Stefan Elbers

165 Preventing relapse after successful treatment workbook was introduced. As a consequence, not all intervention components were used effectively by all participating patients. For example, HCPs could use the Insight Cards to check if the patient understood important treatment principles as intended, but the dataset includes no mention of such a teach-back occurrence. Therefore, we believe that, in line with other study findings, an extensive onboarding procedure with additional guidelines, examples, and training sessions would improve overall implementation and optimize the potential of the workbook (Chan et al., 2017; Kaipainen et al., 2017; Pope et al., 2018). Based on the evaluations in this study regarding patient characteristics and requirements for optimal use, this onboarding procedure could also contain a deliberate consideration whether either or both interventions may benefit a patient. Second, the VBG sequence needs revision to improve clarity for patients and ensure that the goal-setting procedure matches the treatment program. The sequence was based on the insight that value-based goal-setting procedures outperformed specific, measurable, achievable, relevant and time bound (i.e. SMART) goal setting (Chase et al., 2013; Höchli et al., 2018). However, patients reported difficulties in understanding the concept of values through written instructions in the workbook, particularly when the treatment program did not structurally include a values assessment. Altering the VBG procedure to shift the initial emphasis from values to goals may increase clarity; patients could begin formulating specific goals related to improved physical functioning instead of starting with personal values. Subsequently, assessing why this particular goal is relevant to the patient could direct attention toward associated values. Third, HCP responses concerning the amount of time spent with the prototype intervention suggests that they experienced a trade-off between focusing on the treatment program or preventing relapse with the workbook. This indicates that relapse prevention with the current version of the workbook is not yet perceived as an integral aspect of the treatment. Given that the workbook was introduced as an addition to the existing IMPT, this finding is not surprising. Nevertheless, future development should take time efficiency into account and focus on increased integration of the relapse prevention strategies into the existing treatment protocols. One possibility is to relate the identification of problems in daily life functioning during the assessment phase (e.g., by using instruments such as the Canadian Occupational Performance Measure) to the goal- setting procedure of VBG. Furthermore, integration of Insight Cards into clinical practice could be enhanced by routinely relating this to specific communication strategies, such as a teach-back approach (Feinberg et al., 2019; Klingbeil & Gibson, 2018). Reflecting on Insight Cards during patient-therapist conversations could facilitate both shared decision making and teach-back and empower patients to actively participate. One promising direction for the development of the prototype is to embed these strategies in an mHealth app (i.e. software apps designed for mobile devices to provide or support health care services) (Silva et al., 2015). This domain is becoming increasingly important