Workshop content was structured around the study aims. The community artist and/or the local charity delivered the workshops, with researchers gathering data via observation, photos, and audio-recordings, which were analysed using the framework method. All four groups noted that the benefits of physical activity should be included within any communications efforts, though not restricted to health-related benefits. Language used should be simple and jargon-free; terms such as “sedentary”, “vigorous” and “intensity” were deemed inaccessible, however all groups liked the message “some is good, more is better”. Views about preferred mechanisms, and messenger, for delivering physical activity messages varied both between, and within, groups. Recommendations for those working in physical activity communications, research, and policy are provided.Despite many countries having physical activity guidelines, there have been few concerted efforts to mobilize this information to the public. The aim of this study was to understand the preferences of under-served community groups about how the benefits of physical activity, and associated guidelines, can be better communicated to the public. Participatory workshops, co-developed between researchers, a local charity, and a community artist, were used to gather data from four groups in Bristol, UK: young people ( In 2019, the four Chief Medical Officers (CMO) of the United Kingdom (UK) published updated guidelines for physical activity. These were first introduced in 1996 and updated in 2004 and 2011  cost money and time–things which people don’t have” (Adults’ workshop).All groups reported that providing examples of physical activity at the different intensities would be helpful, in particular highlighting how physical activity can be incorporated into daily life or take account of pain, mobility or other health issues. Physical activity messages should also challenge the assumption that being physically active requires playing sport or going to the gym, for example: “normal people-selection of different people, of all different ages and backgrounds, doing different types of activity as part of normal life—this should be the imagery in the campaign”. Participants also suggested that the content be “motivating”, “encouraging” and “light-hearted”.Participants also suggested that where images of people are used, it is imperative that they are relatable : “Because of my religion, I would not be able to exercise in the park, or wear revealing clothes, it has to be inside. Indoor exercise, with only ladies and a female instructor would be the only way. [Also] having an instructor who understands that religious clothing would still need to be worn when exercising.”For the Somali women, the content also needed to demonstrate an understanding of cultural sensitivities, as this extract shows: “All groups reported that the language used should be simple, non-academic and jargon-free, highlighting the need for the ‘translation’ of the language used in the UK guidelines, which was largely percieved as inaccessible by all four groups. Words such as aerobic, intensity, and sedentary were identified as words to avoid, as demonstrated through these quotes and observational excerpts:“I thought sedentary was some kind of rock.”(Children and young people’s workshop)“Didn’t understand the word aerobic–associated with jumping around in a leotard.”(Older adults’ workshop)“No idea what ‘intensities’ are.”(Adults’ workshop)“Words like moderate, vigorous, intensity, aerobic are scary/frightening.”(Older adults’ workshop)snappy”, “chatty”, “friendly” and “encouraging”, and along with the older adults, recommended using humour. By contrast, some of the Somali women said that more instructive, direct messaging would be necessary to influence motivation to be more physically active. When critiquing the UK guidelines, all groups stated that the message, “some is good, more is better”, struck the right tone.Three of the groups  suggested that messages should be invitational rather than instructive (terminology used by the community artist), avoiding the sense of being told what to do. The children and young people wanted language that was “There was variation between groups, and in some cases within groups, in preferences around the messenger. Whilst all groups highlighted the need for the messenger to be trustworthy and influential, the type of people they believe had these characteristics differed. For example, the Somali women perceived that healthcare and physical activity professionals were key influencers, whereas the children and young people mentioned celebrities, sports stars and YouTubers (many of whom the young people could relate to).“Celebrities were seen as the best messenger of this information. Group believes what celebrities say to them/show them. For example, if they see a celebrity being active or talking about activity, they assume that the celebrity is active themselves.”(Children and young people’s workshop)There were mixed views about celebrities in the adults’ and older adults’ groups, with some finding celebrity endorsement persuasive, whilst others questioned how relatable and trustworthy they are.“If it comes from someone who is really attractive, really fit, you think ‘they don’t work a real job’, you just work out all day, I have got to go to work…I don’t have an army of people doing all my chores.”(Adults’ workshop)“Celebrities are perceived favourably. Noted that it is good to see Serena Williams in the Nike advert, and to see footballers doing work in the community around knife crime…”(Older adults’ workshop)everyday people, people like us.” (Adults’ workshop) and include people of different ages, genders and cultures. Friends and peers were mentioned, in particular, by younger participants and by the older adults and community and social networks by older adults and Somali women.That messengers should be relatable was again a key finding; messengers should represent “The groups suggested that a variety of mechanisms are needed to deliver the message. All groups preferred visual mechanisms, and suggested that multiple mechanisms  be used to both increase the reach of the message (due to seeing the message in many places) and to reinforce the message (due to a consistent message being communicated). Social media channels  were mentioned by all except the older adults. The younger participants also highlighted YouTube, streaming platforms, podcasts, apps and video games as potential vehicles for the message. Adults and older adults mentioned eye-catching posters, on billboards and bus stops and leaflets available in libraries or distributed though schools or in healthcare settings. Utilising local advertising opportunities, such as community noticeboards or newsletters was highlighted by the Somali women in particular. Radio and TV were also mentioned, but with mixed views about their reach. The use of inspiring and emotive personal stories was a suggested mechanism for communication by adults.“Need to have a campaign that can be seen everywhere–in the places that people are . Posters on the bus stops—‘everyone sees bus stops’. Not everyone goes to the doctors, not everyone has a TV. Need to cater for multiple audiences.”