Second language (L2) learners are often aware of the typical pronunciation errors that speakers of their native language make, yet often persist in making these errors themselves. We hypothesised that L2 learners may perceive their own accent as closer to the target language than the accent of other learners, due to frequent exposure to their own productions. This was tested by recording 24 female native speakers of German producing 60 sentences. The same participants later rated these recordings for accentedness. Importantly, the recordings had been altered to sound male so that participants were unaware of their own productions in the to-be-rated samples. We found evidence supporting our hypothesis: participants rated their own altered voice, which they did not recognize as their own, as being closer to a native speaker than that of other learners. This finding suggests that objective feedback may be crucial in fostering L2 acquisition and reduce fossilization of erroneous patterns. At one point in time, a language-learning company ran a TV commercial making fun of a German accent in English, with a German coast guard confusing the words “think” and “sink”. Replacing the “th” sound with /s/ is indeed a common mistake in German-accented English . Maybe sOne obvious possibility would be that the Germans who laugh at such jokes are not the ones who make the mistake. However, there are other possible explanations. Maybe learners have a bias to implicitly overestimate the relative level of their own accent in comparison to others. Such a bias would have far-reaching consequences. It would, first of all, explain the above paradox, because listeners then perceive errors in the speech of others more easily than in their own speech. Moreover, such a bias would have consequences for the perception and improvement of a wide range of aspects of a given accent, including those aspects that are less well-known than the infamous "th" for German learners that is typically used when Germans are portrayed speaking English. For instance, it would also include the prosodic level where German learners need to adjust their speech rhythm to sound more like a native (L1) English speaker, which they only seem able to achieve partially  one's own voice more than that of others or over- or underestimating one’s own L2 performance.The study of  comparedcomprehend their own accents. However, the fact that learners can guess the intended target better for their own production does not necessarily mean that they also assume that their own productions are closer to the native speakers’ phonetic categories. An analogy might clarify this; consider listening to the voice of the cartoon character Daffy Duck, which has an exaggerating lisp. Getting used to and better comprehending this voice does obviously not mean to accept the lisp as being part of the standard pronunciation. Similarly, the higher success rate in the minimal-pair identification task with the own voice compared to others does not necessarily translate into the perception that the own accent is closer to L1 speakers than that of others. However, since perception of novel L2 sounds is shaped by the phonological and phonetic system of the learners' L1 , percepe, e.g.,  and proce, e.g., , 14 but e, e.g., , 17, 18.e, e.g.,  speculatAt this stage, it is worth considering whether it is in fact useful to ask L2 learners to judge the accentedness of their own speech, because it has been repeatedly pointed out that the goal of an L2 learner should be intelligibility—which is defined as the addressee’s comprehension of the intended words, similar to the word-error rate metric used in automatic speech recognition—rather than imitating a native speaker and that these two goals are not necessarily the same , 21. FirIn the context of the current question, however, it is nevertheless useful to ask learners about accentedness. First of all, intelligibility measures can suffer from ceiling issues when speech is presented in absolute quiet, and such measures may underestimate the impact of accentedness on the cognitive effort required to comprehend a speaker. Secondly, when a learner monitors him- or herself, intelligibility is not available as a category, since the speaker knows what message he or she produces, so that even an—to a third party—unintelligible message will be restored for the speaker producing the message . TherefoHowever, the prospect of asking learners to rate the accentedness of their own versus others' voices raises another immediate concern: the questionable validity of accent ratings when one judges oneself. This was, in fact, one of the motivations for  to use afossilization in L2 acquisition, which describes the fact that L2 learners at some point typically do not further progress towards the L1 target ),After this main rating task, a second task was administered to assess whether, despite the changed-gender manipulation, participants would recognize the similarity of their altered voice to their own actual voice. Each participant was presented with ten of the sentences produced either by themselves or the other three speakers. The subset of these ten sentences was the same for all participants. Participants were asked to respond to the question “how much does this sound like you?” on a scale from 1 to 6. This time, 1 indicated “a lot” and 6 indicated “not at all”. Again, responses were only allowed from 1.5s after sentence onset and the ISI was 500ms. Finally, after this task, participants were asked explicitly by the experimenter whether they had recognized one of the voices as their own voice.In order to ensure that during the main experiment each participant would hear a similar range of good vs. poor accents, all recordings were first ranked with regard to their accentedness. Then six groups of four participants were created, so that each group contained one speaker from each quartile.s = 0.79–0.82) as well as between the German raters and the British-English rater (rs = 0.73–0.82).The ranking was based on accent ratings for each sentence on a 9-point scale. Raters were three phonetically-trained advanced German learners of English who use English on a daily basis. In addition, a native speaker of British English rated a subset of the sentences for validation. Ratings were blocked by sentence, that is, each rater heard a given sentence from all speakers before moving on to the next sentence. Within each block, the order of speakers was randomized. Raters first heard two sentences from each speaker as a warm-up to familiarize themselves with the range of accents. Each of the German raters judged all speakers for twenty sentences, and the British speaker rated all speakers on the ten sentences that were most diagnostic for the overall score in the ratings of the three German raters, that is, those that had the highest correlation between the mean rating for a given sentence and the mean rating of the other 59 sentences. Over raters, ratings were highly correlated both amongst the three German raters  using the package lmerTest . We usehttps://osf.io/7tg8p/.The linear mixed-effects model produces t-tests for each experimental effect, for which degrees of freedom  were estimated based on the Satterthwaite's method as implemented in the R library lmerTest. Random effects were used for participant and item . The random-effects structure was near maximal, that is random slopes were used for fixed effects that varied over participants and items, except for the exclusion of correlation parameters between random effects . As an aOur main question was whether accent ratings were different for trials in which participants judged their own altered voice compared to those of other speakers. However, first we wanted to investigate whether participants really did judge accentedness. Given the potential influence of hearing one's own  voice, we used only trials in which others' voices were judged and tested whether the “source quartile”  had an influence on participant ratings. This was clearly the case: average ratings decreased monotonically with quartile (see p <0.001). It is worthwhile to note that the effect of hearing one's own versus another voice is similar in size to the effect of quartile, both being around one half. This means that, hearing oneself, the perceived accentedness is one quartile higher. Hence, an L2 learner who is average (50th percentile) would perceive herself as being better than three out of four other speakers .This leads to our main question whether ratings for learners' own voice were better than ratings for other voices. This was clearly the case: the mean rating for own-voice trials was 2.09 (close to the mark “good” in the German marking system) and that for other-voice trials was 2.59 .Results of the voice-similarity judgement task that followed the main accent rating task showed that participants rated their own altered voice as more like their own voice than that of others. On the scale from one to six, participants rated, on average, the similarity of the presented voice to their own voice as 2.00  when they heard their own altered voice but only as 3.25  when hearing another altered voice. A linear mixed-effects model with similarity rating as dependent variable and voice (self vs. other) as independent variable showed that this difference was significant  = 6.28, all sentences played in the similarity rating task were from her own voice, giving high similarity ratings to her own and others' voices (mean = 1.0 for both cases). The third one of these three participants was in between these patterns with slightly lower similarity ratings for the own voice  and relatively low ratings for other voices (mean: 3.7). Notably, the effect of voice (self-other) described above is virtually unchanged, if we exclude the three participants who did recognize their own voice  = 4.97, p <0.001)During debriefing only three participants indicated to have recognized their own  voice. While one participant clearly showed evidence of explicit recognition with high similarity ratings for the own (mean: 1.3) but very low ratings for the other voices (mean: 5.4), another of these three participants thought that p < 0.001), no significant effect of perceived Similarity on the “own-voice” intercept level of the Voice factor  = -0.58, p = 0.56) but a significant interaction  = 2.56, p = .014). This suggests that, when rating the own altered voice, participants did not give better scores if they perceived the voice as more similar. However, other voices were rated better when they were also perceived as above-average similar to the own voice.An additional model tested to what extent the perceived similarity of the altered voice to one's own voice influenced accent ratings. From the similarity ratings, we generated the average similarity rating for each pair of rater and listener . Since the pairings were the same for the accent and similarity rating tasks, this average similarity rating could be used as a co-variate in