er tijdens werktijd een momentje zou zijn weggelegd om je even te kunnen

afzonderen al is het een half uurtje. […] ik denk dat het zeker helpt als mensen op hun werk bezig zijn en het idee hebben dat hun baas het belangrijk genoeg vindt om ook salaris door te betalen in dat half uurtje dat een werknemer werkt aan zijn/haar mentale welbevinden.” (P1)

Discussion

Most eMental Health interventions are still not evidence based or not tested on employees in specific (Stratton et al., 2017). This study is unique, because it provides insight into a preventive eMental Health intervention for the occupational setting, named Gezondeboel. This intervention has not been studied before. The quantitative and qualitative data are integrated described referring to the four research questions about usage, appreciation, effect and implementing eMental Health at work.

5.1 Usage

This study started with the research question: “What are reasons of employees to work on the programs,

what is the way employees chose the programs, and which choices are made about how to (not) proceed with the programs?”.

First it became clear that it was difficult to collect participants who started using the programs. It was planned to include at least hundred participants during this study. Despite employees were very enthusiastic about the study beforehand, only twenty-nine participants filled-out the pre-test, and only eleven of them made use of the eMental Health programs of Gezondeboel. The programs “Mindfulness” and “Stressles” were chosen most often. Despite the fact that participants had four months to use the programs, they only used them between the first and sixth week. Moreover, almost none of the participants had totally finished a program. High dropout rates are a common problem in eMental Health research. For example, the study of Bennett and Glasgow (2009) showed low website usage and experienced a steady dropout in usage over time. Furthermore, many participants did not achieve the level of usage prescribed by the program (Bennet & Glasgow, 2009; Glasgow, 2007; Norman et al., 2007). It might be of benefit to add evidence-based components to web-based interventions, such as human counselling or motivational interviewing. This results in greater website usage, compared to web- based interventions that provide basic education or information only (e.g. significantly higher numbers of log-ins) (Gold, Burke, Pintauro, Buzzell & Harvey-Berino, 2007; Shingleton & Palfai, 2016).

During the current study, participants mentioned several reasons to work on the programs. Most participants mentioned support with mental complaints and deepening or refreshing knowledge as main reasons. Some participants first scanned several programs before they started. Others started directly with a program of their interest. Furthermore, several reasons for (temporarily) quitting the programs were reported: (1) time constraints, (2) lack of motivation, (3) technical or computer-access problems, (4) the lack of face-to-face contact, and (5) forgetting about the program’ as an important reason. Consequently, participants did not finish the programs as far as they wanted or did not continue working on them at all. The first four reasons are in line with the results of previous research. The study of Christensen, Griffiths and Farrer (2009) identified the same reasons for dropout from eMental Health trials. They also added perceived lack of treatment effectiveness, improvement in condition, and burden of the program. All participants mentioned they missed something to keep them on track. A recommendation for practise is to implement something in the programs that is evidence-based and helps

participants to increase their user-compliance. Guidance from a professional (e.g. psychologist or coach) could be a suitable solution, since interventions that included guidance throughout the intervention period showed better improvement than unguided interventions (Andrews, Cuijpers, Craske, McEvoy & Titov, 2010; Andrews, Cuijpers, Carlbring, Riper & Hedman, 2014; Shingleton & Palfai, 2016). Furthermore, we recommend Gezondeboel to adapt the mentioned negative aspects (Table 14, e.g. make it less time-consuming) and adjustments (Appendix J, e.g. include reminders or something that keeps users on track) to increase participants’ long-term usage.

5.2 Appreciation

The second research question was as follows: “Which aspects of Gezondeboel are positively appreciated

by employees, which aspects are negatively appreciated, and how do employees appreciate the ‘coach’ feature?”.

It appeared that participants who used the programs were enthusiastic about it. All participants mentioned the clear structure, lay-out, user-friendly design and low threshold as positive aspects. They also really liked the possibility to choose (e.g. the video therapist, and which themes and assignments they could work on). However, some negative aspects and suggestions for improvement were reported. Some participants mentioned that the programs in general and writing down the assignments were too time-consuming. Also, the uncertainty about participants’ privacy when filling in the assignments was mentioned, and their privacy when they might contact a coach. Primarily there was discussion about how users could have contact with their coach. This finding is in line with the statement of Van Gemert- Pijnen, Peters and Ossebaard (2013). They state that new technologies raise new ethical concerns, such as the need to accommodate for people’s privacy preferences. According to the participants of this study, the coach could be best provided via email, chat, telephone call or video call. All these types of communication bring privacy-issues, especially video calling. Boyle, Neustaedter and Greenberg (2009) see the need for technologies that allow people to smoothly move into properly timed video calls that consider users’ needs for solitude and autonomy at home (e.g. privacy protection strategies like features to obscure the background).

Not only did participants have their own perspectives and preferences on how coaching could be best provided. Gezondeboel in general needs to consider the security and privacy of personal information, and fulfil a whole set of security requirements. The study of Kargl, Lawrence, Fischer and Yang Lim (2007) addressed these issues. They emphasize the importance to recognize that it is not enough to solely look at the sensor network, but that an integrated discussion of the whole system, including back ends, is necessary. Moreover, national laws on privacy need to be considered. Another