(Adults’ workshop)“Some thought TV would be a good place to put the message  but others said they didn’t take much notice of TV.”(Older adults’ workshop)This study explored how members of the public, from under-served areas in Bristol, would prefer physical activity messages, and the new 2019 UK physical activity guidelines, to be communicated to them. The results demonstrate commonalities and differences between the four groups regarding their messaging preferences. We have used our findings to propose several key recommendations for those wishing to communicate physical activity messages to the public, and particularly to groups who are most likely to be amongst the least active in the UK.Getting the content of a physical activity message right is imperative. Our findings indicate that a physical activity message should include the benefits of being physically active, but, as other research suggests, these benefits must go beyond those relating to physical and mental health improvements, to also include social benefits. Across most groups, enjoyment and the opportunity to socialize, were highly regarded benefits of physical activity, and all groups suggested that these benefits are key content for a physical activity message, which Bergeron et al.  and Latineeds” and “wants”. Such segmentation will enable message content to be tailored to the preferences of various population segments. Third, by outlining their perceived benefits of physical activity, participants provided information that can help create an attractive and motivational physical activity message, so much so that it prompts behavior change . Whilst the UK physical activity guidelines and respective infographics use gain framing by including the health benefits associated with increased physical activity, those creating messages in the future should also emphasize the wider benefits of physical activity  which are salient to specific audiences. And lastly, two groups  said that the message should demonstrate how physical activity can fit into people’s daily lives, rather than having to compete for time against other daily priorities. This may increase individual motivation to undertake physical activity [These findings are consistent with framing theory , and higactivity . Many ofactivity  and Wakeactivity .what ‘moderate-to-vigorous’ looks like and how it can be achieved—a finding echoed by others [Another key consideration regarding message content is whether to include the physical activity guidelines in the message . Our findings are consistent with other studies which suggest that the guidelines can appear unobtainable, and therefore their inclusion may be demotivating ,41,42,43y others ,20,27,29sedentary”, “intensity”, and “muscle-strengthening” were not understood by many, and the tone was perceived by all as instructive and/or clinical. Three of the groups believed this tone to be ineffective due to the attached connotations that the message originates from a Government organization. On the other hand, the statement “some is good, more is better” was viewed as simple and understandable, and similar to examples of Latimer-Cheung et al. [We sought to understand what language and tone was appealing to the four community groups within physical activity messages. All groups stated that they wanted simple, jargon-free language to be used, and a tone that does not challenge their sense of autonomy. Whilst the UK guidelines are not intended for public consumption, they often end up being communicated to the public  could be, it was important to all that they were deemed as trustworthy, influential and relatable. Berry et al. , LatimerLastly, our results indicate that the groups had inconsistent preferences regarding the mechanism of delivery. It is likely that some mechanisms may work better than others, linked into the influence and trustworthiness of the messenger, but it also reinforces the need for a comprehensive, multi-modal approach to physical activity messaging . Across the literature, this is a recurrent finding ,43,45,47This study, as part of its aims, set out to create a series of practical recommendations for those who communicate physical activity messages, and the guidelines, to the public. Due to the groups that we worked with, our findings may also be particularly relevant when aiming to develop messages for people who live in under-served communities. This study was designed to capture the views of under-served community groups in Bristol, UK. In doing so, colleagues from ARC West worked in collaboration with KWMC (an arts-led community-based charity) to effectively engage a diverse range of community members. Given that three of the four workshops were well attended, particularly those with younger people and Somali women, suggests that we successfully engaged these groups. This success underlines the importance of carefully co-designing these types of physical activity with community-based organizations. It is unlikely that the sample of participants would have been recruited as efficiently without the expertise of KWMC. Similarly, in working collectively with KWMC, we were able to commission a local art organization, Mufti Games, to help design and deliver the participatory workshops. This three-way collaboration enabled the team to develop creative and novel methods to gather data from workshop participants—a major strength of the study.n = 5)-the reasoning for which is unclear. To understand whether the findings from this workshop were reflective of other older adults in Bristol, we ran a public involvement event (a 2-h conversation guided by the main research questions) with a demographically similar group . Broadly, the information ascertained from the involvement event was in line with that of the study participants, however they suggested that TV was not an important mechanism for physical activity messaging, that celebrities were therefore not an important messenger, and lastly, that improving mobility was also an important benefit to consider. We hope that this public involvement increases the trustworthiness of our findings with regards to the preferences of older adults. Second, we also note that the four groups are not homogenous; a sentiment which members of the older adult’s group also expressed, and we did report several within-group differences in our findings. This limitation reinforces the need for future work to consider the use of segmentation, and to inform this segmentation through high-quality formative evaluation.The study also has two main limitations that should be recognized. First, we had fewer older adults attend their respective workshop than anticipated (Physical activity messaging is an important component of a comprehensive approach to increasing population physical activity levels. However, given that poor physical activity messaging may cause disengagement amongst the public, the need to ensure public resources are well spent on effective communications efforts is pressing. Through working with four community groups, and in hearing the voices of people who may not engage in traditional research methods, our study illustrated how the updated CMO physical activity guidelines can be mobilized to design messages that are aligned with the motivations, experiences and goals of different population groups. We also demonstrated the value of including target recipients in scoping out physical activity messaging preferences; it is suggested that target recipient involvement will improve the outcomes associated with such campaigns. Our findings emphasized the importance of tailoring message content and language to the needs of different audiences, using a wide array of messengers and delivery mechanisms. Although many of our conclusions align with the existing literature base, this study has provided several new insights around physical activity messaging to under-served community groups. We hope that the findings of this study will inform future work around the communications of physical activity and physical activity guidelines.