the analysis of the accent ratings. That is, for all trials on which participant X rated participant Y, the average similarity rating by participant X for participant Y was used. Because these are collinear with the fixed effect of Voice , the similarity ratings were normalized. That is, for “other” similarity judgements, the mean of all “other” judgments was subtracted, and for “self” judgements, the mean of all “self” judgements was subtracted. This measure of perceived similarity then reflects, for the level own-voice, whether a given participant rated her own altered voice as more similar to her real voice than the other participants. For the other-voice level, it indicates whether a given other voice was perceived as more or less different than the average other voice. A linear mixed-effects model was run with accent rating as the dependent variable and Voice (self vs. other), perceived Similarity (as a numeric predictor) and their interaction as fixed factors. The categorical variable Voice was dummy coded with the level “self” mapped on the intercept. The results showed an effect of Voice  = 5.60, This experiment set out to test whether L2 learners would rate their own L2 productions as better, that is, less accented, than productions of fellow learners from the same language and social background. Such a bias would have consequences for their ability to further improve their L2 pronunciation, as they perceive themselves as more target-like than they are. Note that by asking how well a given sentence was produced we obtained accentedness ratings by asking learners to compare a given stimulus to how they considered a native speaker to sound. We used a measure of accentedness rather than intelligibility since in a situation of self-monitoring learners know what they intend to say, hence are fully intelligible to themselves. Critically, we strove to ask L2 learners to rate their own accent in comparison to other learners without them noticing that they are doing so. By changing the voice characteristics, we were largely successful in preventing learners from recognizing their own voice: only three out of 24 participants claimed to do so, and the explicit recognition partly dissociated from similarity ratings that those participants gave in a similarity-rating task. Moreover, we were able to show that participants focussed on rating the accentedness of the voices, given that their ratings largely followed the assignment of learners into quartiles, which had been determined based on phoneticians’ and a native-speaker’s ratings. This shows that participants were, first, focussing on accentedness and, second, were not fully aware that they are rating their own voice in comparison to others.same stimuli rated by different learners. That is, the identical stimulus was rated differently (in comparison to others) depending on whether the learner had produced it herself or not. This finding reveals a cognitive bias that may have serious repercussions for L2 acquisition. If learners perceive their accent as better than that of others, this might make them less likely to notice errors. If they fail to notice their errors, continuing this rationale, they are unlikely to correct them as there may be little motivation to further improve. Given that the bias is also relatively large , this is a realistic scenario, above and beyond just being a statistically significant effect.Nevertheless, learners rated their own accents as better than that of others. Note that this cannot be due to real differences in accentedness, as this comparison is focussing on the There are at least two possible explanations for the higher self-ratings. It may be another instance of the mere-exposure effect , which dRather, both are in line with studies demonstrating that listeners who are frequently exposed to non-canonical speech of others adapt to it. This adaptation is reflected in better understanding and processing on one hand e.g., , 12), bu, bu12]),fossilization in L2 learning. If learners perceive their own accent as better than that of others, they may not feel a need to further improve. This does not imply that learners cannot improve their pronunciation at all. We deem it likely that more practice typically leads to better pronunciation over time, even though learners perceive themselves in a biased fashion. However, perceiving one’s accent as better than it objectively is may be one reason why learners persist in speaking with an accent even after many years of practice, which we refer to as fossilization. Crucially, this also means that learners may not profit from pronunciation training that requires them to notice differences between their own speech and that of a native speaker themselves—both in terms of phonemic errors and subphonemic and prosodic detail—without external corrections. That is, our results suggest that external feedback may be essential for pronunciation training to highlight those aspects of the accent that should be improved. Feedback may be provided by teachers or, less costly but not yet fully accurate, computer-assisted learning programs [Our data may also contribute to explain the finding of programs . Interesprograms , 45). A programs ). While


Mild cognitive impairment (MCI) is characterized by cognitive, psychological, and functional impairments. Digital interventions typically focus on cognitive deficits, neglecting the difficulties that patients experience in instrumental activities of daily living (IADL). The global conjecture created by COVID-19 has highlighted the seminal importance of digital interventions for the provision of healthcare services. Here, we investigated the feasibility and rehabilitation potential of a new design approach for creating highly realistic interactive virtual environments for MCI patients’ neurorehabilitation. Through a participatory design protocol, a neurorehabilitation digital platform was developed using images captured from a Portuguese supermarket (NeuroVRehab.PT). NeuroVRehab.PT’s main features  were established according to a shopping behavior questionnaire filled in by 110 older adults. Seven health professionals used the platform and assessed its rehabilitation potential, clinical applicability, and user experience. Interviews were conducted using the think-aloud method and semi-structured scripts, and four main themes were derived from an inductive semantic thematic analysis. Our findings support NeuroVRehab.PT as an ecologically valid instrument with clinical applicability in MCI neurorehabilitation. Our design approach, together with a comprehensive analysis of the patients’ past experiences with IADL, is a promising technique to develop effective digital interventions to promote real-world functioning. Mild cognitive impairment (MCI) was initially conceptualized as a clinical entity affecting the cognitive functioning exclusively  . HoweverVirtual reality   has beenShopping for groceries is perhaps one of the most studied IADL, with several studies showing that patients with executive deficits reveal in VEs a similar pattern of impairments to those observed in real-world tasks ,25,26,27The feeling of “being physically present” in the virtual world, known as presence, is described as the phenomenon of users acting and experiencing emotions as if they were in the real world ; this isBased on the limitations mentioned above and considering the concept of function-led instruments , in whicThe goals of this study are twofold: (1) to describe the design process of NeuroVRehab.PT and (2) to characterize health professionals’  perspectives about the rehabilitation potential and clinical applicability of NeuroVRehab.PT for VaMCI patients’ neurorehabilitation.This study was conducted using a participatory design research protocol and reported according to the consolidated criteria for reporting qualitative research checklist (COREQ) guidelines   and Comissão de Ética para Recolha e Proteção de Dados de Ciências (CERPDC) (reference number CERPDC/16/2019)  presented the project and explained how the data gathered through the questionnaires would support the research team’s decisions regarding the main features of the virtual supermarket, such as the use (or not) of a shopping list, the number of products included in the shopping list, and the type of supermarket (grocery store vs. supermarket vs. hypermarket), among other features. To be eligible, the participants had to be more than 60 years old, be community dwelling, be responsible for grocery shopping, and give written informed consent.A questionnaire with 11 multiple-choice questions that aimed to analyze the shopping behaviors and routines of older adults was developed and reviewed by the research team  was used to conduct descriptive analyses of the data collected through the shopping behaviors questionnaire with older adults. For nominal variables , tables of frequencies were calculated. For continuous variables , the mean, standard deviation, mode, minimum, and maximum were calculated.n = 8, 8.1%) stores or big department stores . Fifty-nine (56.2%) claimed that they usually make shopping lists, but only 42 (75%) use it during shopping. Before going shopping, 44 (79.4%) participants claimed that they included items in the shopping list as they remember what they need, and 10 (14.7%) organized the products according to the products’ position in the supermarket.A total of 110 participants aged between 61 and 86 years (70.92 ± 5.94 years) filled in the questionnaire. Twenty-eight were men (26.7%) and 77 women (73.3%). Fifty-three participants (53.5%) stated that they usually go to supermarkets as opposed to local grocery , alone , and to buy groceries for weekly necessities . On average, the participants spend 59.24 ± 33.68 min on each visit to the supermarket. Sixty-one participants (58.1%) claimed that they have an estimation of how much they will spend before going to the checkout counter, and 33 (35.9%) stated that, after being informed of the value of the bill, they know precisely how much they should receive in return  and require less hand–eye coordination . Older aNeuroVRehab.PT is a prototype of a web-based digital neurorehabilitation platform composed of three independent game modes—supermarket, recipes, and shopping list. The supermarket is the central part of the platform and the key component of the three game modes.Maria, a virtual shopping assistant, will guide users for the first time and regularly provide information about the game mechanics and behavioral shopping strategies that can be used in real life. Users experience the virtual supermarket from a first-person perspective  and can walk through the 19 supermarket sections  using the arrows displayed on the screen . This way, users can have a clean screen to prevent distractions, as reported in previous studies . Maria, e screen . Navigate screen a.The system provides fourteen game levels that ask users to go shopping with a predefined shopping list b. LevelsAfter selecting all the products