Govert Veldhuijzen

23 General introduction, history of patient education in endoscopy, aim and outline There is evidence to suggest that eHealth interventions are effective in improving information transfer to patients. 118 Internet based education offers a number of advantages: it can easily visualize information through use of HTML scripts, providing information in a comprehensible and appealing format, it is accessible at any desired moment, and provides the option to remind patients in a timely fashion. 14 Previous studies show that focused e-learning or computer based education paths enables good comprehension and learning and enhances patients satisfaction. 119 The latest developments in eHealth interventions opens a whole new field with the development of virtual reality (VR) that even allows eHealth to be implemented during an endoscopic procedure. As several studies have examined non-pharmacological interventions to reduce anxiety and pain during endoscopy. 120-123 These studies used a mix of visual or auditory stimuli and found that while true efficacy is not fully established, combined visual and auditory distraction is better in reducing discomfort compared to auditory distraction alone. 121 VR integrates computer generated visual and auditory signals to recreate an illusionary perception of the actual physical world. 124,125 The distraction that comes with immersive VR induces an analgesic effect and has been used as an adjunct to control pain and anxiety during operative procedures. 126,127 VR technique has become more affordable and better portable, adding to its immersive qualities. 128 APPROACH OF THESIS The preceding description of the history of patient education before and during the introduction of endoscopy as a diagnostic and therapeutic tool together with the introduction of the first eHealth strategies in 2013 have resulted in several research questions at the start of this thesis. The main insights gained from literature are presented after each question. I. What are key elements in designing content of an eHealth patient education intervention? Important informative elements to prepare for colonoscopy deduced from literature are diet measures, instructions on use of purgatives. Next, practical information such as the route to the department should be incorporated as well as the technical explanation of the procedure and the alternative investigations. 37,41,46 Items requiring patient input are comprehension of risks and complications and the risk assessment for sedative use to gain informed consent. 16,35 A two-way communicating platform could be the nexus between the patient and the endoscopist. State of the art technical audio- visual features should be utilized. To employ computer animation helps to capture 1