In scaling up an ultra-rapid genomics program, we used implementation science principles to design and investigate influences on implementation and identify strategies required for sustainable “real-world” services. Interviews with key professionals revealed the importance of networks and relationship building, leadership, culture, and the relative advantage afforded by ultra-rapid genomics in the care of critically ill children. Although clinical geneticists focused on intervention characteristics and the fit with patient-centered care, intensivists emphasized the importance of access to knowledge, in particular from clinical geneticists. The relative advantage of ultra-rapid genomics and trust in consistent and transparent delivery were significant in creating engagement at initial implementation, with appropriate resourcing highlighted as important for longer term sustainability of implementation. Our findings demonstrate where common approaches can be used and, significantly, where there is a need to tailor support by professional role and implementation phase, to maximize the potential of ultra-rapid genomic testing to improve patient care. Despite growing evidence of efficacy, implementation to date has been mostly limited to single academic centers, and most of the reported outcomes have been restricted to diagnostic yield and clinical utility6. Although it is recognized that implementation science principles can be used to cultivate a learning healthcare system7, expediate spread and scaling up of innovation and provide a framework for iterative learning, aiding replication, and planning9, there are concerns that the limited application of such frameworks is hampering efforts to integrate genomics into healthcare10. To overcome this impasse, effectiveness-implementation hybrid study designs11 can be used to evaluate processes and outcomes simultaneously, thereby reducing time to translation of findings into clinical practice. Employing a hybrid design from the outset allows a structured approach to early identification of implementation strategies to match the specific clinical context13, while the evidence base for clinical efficacy continues to grow.Rapid genomic diagnosis can influence the management of critically ill infants and children with genetic conditions14, which facilitates systematized understanding of the influences on the implementation process and can be used to inform implementation strategies. Formed from five domains with 39 underlying constructs 19. This highly coordinated clinical and laboratory program in a public healthcare system delivered laboratory reports with a mean time of 3.3 calendar days (95% CI: 3.2–3.5), with a diagnostic yield of 51%. A high degree of consistency was achieved between the clinical and laboratory sites, with little variability in the duration of each step of the diagnostic pathway . However, there was marked variation in rates of recruitment between sites, and the longest component of the diagnostic pathway remained time from hospital admission to test initiation, resulting in an overall time from hospital admission to genomic result of 17.5 days (95% CI 14.6–21.1)19.We used the CFIR to design a collaborative multi-site network, the Australian Genomics Acute Care program, to deliver ultra-rapid genomic testing across 12 tertiary hospitals and two laboratories in AustraliaHere, we sought to apply implementation science principles and theory to investigate the experience of key professionals involved in delivering the Australian Genomics Acute Care program across multiple sites, in order to examine major influences on implementation and identify future implementation strategies for sustainable ultra-rapid genomics services.20 and state governments21 through a mixture of healthcare funding and investments in major translational genomics projects such as the Australian Genomics Health Alliance.Healthcare in Australia is funded through a combination of public and private sources; about a third of services are private, and two-thirds public. The federal government is responsible for the universal public health insurance scheme and both the state and federal governments fund the local public hospitals and associated services. Clinical genomic testing in Australia is currently funded by the federal22. Leveraging research and operational infrastructure provided by the Australian Genomics Health Alliance, a national genomic medicine initiative20, the Acute Care program scaled up ultra-rapid genomic testing to multiple sites using a Hybrid 223 effectiveness–implementation study design during 2018–19, as evidence of clinical effectiveness increased6. We used the CFIR to design an implementation plan emphasizing communication and feedback, standardized processes, co-ordination, distributed leadership, and collective learning19. This Hybrid 2 study was undertaken with the intention of leading to future “mainstream” implementation as a Hybrid 3 study  across two hospitals in 2016–17, as part of a Hybrid 1 effectiveness-implementation study  and all were interviewed. Participants came from four Australian states (participated/invited): New South Wales (7/18); Queensland (4/6); South Australia (5/8); Victoria (16/29). The disparity in location representation reflects the proportion of patients recruited to the project from each state. Participants varied by professional role (participated/invited): clinical geneticists (10/24); clinical genetics trainee (4/5); genetic counselors (8/11), intensivists (5/7); laboratory scientists (3/11); project officers (2/3). Reporting by professional role does not include the project officers or laboratory scientists, owing to small sample sizes. See Supplementary Table All CFIR domains were reported in the participant interviews, though the Outer Setting was least well represented. The most commonly described CFIR domains across all interviews, indicated by numbers of interviewees or proportion of transcripts dedicated to discussion, were the Inner Setting and Intervention Characteristics. Of particular interest, and providing more nuanced insights, are the constructs that regularly arose across all interviews, regardless