on the shopping list, users are asked to go to the checkout counter zone and pay the groceries by choosing one of the payment methods (cash or credit card). At the end of each level, a three-star rating is attributed based on the users’ performance .The recipe game mode allows users to shop for the ingredients that are required to cook a traditional dish. Users may select among six traditional recipes—one soup, four main courses, and one dessert a. Each rIn this game mode, users can create personalized shopping lists. A list ID is identified by a name customized by users, and they may add products by writing the name of the product in the search field. As they write, a drop-down list appears with products matching the search query c. To selA purposive sample of health professionals  identified through professional networking was contacted and invited to participate in the study. Health professionals were identified based on (1) their clinical and scientific experience (≥5 years) with ageing, age-related neurological disorders, and cognitive decline; (2) their knowledge of the main theoretical models of human cognition and neurorehabilitation; (3) their familiarity with computerized cognitive training or rehabilitation programs. All the participants who were contacted (face-to-face) agreed to participate, and an individual session was booked at the participants’ convenience . All the participants signed the written informed consent.Interviews took place in quiet and private rooms and lasted approximately 60 min. The participants sat in front of a desk where a Huawei MediaPad T5 tablet (Android 8)  was supported horizontally at 25° degrees (approximately) using a tablet stand. The platform was run in the Google Chrome application . A neuropsychologist with previous experience in qualitative research (FFB) conducted the interviews, and a second researcher member  was also present in five of the seven interviews and ensured that the sessions went on without any technical problems.Each session was divided into two moments. In the first part of the interview, the participants were encouraged to express their opinions and thoughts verbally—the think aloud method (TA) —while usk = 0.82 was obtained by calculating the mean of Cohen’s kappa indexes per interview (Cohen’s k ≥ 0.80). This kappa index was used as indicative of strong interrater reliability in healthcare research , I think it is good.”Participant 5: “[While performing a task in NeuroVRehab.PT] Ok, hot chocolate. Hot chocolate, now I have to find…. this is really realistic. In fact, it is real, I did not have this expectation.”Participant 6: “It seems very realistic, hyper-realistic.” (line 51) “The locations, the type of products, yes, yes, I think is quite realistic.”Participant 7: “The environment sound is very good; it really puts you inside of a supermarket (…) we know where we are, perfectly.”The participants identified and played the three game modes without relevant difficulties. However, the navigation controls and the sense of orientation inside NeuroVRehab.PT were identified as two aspects that should be improved in order to provide a more smooth and pleasant experience. For instance, some participants misinterpreted the meaning of the navigation controls and interpreted them as mandatory actions to progress in the game.Participant 2: “The arrow appears, I assume this means I need to follow the arrows.”Participant 1: “… the arrow then… means that I need to go back to the fruit section?”Other participants considered the arrows as hints to the location of the next product in the shopping list.Participant 5: “The arrow helps to orient, doesn’t it? I did not understand if the arrow gives you a hint or if … Does it give you a hint?”Regarding the sense of being oriented within the supermarket, the participants felt that it “… could be useful, for example, before starting (the game levels) that the person visits the whole supermarket, a kind of orientation exercise, to learn (the supermarket) more or less.” (Participant 1). Still on this subject, another participant referred to the famous experiment of Willard S. Small  to explaThe health professionals considered NeuroVRehab.PT a useful and innovative instrument for cognitive stimulation that they would recommend to their MCI patients. Participant 5: “[regarding another virtual supermarket for IADL rehabilitation] (…) it was prehistoric when compared to this one.”Participant 2 “… a good alternative for cognitive stimulation.”The participants considered NeuroVRehab.PT “… sufficiently appealing and demanding for MCI patients…” (Participant 5) and comprehensive in terms of the cognitive functions stimulated—namely, executive functions , memory, attention, spatial orientation, and math abilities.Participant 5 “… working memory, of course, always pumping in my head (…) Manifestly, this also trains orientation….”. […] From an attentional point of view, it is quite demanding”.In addition, the choice for a shopping activity as the core activity of this digital intervention was considered as “…meeting the necessities of this population.” (Participant 1) and “… important, crucial for [patients] daily-life, if they do not have someone to do the shopping for them, they have to do it themselves…” (Participant 7).The realism of the scenario was also identified as an asset that could be used to promote patients’ motivation to comply with long and emotionally demanding rehabilitation programs.Participant 7: “[regarding other CCTP] I think there is not an effort or an intent to be similar to the person’s daily life. Here I notice that effort (…) and that could be more motivating for the person who is doing the training”.NeuroVRehab.PT elicited a sense of presence in some participants; “… I already knew that the milk would be closer to where eggs were, it is similar to other supermarkets where I go, I knew that… even if some fruits are not displayed on the fruit exhibitor, they are right there, it is essentially like… my experience in other [real] supermarkets.” (Participant 1).Participants were divided concerning NeuroVRehab.PT transfer capacity to patients’ daily life. Four participants considered that the activities proposed on NeuroVRehab.PT are “… more easily generalized than the paper-and-pencil exercises that we often do.” (Participant 5) and “Once the person succeeds in the game, I think…, I would say that it is easy to transfer to real life.” (Participant 6). Other participants considered that the transfer of the trained skills could not be assumed only based on the similarities between the virtual and real-world environments. Finally, a third group of participants claimed that the transfer of trained skills is more likely to occur if the activity/exercise is meaningful within the patient’s life context. Participant 2: “It has to make much sense [to the patient] to have any impact or transfer to real life. And even with this software, it is either something that meets what the previous life of the person was, and it has any meaning to him/her, or it ends up [just] being an interesting game…”.Finally, it was also pointed out that, despite being very realistic, our virtual supermarket is still a controlled environment  and different from the supermarket frequented by the patient.n = 4), fatigue (n = 2), anxiety (n = 2), and irritation (n = 1). Feelings of frustration were primarily associated with the process of learning how the platform works. Nonetheless, the participants considered that potential negative psychological side effects could be easily managed if a therapist is present and supports the patient’s learning process by explaining game mechanics and controls and helping the patient cope with feelings of frustration.Among the potential negative psychological side effects that MCI patients might experience associated with the use of our platform, the one most referred to by the participants was frustration , followed by stress (Participant 7: “I believe they [the patients] will have some doubts (…) I had someone by my side to explain it to me, and they do not have it”.Participant 3: “I think in some cases, some patients can easily start to get frustrated. And it is advisable not to continue. And I think there will be some situations like that, which is perfectly normal with this type of activity. Therefore, it is necessary to have resources [as therapists] (…) to be you to finish the activity and help the patient to move on …”n = 1) as a potential negative side effect as a result of the temporary blurred vision associated with the process of going from one image (sphere) to another. No other physical adverse effects  were foreseen by the participants, although difficulties associated with ageing, such as low visual acuity, were referred to.Nausea was also referred to , stroke, and early-stage dementia patients. Some participants also suggested that the platform could be used as a means to increase technology literacy in healthy older adults.Three participants reported they would like to see some degree of interaction between users. One of the suggestions was to provide patients with the possibility of sharing recipes and cooking tips with other NeuroVRehab.PT users , thus creating a virtual community. The participants also stated that it would be interesting if the therapist could create shopping lists (participant 5) that reflect the patient’s diet and/or food restrictions (participant 3). The fact that NeuroVRehab.PT is an online platform was identified by another participant as a way to promote family engagement, especially from younger people. “This (NeuroVRehab.PT) would be much more playful and (…) maybe it could even be more interesting to attract family participation (…) even for grandchildren, it would be much more interesting than sitting next to the grandmother, with a paper and pencil activity” (Participant 7).The possibility of exploring other IADL  as well as real-life scenarios  was noted as being one of most significant opportunities that the design approach presented here could bring to the field of neurorehabilitation. Other proposed activities were to invite patients to cook the recipes available in the recipe game mode, explore public places, and train their capacity to use public transportation.The use of photo-realistic interactive virtual environments is a promising approach to develop accessible, cost-effective, and ecologically valid instruments for neurorehabilitation in VaMCI patients. The availability of digital instruments has gained even more prominence with the current global health conjecture due to the COVID-19 pandemic, where contact between health professionals and patients is restricted or drastically reduced. In this paper, we described the design and development process of a fully navigable and interactive virtual supermarket built from photos of a typical Portuguese supermarket—the NeuroVRehab.PT. Furthermore, health professionals with extensive clinical and research experience in neurodegenerative and age-related disorders assessed our platform and identified the advantages and challenges associated with its clinical use in VaMCI neurorehabilitation.The participants considered NeuroVRehab.PT a remarkable improvement in the design of VEs for neurorehabilitation. The use of real-world supermarket photos as a core element of NeuroVRehab.PT resulted in a highly realistic and ecologically valid VE. In previous studies, the ecological validity of virtual supermarkets for assessment or training purposes was established through the relationships obtained between the participants’ performance in the VE and in related measures of executive functions and everyday functional capacity ,26,51,52Moreover, our platform allowed the participants to interact and choose between grocery products that they are familiarized with and use in their daily life. This additional layer of customization  enables coupling between therapeutic exercises and the patients’ interests and routines, thus resulting in meaningful exercises with practical  applications . In otheAnother layer of NeuroVRehab.PT aiming to promote patients’ engagement is the use of gamification processes. Gamification  ,56 has bFrom the semantic thematic analysis, two subthemes emerged regarding the rehabilitation potential of our platform: cognitive stimulation and transfer capacity. Health professionals considered that the activities proposed in NeuroVRehab.PT are feasible by VaMCI patients and target the cognitive functions recruited during a shopping activity . Furthermore, the participants referred to the training provided by our platform as being more easily generalized to the patient’s daily life when compared to other forms of cognitive stimulation, such as CCTP and Brain Training Games (BTG). Despite the undeniable social and economic impact of CCTP and BTG, the evidence regarding the efficacy of these programs is still scarce, with few studies showing an impact on other cognitive functions beyond those directly targeted by the cognitive training program, and even fewer studies showing an impact on behavioral outcomes ,61,62,63It is noteworthy that the theoretical framework used in NeuroVRehab.PT highly contrasts with the one used in CCTP and BTG. While, in CCTP and BTG, individual exercises are developed to target isolated cognitive functions ,65,66, iNonetheless, not all the participants were sure about the transfer capacity of NeuroVRehab.PT. For instance, participant 3 stated that patients’ predisposing characteristics  rather than the VE characteristics would influence patient adherence and skill transfer. The perspective that different people need and want to (re)learn different things and do this in different ways, using different strategies, is an established fact in the neurorehabilitation field, and programs should be committed to identifying which activities patients perceive as relevant in the actual context of their life . In otheAlthough NeuroVRehab.PT has been designed to be used independently by VaMCI patients, health professionals were in agreement regarding the importance of the presence of the therapist during the training sessions . The therapeutic bond established between the health professional and patient  is a strong predictor of psychotherapy outcome , the decFurthermore, we acknowledge that VaMCI patients may also experience other difficulties observed in healthy older adults, such as the fear of failure and peer judgment, anxiety about using computers, and a low assessment of their skills and capacity to learn new things . TherefoTaken together, our results show that the NeuroVRehab.PT is an engaging, ecologically valid neurorehabilitation digital platform for VaMCI patient neurorehabilitation. Although some interface components such as the navigation controls should be optimized to improve the patients’ UX, health professionals considered this platform a significant step forward to the design of efficient and family-inclusive digital interventions for cognitive stimulation and IADL training. The present study also highlighted the impact that the perceived personal and social relevance of the training activities might have on patients’ adherence and long-term use and, ultimately, the interventions’ efficacy. Finally, our results are elucidative regarding the potential positive impact of the therapeutic bond between the health professional and patient on an intervention’s outcomes, and so this should not be dismissed even in interventions supported mostly by digital resources.


Unhealthy alcohol use among young adults is a major public health concern. Brief motivational interventions for young adults in the Emergency Department (ED) have shown promising but inconsistent results.Based on the literature on brief intervention and motivational interviewing efficacy and active ingredients, we developed a new motivational intervention model for young adults admitted in the ED with alcohol intoxication. Using an iterative qualitative design, we first pre-tested this model by conducting 4 experimental sessions and 8 related semi-structured interviews to evaluate clinicians’ and patients’ perceptions of the intervention’s acceptability and feasibility. We then conducted a consultation meeting with 9 international experts using a nominal group technique. The intervention model was adjusted and finally re-tested by conducting 6 new experimental sessions and 12 related semi-structured interviews. At each round, data collected were analyzed and discussed, and the intervention model updated accordingly.Based on the literature, we found 6 axes for developing a new model: High level of relational factors ; Personalized feedback; Enhance discrepancy; Evoke change talk while softening sustain talk, strengthen ability and commitment to change; Completion of a change plan; Devote more time: longer sessions and follow-up options . A qualitative analysis of the semi-structured interviews gave important insights regarding acceptability and feasibility of the model. Adjustments were made around which information to provide and how, as well as on how to deepen discussion about change with patients having low levels of self-exploration. The experts’ consultation addressed numerous points, such as information and advice giving, and booster interventions.This iterative, multi-component design resulted in the development of an intervention model embedded in recent research findings and theory advances, as well as feasible in a complex environment. The next step is a randomized controlled trial testing the efficacy of this model. Alcohol use is the first cause of mortality among adolescents and young adults in the world, and is related to 20–25% of all deaths among this age group in Europe . Heavy eEmergency Department (ED) admissions related to alcohol intoxication represent a large burden on the ED clinical teams and account for a significant part of the resources in EDs –6. In SwWhile young adults incur significant harm due to unhealthy alcohol use, studies of the natural history of alcohol use disorders have shown that the likelihood of such disorders is lower among younger individuals than it is among older individuals; if present, they are probably milder in severity e.g. . TherefoTwo recent systematic reviews addressed the efficacy of BMI conducted in the ED for young adults and both found mixed findings , 19. NewThe studies summarized above typically used a systematic screening process to include participants. Therefore, results might not be generalizable to populations admitted in the ED while intoxicated. One recent systematic review  investigIf current findings have shown mixed effects for BIs among young adults in the ED, and promising effects for MI among those intoxicated, more advanced research is needed on how to optimize this secondary prevention opportunity. This includes information on key intervention components, ideal quality of intervention delivery, and which particular sub-groups are most likely to benefit from the intervention. We believe this is an important direction for intervention research with the potential to improve existing models .http://www.isrctn.com/ISRCTN13832949) and evaluate the mechanisms of the intervention effects. This first phase consisted of an iterative process to develop and pre-test the intervention model through qualitative evaluation and refinement of the intervention tool.This study thus aimed to develop a new motivational intervention model for young adults admitted in the ED with alcohol intoxication. The present article reports the first phase of a larger project using a general mixed methods approach e.g. , in whicOur iterative process comprised four rounds : Round 0This preliminary round was conducted in 2015 and comprised a review of the literature and the setting-up of the first intervention model.Round 1 aimed at testing the Intervention model 1 in the real world and collecting clinicians’ and patients’ feedback regarding the intervention. Four experimental sessions were conducted to examine acceptability and feasibility of delivery.n = 2) were psychologists who were trained to deliver the Intervention model 1 in a workshop involving role-plays with the members of the working group team. Patients  were the first four patients corresponding to the study’s inclusion and exclusion criteria. A sample of 4 sessions and 8 semi-structured interviews with each patient and clinician involved was planned a priori, taking into account the exploratory nature of the study and its iterative process. Recruitment took place at the ED during six mornings between July 28 and August 28, 2016. Fourteen patients met inclusion criteria, i.e. aged 18–35, admitted to the ED for any cause, and with alcohol intoxication (> 0.5 gram/liter BAC). Of those, 7 were excluded , 1 left the ED prior to receiving the information session and 2 refused to participate.Clinicians  and all participants provided written informed consent.Eight individual semi-structured interviews were conducted. We interviewed both patients and clinicians on their experience and perceptions of the intervention using an interview grid . The intQualitative data were subject to conventional content analysis using ATLAS.ti 7 qualitative data analysis program . ConventIn this round, international experts in MI and BMI were consulted about the intervention model. To best capitalize on experts’ experience and insights, we used a consultation group meeting format in order to discuss the practicality, appropriateness, and theoretical soundness of the model, by generating propositions and working on a consensus on these for an amended model to be tested in Round 3.Privatdozentin, Institute of Social Medicine and Prevention, University of Greifswald, Germany; Prof. Nick Heather, PhD, Emeritus Professor of Alcohol and Other Drug Studies, Department of Psychology, Northumbria University, UK; Prof. Molly Magill, PhD, Assistant Professor of Behavioral and Social Sciences, Center for Alcohol and Addiction Studies, Brown