of professional role, implementation phase, or location. These CFIR constructs included: “networks and communication”, “implementation leaders”, “culture”, “relative advantage”, and “available resources’.Overwhelmingly the most commonly reported construct centered on networking and developing relationships. Some focused on communication, e.g., “I did think that the kind of email chain [communication as each stage of the diagnostic process was completed] that happened, that was excellent.” [PO1]. Participants also described the development of relationships, e.g., “I think it has really helped us establish a really good relationship with intensivists where we may not have had as close a working relationship with them in the past” [GC7]. However, there were areas that could be improved, “What would help to have a better relationship would be something like weekly genetic rounds in PICU… At the moment it is still there but ad hoc, and it depends a little bit on that level of suspicion from within ICU team, or the genetics team, as to when a geneticist gets involved.” [I4].The agility and success of the program were attributed in part to the program leads, e.g., “I think this is a standout program in a nutshell. It was really the adaptability and the preparedness, whether that’s because of the acuteness of that program, or the leadership—those were the two things which I thought really contributed to this program to be a standout success” [L3]. The extent of the whole multidisciplinary involvement was recognized, e.g., “I know it’s taken a lot of work for lots of other people to get it running that way but it’s been a huge undertaking for the lab people as well as the clinical people and I think the whole process of the Australia-wide leadership team, that’s been incredibly good. They’ve all been really engaged, and it’s moved quickly so I’ve been quite impressed with it.” [CG8].The different cultures within genetic services and intensive care settings were apparent, e.g., from the genetic services: “They’re [intensivists] not as onboard and our [genetic] counselor would say…‘I really need a sample from this child now,’ and the child would have an indwelling collection line… and the nurse would say, ‘I’m not going to do … I need a doctor’s order for that and I can’t get the doctor because the doctor’s busy.’ So, they might have to literally wait hours to get a sample that could actually take two minutes.” [CG10], and from NICU/PICU: “I still have a bit of a feeling that geneticists come very briefly as guests and do their thing and go again. I don’t think they are as much part of our clinical team as I, personally, think they should be.” [I2]. Trust also featured within the “culture” construct, e.g., “They were clearly busting their guts, to get the time frame. You know, you could see [Program Lead] was getting e-mails at 11pm on a Friday and you know 2am on a Saturday. And to be able to quote that back to the family was tremendously helpful. And not only that but to then trust that that would actually be the case.” [GC7].Participants noted the benefit of accessing ultra-rapid testing for acutely ill children in comparison with traditional diagnostic approaches that typically yield results over a period of months or years, e.g., “I can’t see why it wouldn’t be useful. I can’t think of a situation where you wouldn’t want to know that [result] quickly.” [I3], and in particular for decisions about care and for the family “It’s just really nice to have this fast test where you can give a result to people quickly and to be able to make management decisions from that, or at least give a family a diagnosis or a reason why this has happened.” [CGT3].Occasionally discussion around resources focused on the implications for the financial budget, e.g., “We’re looking forward to more rapid answers and without having to impact on our clinical budget.” [CG10], although more commonly centered on the staff resources, e.g., “the time frames were quite tight, so the turn around times require the pathologists just obviously to be ready and have the capacity.” [PO2]. There was also an awareness of the potential for ultra-rapid genomics to alter resource allocation in the healthcare system on a broader scale, e.g., “Obviously, there’s a massive financial side to it, you know. When you stay, when you keep someone alive, for example, for, you know, four to six weeks waiting for an answer, I’ve been in that situation before, so my expectations were that a three to four day turnaround was going to make really significant management changes. There was certainly going to be some babies [where it would] influence withdrawal of care decisions.” [CG5].The CFIR constructs of “networks and communication”, “implementation leaders”, “culture” “relative advantage”, and “available resources“ were found across the interviews. However, findings by CFIR constructs varied by professional role and implementation phase.In addition to the CFIR constructs listed above, clinical geneticists raised the importance of “design quality & packaging” to ensure rapid genomic testing was focused on the family, e.g., the process of informed consent being appropriately tailored to the acute care environment. Although the importance of “networks and communication” was a theme across professional roles, it was an overriding area of discussion for genetic counselors. This professional group stressed the value of developing local and national networks, in person and virtually, for relationship building as key for the long-term compatibility of the program, and also for knowledge transfer. The genetic counselors were highly involved with many of the logistical, patient-facing challenges, such as getting samples to the laboratories and so, perhaps unsurprisingly, also reported “executing” as a strong theme. In addition to some of the constructs common to all professional roles, the intensivists reported “accessing knowledge”, in particular from the clinical geneticists and clinical genetics trainees, to facilitate decision making.24. The success of the project was also determined by “other personal attributes”, including self-motivation and enthusiasm for the provision of ultra-rapid genomics for this patient group.The reported CFIR constructs varied in prominence across implementation phases. Pre-implementation the focus was on the “relative advantage” of using ultra-rapid genomics in providing a timely diagnosis for families with critically ill children. Concerns at this early stage primarily centered around “design quality & packaging” with some apprehension about how compatible the program was with regular clinical activity, in particular how to support staff delivering the ultra-rapid service. Post-implementation “networks and communication” were noted to have played a key role in engagement. The perceived fit of ultra-rapid genomics was, at times, challenged by the “design quality & packaging”, especially in relation to ensuring the service was designed around the families, who are often in a highly distressed state due to the critical nature of the illness in their childLooking to the future and considering the sustainability