University, USA; Prof. Jim McCambridge, PhD, Professor and Chair in Addictive Behaviours & Public Health, Department of Health Sciences, University of York, UK; Prof. Peter Monti, PhD, Professor of Behavioral and Social Sciences, Director of the Center for Alcohol and Addiction Studies, Brown University, USA; Prof. Stephen Rollnick, PhD, Honorary Distinguished Professor at Cochrane School of Primary Care & Public Health, Cardiff University, UK; Prof. Richard Saitz, MD, MS, Professor of Medicine and Epidemiology and Chair of the Department of Community Health Sciences, Boston University, USA.Participants and setting. This group meeting took place on Thursday 22 September 2016, in Lausanne, Switzerland. We took advantage of the 13th Annual Conference of the International Network on Brief Interventions for Alcohol Problems (INEBRIA), which was hosted in Lausanne at that moment. Among the 11 experts invited to participate, 2 were interested in participating but were not available to attend, and 9 accepted invitation and participated. These were : Prof. Gail D’Onofrio, MD, MS, Professor of Emergency Medicine and Chair of the Department of Emergency Medicine, Yale University, USA; Prof. Craig Fields, PhD, Associate Professor, Department of Psychology, University of Texas at El Paso, USA; Dr. Jennis Freyer-Adam, PhD, Generating ideas (the facilitator presents the question/issue and each group member silently generates and writes down ideas); 2) Recording ideas (each group member exposes his/her idea(s), the facilitator records them on a screen); 3) Discussing ideas (each idea is discussed to determine clarity and importance); 4) Voting on ideas (each group member votes privately to prioritize ideas). For the voting phase, experts were asked to select the 5 most important propositions, and then to rank them from the most to the least important on a scale from 1 (least important) to 5 (most important). Votes were collected and scores for each proposition were summed across experts. Propositions with higher scores were considered the most favored group actions or ideas in response to the question posed.The meeting was a 4-hour workshop which was led using a participatory research approach inspired by the nominal group technique as a consensus method . The fouRound 3 replicated methods used in Round 1 but by testing our new intervention model  were the same psychologists as in Round 1, trained in using the new features of the intervention model. Patients  were the first six patients corresponding to study inclusion and exclusion criteria. Again, this sample of 6 sessions and 12 semi-structured interviews was planned a priori, taking into account the exploratory nature of the study and its iterative process. The full process resulted in 20 semi-structured interviews, which effectively led to data saturation. Recruitment took place at the ED during 10 mornings between October 8 and November 11, 2016. Twenty-one patients met inclusion criteria. Of those, 10 were excluded , 3 refused to participate, 1 left the ED prior to receiving the information session and 1 was not approached by the research team by lack of time.Clinicians  to identify new categories that did not appear to fit into the original codebook. The codebook was modified accordingly. Then, the second author rated all qualitative data from Round 3.This preliminary round aimed at drafting the first model of the intervention. This model was based on a recently published literature review on BI mechanisms  and MI mRelational factors can be significant determinants of addiction treatment outcome . EmpathyEarly BI models have focused explicitly on feedback on risk or harm as a tool for instigating change . Meta-anTo develop discrepancy between the individual’s current behavior and their broader life goals and values is a core feature of MI . In one MI has been described as a collaborative conversation style for strengthening a person’s own motivation and commitment to change , and cenCompletion of a plan to change alcohol use is an MI component resulting in verbal statements of intention, and a written contract for behavior change . Magill Systematic reviews on alcohol BI and BMI have not clearly determined the optimal intervention length , even ifCategories yielded in the current analysis reflected participants’ and clinician’s perceptions of the intervention’s feasibility, acceptability and utility.Suitability of the intervention in the ED. Participants and clinicians uniformly reported that the ED was overall suitable for the intervention. They noted both disadvantages and advantages related to this setting. On the one hand, clinicians reported that it was feasible to provide the intervention in this setting, even though it required adapting to specificities related to the ED, such as noise or being interrupted several times by other staff or participants’ relatives during the intervention. One clinician explained, “It can be difficult to get back on track, to know where we were, what I had in mind that I wanted to say, what the patient was saying” (Q1). Participants’ tiredness was mentioned as another disadvantage by clinicians who sometimes felt urged to end the intervention. Relatedly, a participant mentioned her “feeling that by giving [us] time, [she] was wasting time to able to get out [of the emergency department] sooner” (Q2). Tiredness was also frequently mentioned as a barrier to participate in the intervention; one participant explained for instance that although he found the intervention interesting, he first did not want to participate because he felt too tired. That said, one participant noted that the setting  eased the discussion that might otherwise be uncomfortable. Another participant corroborated this point of view noting, “I cannot see another context in which such a discussion could have happened” (Q3). On a similar note, the context was perceived as a change trigger by this patient: “It is not, well, it is really not trivial and I think one should be a bit I don’t know, simple-minded [laughing], stupid to not, well, not seeing this like, […] it is not anything, it is, I am at the emergency department, it is not for nothing and there is a problem, here, it really makes you think, operate a change” (Q4).Perceptions of the intervention model applicability. Both clinicians indicated that the model was overall applicable in the ED setting. They described the model as “flexible” and “tailored to the situations” they had met. They also mentioned that the three steps . Notably, both clinicians shared difficulties in deepening discussion at some point during the interviews. A clinician mentioned for instance that she “didn’t have the impression of being able to go very far in the discussion about alcohol, about what brought [the patient] here at the emergency department that day” (Q6). More generally, addressing plan to change patterns of alcohol use was uniformly reported as challenging by clinicians: “When I asked her how she saw her drinking in the future, she couldn’t really answer, and then, well she said that it would get better and better, but then in the planning phase there wasn’t really a concrete objective, well, but… I asked anyway how important it was for this person, how much she felt confident, so, well, I asked, it was ok, but it’s true that there wasn’t necessarily something concrete either” (Q7).ee steps  made senParticipants’ general acceptability of the intervention. Overall, the intervention was well received among participants, who reported liking it. They all mentioned feeling at ease and experiencing the intervention well. Although most participants noted that the intervention length was adequate, one participant considered that it was too long and that it may represent a barrier to its acceptability: “In my opinion, this could be very dissuasive for some people. When you see the 20 to 60 minutes range, it’s quite scary!” (Q8). Echoing this point of view, another participant noted, “I am sure there are people who actually want to do your thing [the intervention] but who tell themselves no, they will waste their time, that it will make them waste even more time” (Q9).Participants’ perceptions of the clinicians. Most participants perceived the clinicians positively. Clinicians were commonly described as “very kind,” “open,” “soothing”, and “understanding.” Participants frequently reported feeling at ease and understood, and appreciated the discussion they had with the clinicians: “It was not, how can I say, intrusive, or, she was not looking for something, she was not trying to get something and, well it was a relationship […] I could really talk normally” (Q10). Other positive perceptions mentioned by some participants included professionalism and attentiveness. Finally, one participant considered that the clinician was too neutral and noted, “She [the clinician] doesn’t judge, she just takes information” (Q11). This participant disclosed, “Yeah, I would have been interested in having her point of view regarding what I said; because at the end, she just listened to me, she asked me questions, but she gave me no opinion actually” (Q12).Participants and clinicians’ perceptions of the intervention’s content. Overall, participants held positive perceptions of the intervention’s content. The intervention was described as “well-crafted” and “complete.” However, perceptions regarding alcohol-related information content were more diverse. Although alcohol-related information  was not systematically provided in this first round of experimentation, participants and clinicians were asked about this content’s fit and acceptability. Half of the participants considered that providing alcohol-related information might be useful. For instance, a participant explained, “It [a personalized alcohol-related feedback] may be useful, yes […] to indicate, well, to know where we really stand, because, I think that many people believe they do not drink much but at the end they’re already good drinkers” (Q13). Whereas clinicians agreed that providing alcohol-related information was useful, they expressed feeling insecure about when and how to provide it during the intervention:Clinician: I felt like wanting to give more, I, well… maybe I could have done so, right, but I would have liked to give more information [to the participant].Interviewer: About what?Clinician: About the fact that, when she says that, in her opinion, a completely normal and non-problematic consumption is actually something relatively high; well I would have liked to provide her, well to give her this feedback, so that she could compare herself with respect to an actual norm, because without that, well maybe I should have allowed myself to do it right, but without doing it, it was almost as if I heard that she drank that but I normalized it as well or … […]; but my question was whether I could do it while keeping a motivational stance. (Q14).I think that you should be careful if you do, where you will give it, actually [talking about a list