of the program, participants again noted the importance of “networks and communication”, centering on the building of relationships and developing networks. Open and transparent communication enabled participants to feel engaged with the project. Having the “available resources” of time and appropriate skills was seen as essential to longevity, in particular, those required for counseling,25, the construct “networks and communication” was a recurrent theme. However, there was an evolution from our initial Hybrid 1 effectiveness-implementation study  delivered by a service, treatment or practice. Outcomes include: (1) implementation, i.e., the impact of implementation strategies; (2) service, i.e., the effect on the healthcare system; (3) health, i.e., the effect on clinical or quality of care measures.Before determining appropriate implementation strategies, it is essential to consider the intended outcomes. Used alongside the effectiveness-implementation hybrid modelh32 Fig.  allows a33 with an example of how this may look, complete with the proposed outcome. For example, the clinical geneticists were focused on the intervention characteristics of the design quality and packaging of ultra-rapid genomic testing to ensure it is patient-centered. An implementation strategy of regular audits with feedback would provide transparent feedback on clinical outcomes and provide information on the implementation outcome of effectiveness. In the next iteration of the project, we will compile these approaches into categories 35 to provide a comprehensive range of strategies on which to draw. Stakeholders can then be invited to rate the implementation and feasibility of the potential implementation strategies using concept mapping techniques36.From this study, we have identified a range of implementation strategies, for example, building relationships and maintaining open and transparent communications (“networks and communication”) and revising professional roles to enable staff to take up different responsibilities (“available resources“) and identified relevant outcomes. Table 19. This provides an opportunity to employ and test relevant implementation strategies, drawing on quantitative and qualitative data, while ensuring ongoing clinical efficacy.Future scaling up of the Australian Acute Care Genomics program will progress into a Hybrid 3 design Fig.  as clini37. Sites that declined participation, and those that recruited relatively few patients would provide an interesting group for further study. Qualitative research typically involves relatively lower levels of participants than quantitative research, as it does in this case, but allows more in-depth examination of issues. Worldwide, approaches to implementation vary. This study was undertaken in one country, from a public healthcare system perspective, and so caution may be required when interpreting or applying these findings elsewhere. The CFIR is challenging to apply consistently in practice and is time intensive, potentially delaying the identification of findings and therefore the application of relevant intervention strategies38. Although our interview schedule was intentionally broad and centered on participant perceptions to promote open discussion, there were limited findings related to the CFIR domain Outer setting. This absence does not mean the economic, political, and social context is not relevant, as it may not typically be the immediate focus of participants such as ours. A focus on understanding this area may be of benefit in future studies. In addition, participants in this study were patient-focused and did not report costs as a barrier as costs are covered by the research study. The significance of resource consumption merits further detailed health economic analysis and additional investigation with both policymakers and organizational leads.This study has limitations. Just over half of those invited to participate took part, and we had a clear representation across most professional roles, although there was limited input from the laboratory scientists. All sites participating in the Australian Genomics Acute Care program did so on a voluntary basis, and expressed high levels of implementation readiness prior to study commencement9. Investigating the design and scale-up of ultra-rapid genomic testing in critical care pediatrics across multiple sites using implementation science principles and theory reveals many shared priorities of stakeholders, such as “networks and communication”, where common approaches can be employed. Nevertheless, there are differences specific to professional roles and to implementation phases which will benefit from tailoring of implementation strategies to optimize the potential of ultra-rapid genomic testing. This study of professional perspectives forms an important part of the evaluation of rapid genomic testing in pediatrics and is complemented by parental experiences29 and diagnostic outcomes19. The findings from these three areas will support the further development of robust, context-specific implementation strategies that can be applied and tested as we move towards sustainable healthcare system implementation.Combining implementation science principles, genomic medicine ideals and learning healthcare system concepts is helping shape new models of care by which we can apply the findings from biomedical research and can contribute value to the rapidly evolving healthcare environmentOne year after the Australian Genomics Acute Care program commenced, the implementation leaders at each site identified all operational staff delivering the program, including clinical geneticists, clinical genetics trainees, genetic counselors, intensivists, project officers, and laboratory scientists. These staffs were invited to participate in an interview via email (SB), with up to two follow-up invitation e-mails. Owing to slow uptake by laboratory scientists, the Acute Care program lead (ZS) sent one additional email to this group encouraging them to contact the lead researcher directly. Participation was voluntary and only the lead researcher (SB) was aware of participant identities. Ethical oversight was provided by the University of Melbourne, Department of Pediatrics, Research Ethics Committee (HREC Number: 1646785).39. We designed an open semi-structured interview schedule to investigate perceptions by promoting discussion along with implementation phases. Questions centered on what participants expected before taking part in program delivery, how they thought the Acute Care program would fit into their current practice, reflections following implementation, and their thoughts on sustainability for the future. For consistency, one researcher (SB) undertook all interviews, from April to June 2019, either face-to-face or via telephone, dependent on participant location and preference. The interviews averaged 30 minutes duration, were audio-recorded with participants’ informed verbal consent (we did not take written consent), fully transcribed and managed in NVivo 1240. Transcripts were de-identified, numbered and given a unique classification code by professional role .A cross-sectional, exploratory qualitative approach was used38. Step 1: applying the five overarching CFIR domains, and Step 2: interrogation of each CFIR domain by the underlying constructs. Before coding, the CFIR domains and constructs were mapped to the Australian Genomics Acute Care program (Supplementary Table Interview data were coded in two steps, to overcome established challenges in consistently and efficiently applying the domains and constructs of the CFIRFurther information on research design is available in the Supplementary InformationReporting Summary


Digital instantiations of positive psychology intervention (PPI) principles have been proposed to combat the current global youth mental health crisis; however, young people are largely not engaging with available resources.The aim of this study is to explore young people’s attitudes toward various PPI principles to find ways of making digital instantiations of them more engaging.We conducted an explorative workshop with 30 young people (aged 16-21 years). They rated and reviewed 29 common PPIs. Ratings and recorded discussions were analyzed using thematic analysis.Some interventions were conflicting with young people’s values or perceived as too difficult. Participants responded positively to interventions that fit them personally and allowed them to use their strengths.Values, context, strengths, and other personal factors are entangled with young people’s attitudes toward digital instantiations of PPI principles. We are in the midst of an escalating global youth mental health crisis . Among aThus, mental health promotion needs to be more widely available. Research has indicated that the most efficient way of confronting the crisis is by addressing mental health on a population level, as opposed to individual treatment, and that population-level mental health is best improved by expanding mental health promotion services .health and growth psychology in contrast to low ceiling psychology. In terms of intervention mechanisms, PP is a growing ensemble of diverse evidence-based interventions, which we call positive psychology interventions (PPIs). PPIs are often low in complexity and do not require excessive amounts of time or expert supervision [intervention principles such as forgiveness, mindfulness, and gratitude. Gratitude interventions, for example, have shown to improve life satisfaction, well-being, and positive affect and decrease negative affect [Gratitude Letter, a reflective writing activity that consists of first writing a letter about all the things a person is grateful for toward another person and then delivering this letter [Positive psychology (PP) is the area of mental health research oriented toward mental health promotion. According to Seligman and Csikszentmihalyi , “PP is ervision . These ae affect ,12. To is letter . Accordis letter . Consequs letter ,16.reporting interest in using digital instantiations of interventions, young people engage with such digital instantiations only to a limited degree: research revealed low uptake, low adherence, and low engagement of young people with digital mental health promotion [However, despite these ongoing efforts, and despite young people romotion ,18. A seromotion . Subsequromotion . Existinyoung people age range because it allowed us to have more in-depth discussions, as would otherwise potentially have been the case.To explore this further, we conducted a workshop on young people’s attitudes toward PPI and their underlying intervention principles, with 30 young people aged 16-21 years. We decided on the upper end of the individual reflection and (2) group discussion. During step 1, young people individually read, rated, and provided written statements on instructions for 29 common PPIs (refer to the Methods section for how we selected them). They received descriptions of the interventions, on paper, alongside a series of Likert scale questions to what degree the interventions fit to them personally and a textbox to express their thoughts in more detail. During step 2, they discussed the interventions in groups of 6. Both written and verbal statements were subsequently categorized by emotional valence, that is, as positive, balanced, or negative and coded. We assessed valence to allow a systematic overview of how positive, neutral, or negatively specific PPI were perceived. All collected data informed the construction of themes according to thematic analysis [The research phase consisted of 2 steps: (1) analysis . An overGratitude Letter), the intervention principles , and their digital instantiations . The differentiation between interventions, intervention principles, and digital instantiations aligns with the recent calls to focus on the principles more than specific interventions to produce long-term, reliable insights [We will differentiate between specific PPIs  people would be interested in them. If the issue with nonengagement was rooted in how we translate interventions for digital platforms, then we would not expect to find the same criticism leveled against conventional, nondigital interventions. However, the findings of this study indicate that the issues young people see in digital instantiations of PPI are in fact inherited from their nondigital predecessors. We might not just need to improve the quality of digital interpretations to make them more engaging for young people but might need to reevaluate the appropriateness of their underlying intervention principles.When analyzing our data, we discovered that the criticisms young people had This paper is structured as follows. We first describe how we recruited 30 young people from a German school to participate in the workshop. We then explain how questionnaires and audio recording during the workshop were used for data collection, followed by how we analyzed the data using common statistical methods and thematic analysis. We then discuss the wider implications of our findings for the design of digital interpretations of PPI for young people.This study is part of a project that investigates how technology may be applied for mental health prevention and promotion in young people, especially how digital instantiations may be designed to be engaging for young people. Insights generated from this study will facilitate applied design research, that is, the creation of a digital toolkit to support prevention approaches for young people.We decided to conduct a workshop with young people for the following reasons. Our goal was to investigate young people’s attitude toward PPI; thus, young people would be our participants. Our questions were explorative and open ended; thus, they would best be addressed by predominantly qualitative data. We wanted our participants to speak openly and potentially critically about the subject matter; thus, they should discuss with their peers, reducing the impact of power dynamics between researchers and participants. Finally, we wanted to set up our research in a way that would provide benefits for our participants. Utilizing the multidisciplinary background of our research team, consisting of experts for design, technology, and mental health, we