of safer-drinking strategies]. Because there are people, like myself for instance, I, if you say that to me I’m going to feel hurt, like well, hurt because you see me as an alcoholic… and I, I will take it badly, it will hurt me because I know that I’m not like that, and it irritates me” (Q15).The other half of the participants, on the other hand, reported no interest in receiving alcohol-related information. One of them explained for instance being more interested in sharing a “real discussion” with the clinician rather than getting information, while another participant considered that being told certain alcohol-related information could be upsetting: “It feels good to see, well to be able to think further, after that [the emergency department experience], because, well, I would never have thought about myself here, so well, I would never have thought about having to think about a change because I am here either” (Q16). Congruent with participants’ reports, clinicians noted that participants appeared at ease when evoking change and that it stimulated reflection.Most participants reported that they valued evoking change in this specific situation. For example, one participant expressed that “it felt good” to talk. One participant reflected: “Well, it feels good to, maybe you don’t realize it at first but, it feels good to have the opportunity to talk, about, about what happened, yeah, it is always good to talk about … Keeping stuff to yourself isn’t good and if you can talk to someone else, it is always good”“ (Q17).Participants commonly reported that “It makes you think, always, and, well, it is not harmless, it’s a drug anyway, and even though it is accepted by society I mean, being able to find the right balance, well, being able to adapt your drinking, […] avoiding having the glass too many” (Q18).Furthermore, most participants noted that the intervention made them think about alcohol use and related harm: “I tried to connect it, well, anyhow it is someone who fell down the stairs, while intoxicated, at the end of the party, and she initially said that it was just unfortunate, that it had nothing to do with alcohol… At the end of the interview, she said that, indeed, if she hadn’t drunk she wouldn’t have fallen. I thought that, in any case, maybe it was the use of it [the intervention], to have her verbalize it … and that she heard herself say, “Indeed maybe if I hadn’t drunk I wouldn’t have fallen” (Q19).Relatedly, a participant mentioned that the most useful part of the intervention was when they evoked change in their alcohol use. Clinicians’ perceptions of the intervention’s utility were somewhat more nuanced. On the one hand and in line with participants, both clinicians noted that the intervention made participants feel good and think of alcohol use and related harm. One clinician mentioned that the intervention led the participant to attribute causality between alcohol intoxication and ED admission: ““Of course I think about what I could have done differently, about what the patient told me, and then about the fact that I don’t have the impression that she really moved on during this intervention” (Q20).On the other hand, talking about the intervention’s utility sometimes made clinicians think further. For instance, a clinician reported, Overall, the participants appreciated the intervention, felt free to speak, appreciated evoking change, and thought that the clinicians were attentive, kind, soothing, sincere, and non-judging. Clinicians’ perceptions were good overall, even if the hectic context of the ED was sometimes stressful and fostered some auto-pressure to conclude the intervention. The model was judged as feasible and the three steps see  made senThis first experimental session round also stressed the question of providing information. Half of the participants were interested in receiving information, for instance to compare their drinking to others. Nevertheless, the other half preferred an open-ended discussion. The clinicians estimated that providing some kind of information  would have been useful in most interviews. However, they were rather insecure regarding when and how to provide information during the intervention. Providing some feedback, information, and/or advice, using MI techniques was thus formally introduced in the next iteration of the model. It was also held as a main topic for the next round, i.e. the experts’ consultation meeting.After presenting the intervention model in details, we showed the results of the qualitative feedback interviews from Round 1. Experts were also provided an intervention outline as a printed handout. Experts were asked to generate ideas and propositions to answer the following question: “Now that you have the intervention model in mind, what would you add and/or modify?”.add / focus on follow-up contact . This topic was discussed in more details during the 3rd part of the meeting  but it was considered here that admission in the ED should be seen as a moment to engage patient into a discussion about alcohol use and consequences and that this discussion should be continued elsewhere or by other means. A similar idea was also suggested by an expert who thought about the intervention as a way to make connections and engage people, the target of the intervention not necessarily being to change or fix problems . Also in this direction of implementing the discussion and making it last, another idea was to provide something patients can take with them, such as a written change plan, a letter to themselves, a recording of the session, or other personalized item .Overall, experts were supportive of the presented model, which they found feasible, acceptable, and theoretically sound. Experts generated and exposed 29 ideas to strengthen or improve the intervention model overall see . The mosprovide a simple, structured, replicable model. The current model was thought to be somewhat diffuse and complicated. Several experts advised to work more thoroughly on model presentation to make it more structured and easier to apply and replicate elsewhere.The second most endorsed idea, totaling the highest score  was to give advice and directions to the patient. This was considered a crucial ingredient of brief alcohol intervention. Experts added that such advice should be given within the same empathic and acceptant climate, and, as proposed in MI, after having authentically asked permission to offer advice and direction. This idea was close of another idea which was to Give advice about avoiding coming back to ED . It was also related to ideas about giving alcohol-related information, such as Give age-matched normative feedback , and Give information about what they are in the ED for  . Related to the latter, one additional idea was to focus the discussion more on the precipitating event and work on causal attribution of ED admission to alcohol intoxication .The next most important idea  was to work on social support, mainly by adding a discussion about where clients can get it. Close to this, one idea was also to work on peer influence . There was also a discussion about the opportunity to get someone else involved  or approach the group and not just the individual . Even if actually involving other people in the discussion is not feasible in the study design, the experts pointed to the idea of discussing with the patient about how he/she could involve peers, friends, or significant others in their reflections and/or plans about change.Another line of ideas, which was not anticipated and discussed for the model so far, was around social influence and social support. The most endorsed idea in this line  was to give patients a tablet with electronic intervention contents, such as short films and interactive information; the patient would talk for a while with the clinician, then work on the tablet, and talk again with the clinician . Another expert suggested to consider computer-based intervention for less severe patients . However, the study protocol included only face-to-face intervention and there was no budget to develop and pilot-test electronic contents. Another proposed idea was to restrict age group to 18–24 years old  in order to get a more homogenous population having similar alcohol-related problems, but again the study protocol was already planned and accepted by the study funder and the ethics committee with an age range of 18 to 35.Then, two ideas were well received by experts but could not be implemented. The first was to include electronic elements in the intervention. One expert proposed to Finally, there were several other ideas, which were endorsed by only one expert or none, and were thus not considered as receiving sufficient consensus. These are listed in the table provided in We first presented what type of information we thought about giving . Then, we presented results related to information giving from the qualitative feedback interviews from Round 1. Experts were then asked to generate ideas and suggestions to answer the following question: “How would you provide information?”, with sub-questions being “Which information? How to introduce it? When? (during BMI? after BMI in a leaflet? other way?) Systematically? (or according to particular need/circumstances?)”.highly individualized information, which would be summed up in a “letter” given to the client at the end of the intervention. Providing individualized information was considered essential and preferred to generic information e.g. presented in a leaflet. For example, another idea was favorably rated : What information: give tailored advice, with options, and specific not generic information. Other types of information, also tailored to client’s situation, was recommended: Information about intoxication (specific to client BAC) and normative feedback about intoxication ; or Personalized “exercises” on options and strategies . If information and advice were recommended to be tailored to clients, one expert noted that they should nevertheless be simple and standardized to be replicable . Even if not well supported in experts votes, there was also a large consensus during the discussion that some information should be given to everyone, after having asked permission to provide it ; and that minimal information should be given to everyone, with additional information depending on what people need or are interested in .Experts generated and exposed 28 ideas or propositions. Among those, the idea voted as the most important  was to provide no printed leaflet, but using smartphone to send messages tailored on what was discussed . Similarly, another expert recommended to multiply contacts and media  . Several ideas, well received by other experts, were related to computerized ways of delivering information and advice: Provide visually appealing information on a tablet, with graphs ; Sending information from the tablet used during BMI to the client’s smartphone . Experts considered that computerized information would be friendlier, by letting the client decide what information is most useful . In the same vein, but using technologic developments that were not in the scope of the present study, two proposals were supported by multiple experts and might thus be worth testing in another project. The first was to develop computer interactive exercises using the MI technique ‘Elicit-Provide-Elicit’, tailored to target alcohol outcomes . The second was to show a video of a peer (age- and gender-matched) who experiences an appealing, positive story on something they can do since they are not intoxicated , the idea here being to present a positive, desirable story and not a negative story (such as a car crash) which would not be effective after an admission in the ED related to alcohol intoxication.The second most voted idea was related to the way of providing information to a population of young adults. One expert recommended using Again, there were several other ideas, which were endorsed by only one expert or none, and were thus not considered as receiving sufficient consensus. These are listed in the table provided in As an introduction to this last topic, we presented the intended model for booster sessions. Booster were planned to be introduced during the initial BMI, while asking permission to contact participants again. Four modalities were proposed: 1) Send booster letters ; 2) Phone booster sessions ; 3) Drinking goals monitoring using a Smartphone app (proposed in the case of a drinking change plan); 4) Accompany to specialized treatment . After presenting these options in details, we showed the results of the qualitative feedback interviews from Round 1. Experts were then asked to generate ideas and propositions to answer the following question: “Now that you have the intervention booster model in mind, what would add and/or modify?”electronic delivery of the booster letter (e.g. via text message). This idea was consistent with other ideas such as emailing pdf instead of sending letters and using text messages instead of phone calls , using multi modal delivery, including new technologies , and using online technologies, also to remind appointments, collect new data, etc. , or using a Smartphone application . Additional ideas included suggestions of other forms of contact using new technologies such as text messages and videos, but were only marginally supported.Overall, the experts found that the options presented were already a good range of options. A minority of experts debated the need to provide booster sessions at all, since they found that boosters were not necessarily cost-effective, that it is often difficult to reach people, and that some participants might not want to be contacted at that moment. Experts generated and exposed 19 ideas or proposals. Among those, the idea voted as the most important  was to opt for ensure some follow-up contact, for example health care contact in primary care soon after ED admission . The idea was that this contact in primary care would have a booster effect but might also provide an initial intervention for those not remembering what happened in the ED. If this idea was well supported by several experts, other cautioned about it since patients often not come back in person in a clinical setting. Another idea involving primary care was to consider transferring referral to primary care instead of specialized care . Most of the other ideas were related to booster content which should be simple, feasible, and replicable , personalized , memorable , include fresh, individualized data , but limited, i.e. less contact of better quality .The second most important idea was to As for the other topics, there were several other ideas, which were endorsed by only one expert or none, and were thus not considered as receiving consensus for the present project. These are listed in the table provided in Experts were largely supportive of the proposed intervention model, which they found feasible, acceptable, and theoretically sound overall. The ideas and propositions generated during this consultation meeting focused on two major points: ensure some follow-up contact (booster interventions), and provide information and advice. There was a consensus on favoring follow-up contact. The intervention in the ED was considered an opportunity to make connections and engage people in further care or follow-up discussion. Several options were discussed and most experts agreed that multiplying contacts and multi-modal delivery including new technologies  would be more convenient and adequate to contact a population of young adults. Experts also supported the idea of providing something that patients can keep, such as a “letter” summing up what was discussed and/or individualized information, which could be given to the client at the end of the intervention or electronically delivered. Other ways of offering follow-up contacts using new technologies were suggested but were beyond the scope of the present study. For our model, we retained the idea of multiplying contacts and multi-modal delivery by proposing up to 3 contacts through telephone, and a booster letter sent via email or by mail according to patient choice. This letter would also contain links to our website, which contains information on alcohol use and consequences, as well as help and treatment offers.The second main point was related to advice and information. There was a consensus that some information should be given to everyone. Minimal information could be given to everyone, with additional information depending on what people need or are interested in. Information and/or advice should be tailored to the patient. Several ideas highlighted the importance of giving information about what patients are in the ED for  and focusing the discussion on the precipitating event and the causal attribution of ED admission to alcohol intoxication. Experts also insisted on how to provide information, i.e. by asking permission to offer it, by using the same empathic and acceptant climate as proposed in MI, and by providing directions, advice, or strategies with options (and discussion of these options to capture which could be adequate). All these points were retained and added in our next intervention model.A third, unexpected point caught our attention: the work on social support. Our intervention was initially developed in an individual perspective, taking into account mainly intrinsic motivation. We were therefore attentive to the idea brought forward by several experts around working on social support, getting peers or significant others involved, or approaching the group and not just the individual. Since actually involving other people in the discussion was not feasible in our model, we added the idea of discussing with the patient about how he/she could involve peers, friends, or significant others in their reflections and/or plans about change.Finally, there was a strong consensus on the need to describe a simple, structured, and replicable model. We retained this suggestion and further refined our model in an intervention manual, encompassing the main intervention principles and content.Similar to Round 1 evaluation, categories yielded in this second analysis reflected participants’ and clinician’s perceptions of the intervention’s feasibility, acceptability and utility.Suitability of the intervention in the ED. Similar to Round 1 evaluation, participants and clinicians uniformly considered that the ED was suitable for the intervention. Most participants were in favor of receiving the intervention in the ED instead of doing it a few days later. For instance, one participant explained: “Well I would prefer doing it now, because, actually the way I feel now, I mean, I regret I went out, I mean, having taken stuff before, thus I would prefer doing it now than waiting one day and having had a rest” (Q21).shocked” and/or “confused” represents a potential change trigger. For instance, a clinician reported that doing the intervention in that specific moment may strengthen participants’ discomfort and, as a consequence, their motivation to avoid coming back to the ED while intoxicated. That said, similar to Round 1, both clinicians and participants considered participants’ state as a potential disadvantage of doing the intervention in the ED. Participants commonly reported feeling “tired,” “shocked” or “confused” and therefore sometimes not able to deepen the discussion and keep a clear memory of its content. Clinicians shared this point of view while underlying the importance of clinical boosters: “Well I think that it is not possible to do everything in a single intervention in the emergency department, in fact, because the person is still in a state, well, shocked, there is probably still alcohol involved there, there is emotion […] I think that, well, talking again about these things later on, when the person has been able to think, well, I think it is, it would be much, it would be good, effective” (Q22).Similarly, both participants and clinicians reported that doing the intervention in the ED while participants still feel “Perceptions of the intervention’s model applicability. Similar to Round 1, both clinicians indicated that the model and its three steps were overall applicable in the ED setting. Next, similar to the previous evaluation, clinicians uniformly reported encountering difficulties in deepening the discussion at some points during the intervention, as well as in addressing concrete plans to change.the clinician let me express myself […] I did not feel stressed…well, how shall I put it… restricted by time or anything” (Q23), whereas another mentioned appreciating that the clinician took time to understand her.Corroborating findings from Round 1, all participants reported feeling at ease and experiencing the intervention well. Unlike Round 1 however, the intervention’s length was consistently perceived as adequate, and even as an added value. For instance, one participant reported: “helped,” whereas for others, boosters indicated a commitment of the clinician: “I think this is good […] it actually shows an investment between, well, both people [the clinician and the participant]” (Q24).We also investigated participants’ feelings about potential intervention booster sessions (this was not done in Round 1). All participants were interested in receiving a letter summing up the discussion with the clinician. Participants commonly explained that it would help them remember what happened that brought them to the ED, as well as the content of the discussion. In the same vein, participants evenly accepted to be called by the clinician one week later . Some participants mentioned appreciating feeling “Participants’ perceptions of the clinicians. All participants’ perceptions of the clinicians were positive in this round. Similar to round 1, participants reported feeling “at ease” with the clinicians and even “trusting them”. They were commonly perceived as “kind” and “understanding.” Other positive perceptions