developed a workshop for designing digital instantiations. This workshop explored young people’s attitude toward PPI and allowed them to design their own digital instantiations of intervention principles by learning to apply common industry design and design research methods, such as mood boards, personas, and low fidelity  prototypes. As a location for the workshop, we decided on a rural German high school with a specialization for art and design. The school we chose prepares students for higher education in artistic disciplines, anticipating they would act as creative design partners (as they did). Methods we taught during the workshop were discussed before with local teachers to make them suitable for the curriculum.We first contacted the Department of Science and Education for the State of Saxony in Germany to inquire about the protocol for conducting research in local schools. They provided us with a series of questionnaires aimed at identifying possible harm and possible benefits for students, which could result from our research. On the basis of our answers, we were given permission to proceed with the study. We then contacted a local school. The school administration allowed the workshop to proceed. We then presented the plans for our workshop to the students. The school administration recommended a specific class for which they assessed the most potential benefit from attending the workshop.The workshop took place over 3 days before the start of a school holiday. Students of this class were given the choice of attending the workshop or continuing with their regular lessons. All 30 students opted to attend the workshop. As part of enrolling them into the study, every participant received information about the workshop, had the opportunity to ask questions, was informed about their rights as participants, and subsequently signed an informed consent form. For those aged under 18 years, we also required written consent from their legal guardians. All documents were presented and collected during the workshop. Regarding data collection, we decided against video recording of group discussions because of privacy concerns, given the sensitivity of the topic, that is, mental health, and the nature of our participants, that is, young people .Our workshop had 30 participants, aged 16 to 21 years, with a median age of 18 years and variance of 1.9 years. A total of 50% (15/30) of our participants identified as female, 43% (13/30) identified as male, 3% (1/30) identified as nonbinary, and 3% (1/30) did not self-identify their gender. In terms of nationality, 70% (21/30) identified as German, 10% (3/30) identified as Polish, 3% (1/30) identified as Serbian, 3% (1/30) identified as Taiwanese, 3% (1/30) identified as Malaysian, 3% (1/30) identified as Turkish, and 3% (1/30) identified as Chinese.The workshop was conducted over the course of 3 days and consisted of a research phase and a design phase. The research phase is the focus of this paper and consists mainly of a 120-min long 2-step activity, that is, individual reflection and group discussion. During the subsequent design phase (not a subject of this study), the participants went on to create their own concepts for digital instantiations of PPI principles. The workshop took place in a classroom with nonmovable desks and a maximum capacity of 50. Timeline of the workshop is given in Mindfulness and Gratitude, which was useful when looking for representative PPI from common intervention strategies. We selected interventions based on the following criteria, which we derived from a discussion within our research group:To assemble a suitable selection of interventions, we consulted a web-based database for mental health experts, the Positive Psychology Toolkit . To our offices, coworkers, retirement, or other not age-appropriate concerns, to maximize the likelihood that the interventions would align with the lived experiences of our participants.The interventions should be applicable to school-aged young people, that is, not explicitly reference The interventions should be evidence based, that is, based on peer-reviewed research, to exclude interventions that have not yet been shown to provide benefits.complex interventions that consisted of multiple phases or sessions or multiweek programs, to have descriptions that would be accessible to our participants. Given that there would be limited time during the workshop for our participants to understand how these interventions worked and that our participants did not have professional mental health backgrounds, we focused on interventions with few steps.We excluded We estimated that between 25 and 30 interventions would be ideal, to keep the overall number of interventions low enough so our participants would be able to briefly discuss all of them during a 60-min group discussion. We selected them from 315 PPIs available in the database.We included diverse kinds of interventions, spread across domains  of varying duration (5- to 60-min interventions) and using a variety of modalities , to prompt a diverse range of responses.intersubjectivity through consensus within our group and discussed extensively which PPI to include. We apply intersubjectivity in the sense of Heidegger’s use of the term [After working through the database and applying our criteria, we arrived at a list of 29 interventions that were considered suitable for the context of the workshop . This prthe term . As therlocalized, and it is possible that these cultural assumptions and values have had an impact on our participants’ responses.The interventions offered by the Positive Psychology Toolkit and PP research in general are strongly influenced by Western cultures, in particular US culture. Descriptions of interventions were entirely in English, so was the underlying research, and so was (likely) the native language of most participants of the studies on which the interventions were originally validated. For our context, that is, young people from Germany, one of the researchers in our group translated the intervention descriptions into German and into a reading level that was appropriate for our participants, for example, removing technical jargons that would not be familiar to readers without a background in mental health. However, cultural assumptions and values within the interventions could not be statement any comment that related to how PPIs were perceived; we excluded the descriptions of PPIs and off-topic conversations. Alongside the statements, we also collected Likert scale ratings for all PPIs, which participants made individually during step 1.We collected 146 written responses to interventions from step 1, that is, overall 146 statements the participants wrote on the same sheet of paper on which they rated the interventions. The transcribed group discussions from step 2 resulted in an additional 220 statements, that is, 366 statements overall. We labeled a positive, that is, the participant seemed to like the PPI ; balanced, that is, it was not clear whether the participant liked the PPI or not ; or negative, that is, the participant seemed to dislike the activity . This process was concluded