held by some participants included the fact that clinicians were attentive and showed interest in the participants’ discourse.Participants and clinicians’ perceptions of the intervention’s content. Consistent with Round 1, the intervention’s content was well received among participants. At least two participants mentioned that the clinicians asked them “the good questions.” One of them went on explaining he appreciated that the intervention’s content was personalized: “It was not like it was written questions. I mean that, if I say something, she will ask me a question about it” (Q25).interesting” or “complete”. That said, receiving alcohol-related information was also perceived as a “formality” and its utility was commonly questioned. In fact, participants mentioned almost uniformly that they did not learn anything new: “Well, I already knew that there were plenty of risks [laughing], so I didn’t, I didn’t think too much, I already knew” (Q26). This point of view was corroborated by clinicians who reported tailoring the information content to the participants’ knowledge and reactions: “I asked her somewhat if she knew [alcohol-related] effects, and then…, and then, we talked a little bit about that. I didn’t go into lots of details because I didn’t have the impression that she needed more than she already had” (Q27). The clinicians explained that providing information about alcohol-related consequences happened naturally during the intervention, whereas the way of introducing them varied across interventions. For instance, a clinician explained: “After I asked him what he thought about the fact of ending up here, in the ED, and so on, well I thought it was a good time to do that and well he was ok with it, so yes […]. I asked him if he actually agreed to talk about alcohol-related consequences and when he said yes, I started by asking him what he knew […] And so he spontaneously gave you, well told you a bit the risks he knew about alcohol […] and so I asked him if he was ok that I complete what he said, while of course validating what he said” (Q28).Following Round 1 and Round 2 amendments to the intervention model, alcohol-related information was systematically provided in this round. Most participants had a positive perception of the information they received. Information was commonly described as “it felt good talking.” Echoing this point of view, a clinician reflected, “I have the impression that the intervention also did him a lot of good. Well, as he talked a lot, I think he really needed to unwind and I think it made him feel good that there was somebody who, who could listen to him too” (Q29). Both clinicians and participants commonly reported that the intervention made them think. Some participants added that it helped them gain a better understanding of what brought them to the ED, and a better understanding of their alcohol use and related harm more broadly. For instance, a participant reflected: “What helped me a bit, was precisely to understand why I am here [in the emergency department] and, why I did that” (Q30); whereas another reported: “it made me understand that you really need to pay attention to what you drink […] you need not to drink too much either, too fast, you need above all to keep hydrated, to eat well” (Q31). On the contrary, two of the 6 participants reported that they did not find the intervention useful. Specifically, one participant explained that “he did not gain anything from it,” whereas the other participant explained that she did not need the intervention to decide to make a change: “Well, anyway I was already disgusted with myself, by myself, that I would not go out, so it’s not the intervention that influenced it” (Q32).Most participants perceived the intervention as useful. Similar to Round 1, participants frequently reported that “Similar to Round 1 evaluation, participants and clinicians uniformly considered that the ED was suitable for the intervention. The recency of the shock related to ED admission was commonly considered a potential change trigger. However, confusion and tiredness were also mentioned as potential disadvantages, preventing from deepening the discussion and keeping a clear memory of its content. This barrier underlined the importance of intervention boosters. Participants consistently accepted to be called back by the clinician. All participants were also interested in receiving a letter summing up the discussion. Participants commonly explained that it would help them remember what happened, what brought them to the ED, as well as the discussion’s content. It was also perceived as indicating a commitment of the clinician in the relationship being built. Consequently, the booster letter (sent by mail or email) and the phone calls were established in the final model.Following Round 1 and 2 amendments to the intervention model, alcohol-related information was systematically provided in round 3. The clinicians happened to provide information about alcohol-related consequences naturally during the intervention, whereas the way of introducing them varied across interventions. Most participants had a positive perception of the information received, which was commonly described as interesting and complete. Nevertheless, receiving alcohol-related information was also perceived as a “formality” and its utility was commonly questioned since almost all participants mentioned that they did not learn anything new. According to this feedback and to experts’ consultation in Round 2, we further discussed this major point in our working group. In the final model, we specified that minimal information should be systematically provided to all participants in two ways: 1) when introducing the intervention, by specifying that we try to reach out every young adults admitted in the ED while intoxicated since previous studies showed that being admitted intoxicated was related to higher likelihood of being readmitted, of developing alcohol and other drugs problems, or of having psycho-social problems; 2) by providing links to alcohol-related information website in the booster letter. In addition, clinicians should pay attention to patients’ knowledge and systematically address the following topics when needed: 1) causal attribution of ED admission to alcohol use, 2) adjust distorted perceptions, banalization, and misbeliefs about alcohol use and consequences; and 3) suggest change options or strategies if necessary. While doing so, clinicians have to use MI techniques , i.e. ElOtherwise, all participants’ perceptions of the clinicians were positive in this round. Participants confirmed feeling “at ease” and understood, and trusting clinicians, whom they found kind, attentive, and showing interest in their discourse. Consistent with Round 1, participants appreciated the intervention’s content and found that the clinicians asked them “the good questions”. They also appreciated that the intervention’s content was personalized. Unlike Round 1, the intervention’s length was consistently perceived as adequate, and even as an added value (i.e. providing enough time to express themselves and to be understood). On other hand, clinicians felt again that the intervention model strategies and its three steps were applicable overall. However, similar to the previous evaluation, difficulties in deepening the discussion at some points, as well as in addressing concrete plans to change were mentioned. We believe that the possibility of offering information, advice, and change strategies options as described above might also have an effect with patients having difficulties in deepening the discussion and/or addressing concrete plans to change. Booster interventions might also be effective, particularly when difficulties in deepening the discussion are related to confusion induced by intoxication and/or emotional status.Finally, most participants perceived the intervention as useful. Similar to Round 1, participants frequently reported that “it felt good to talk”. The intervention made them think and helped them gain a better understanding of what brought them to the ED, and a better understanding of their alcohol use and alcohol-related harm more broadly. Nevertheless, some of the participants reported that they did not find the intervention useful. When considering these critical remarks, we further refined two parts of our final intervention manual. First, we intensified the importance of relational factors to build a significant relationship, notably through showing curiosity and empathy. Secondly, we further developed the first step of the model where the clinician explores the current situation and puts it into perspective with important things in life and values. Using relational factors and reflective listening, the clinician takes the time to really get to know who the patient is, what are their current situation, their values, and the meaning they give to it.The present article aimed to develop and pre-test a new motivational intervention model for young adults admitted in the ED with alcohol intoxication using an iterative qualitative process. This process generated 20 semi-structured interviews and 76 experts’ propositions. It allowed us to test the intervention model in the real world and to collect clinicians’ and patients’ feedback on their experience, as well as to theoretically refine our model. At each round, data were analyzed and discussed to update our intervention model. A schematic outline of the final model is provided in Discussion of specific study results and related conclusions are provided at the end of each round and, consequently, we do not provide further discussion of study findings here. Overall, this iterative process of intervention development offered a strong support for the acceptability and feasibility of our model to address alcohol use and related problems with young adults in the hectic context of the ED and following an alcohol intoxication. As observed in similar recent studies e.g. –71, qualDespite the above-noted strengths, this study has also some limitations. In rounds 1 and 3, interventions were conducted by the same two female psychologists. If this provided higher internal consistency, it obviously decreased variability in clinicians’ characteristics and within-session behaviors; and results might have been biased by therapist effects , 73. In http://www.isrctn.com/ISRCTN13832949). Results are expected at the end of 2020. A further phase of the project will be to evaluate the mechanisms of the intervention effects using a moderated mediation framework [Nonetheless, by this careful and rigorous iterative process, we were able to develop, pretest, and refine an intervention model, of which the efficacy will be tested as the next phase of the project. This is done using a randomized controlled trial that is ongoing and registered in the ISRCTN registry Click here for additional data file.S1 Table(PDF)Click here for additional data file.S2 Table(PDF)Click here for additional data file.