after the fourth iteration because during this iteration, no further changes to the codes seemed necessary. The codes were then written out on post-it notes and grouped by perceived thematic similarities. Over the course of 1 week, codes were moved through different group configurations in search for what seemed their most meaningful combination. The process involved 4 researchers from our group and was accompanied by many discussions to reduce bias.Subsequently, thematic analysis  was led Mindfulness). We identified 3 major clusters, from which the themes were constructed. We deliberately frame this process as a construction, as we follow Braun and Clarke’s [The Likert scale ratings from step 1 and the emotional valence of statements  served for additional sense checking. Likert scale ratings were processed by calculating the median rating for each PPI and correlated with certain strategies , expectation (of participants that the PPI would help them), and fit (to our participants interests). Although there was notable variation in ratings between PPI, within PPI, the 3 aspects  were consistently close (a plot of the data is shown in Step 1 produced 145 ratings (next to 146 written statements)—5 ratings for each of the 29 PPI—consisting of 3 components : Data Analysis section, we coded each statement and categorized the emotional valence of statements as either positive, balanced, or negative. Of the 366 statements, 33.1% (121/366) were positive, 16.7% (61/366) were balanced, and 50.3% (181/366) were negative. An overview of emotional valence expressed toward PPI is shown in By combining 146 written statements from step 1 and 220 group discussion statements from step 2, we arrived at 366 unique statements participants made toward the 29 interventions. As explained in the We constructed 3 themes from step 1  and step 2 . The rating of step 1 served for additional sensemaking, that is, when deciding whether a candidate subtheme sufficiently reflected trends or majority of opinions during the workshop. For example, if one group would have discussed a certain PPI largely negatively, but the overall rating for this PPI was positive, then we would take this discrepancy into consideration. Practically, the ratings largely aligned with the qualitative statements and thus gave us additional confidence about the appropriateness of subsequent themes. The quotes we decided to highlight are canonical examples of common statements during the workshop.The first theme deals with points of tension between youth cultures and values embedded in PPIs. The second theme addresses the possibility of PPI failing and how it may impact young people. The third theme is concerned with the impact of individual differences and preferences on our participants’ attitude toward PPI.good and that lack thereof is thus bad. Forgiveness, for example, may be viewed as something positive within the moral system within which PP is situated but has also been described as a trait symbolic of weakness [inauthenticity, (2) docility, (3) pathologization, and (4) appropriateness.It became evident during the discussions that PPIs have a normative layer and reflect assumptions about desirable behaviors. Strategies involving, for example, gratitude and forgiveness are not morally neutral; instead, they have wrapped into them assumptions about what behaviors are weakness . These mInauthenticity: Our participants were critical of interventions when they pushed toward behaviors that would not have occurred naturally. Performing certain behavior against one’s inclinations was perceived as dishonest. These types of interventions triggered terms related to oppression, such as forcing, dictating, and pushing (Q1.1 to Q1.3).(1) Q1.1: Random Acts of Kindness:I think you ought to be friendly to other people because you like them, and because you yourself are a friendly person, otherwise you force yourself into a shape that is not really you.: Three Loving Connections:Q1.2I think you should spend time with people because you yourself have a personal need for that and not because some plan dictates that you should.: Gratitude Letter:Q1.3For me this definitely wouldn’t work, because, I would feel pushed to write a letter just to make the other person happy, not to actually reflect on the things I’m grateful for.Docility: A range of interventions was criticized for promoting docile behavior. Our participants spoke negatively about interventions that recommended apologizing and being grateful (Q2.1 to Q2.3). Although they considered that some of these behaviors may be sensible in a measured approach, they worried about people being encouraged to lean toward these behaviors beyond a healthy degree (Q2.1). They also perceived some interventions as accusatory because the intervention sounded to them as if they are not already, for example, apologizing enough (Q2.2).(2) Q2.1: Apologizing Effectively:The thing is, when I don’t have confidence anyway, and then I’m expected to apologize for everything, doesn’t that do more harm than good? —Seriously, maybe I apologize already too much. Like, they think you’re a completely egotistical person and that you wouldn’t apologize by yourself. (...) For me, this wouldn’t work.Q2.2: Gratitude Letter:I also see a risk in that. Here, with all these Gratitude things. They say, ok, write up what you are grateful for. And if you can’t think of anything, are you then un-grateful? But what if there actually are no things to be grateful for? Sometimes you just feel bad, sometimes you get treated badly, and then you are supposed to be grateful. It’s like, eat shit and smile. Do you know what I mean? Maybe it needs an un-grateful letter—yeah, to emphasize—to just emphasize all the things that hurt, or that did hurt, or cause problems—and to show that to someone. You hurt me, and I’m not fucking grateful. It’s also easy to say what you are grateful for because people want to hear that, there is no barrier. Telling someone, this hurt me, you were unfair to me, you caused me problems, that is much more difficult. And if it’s then someone who is above you, like a teacher—yeah you may be laughing but I really could write an un-grateful letter like that to one or two teachers here—but then I only get in trouble.Q2.3: Gratitude for Important People:This is like something—I used to go to church as a kid, I had to, and this sounds incredibly preachy, like something my pastor would tell me to do. Maybe this means I’m a bad person, but I actually don’t think I need to act like that.Pathologization: Our participants expressed several times that perceived negative behavior may still lie within the range of healthy functioning and that it does not necessarily need to be corrected (Q3.1 to Q3.3). This also intersected with triggers of negative emotions for some, for example, regarding sports and weight loss (Q3.2). Triggering negative emotions is discussed more in theme 2. It was questioned whether happiness all the time is necessary and said that being happy wouldn’t mean anything if its rooted in superficial reasons, such as antidepressants—a category within which the participant seemingly also placed PPI (Q3.3). .(3) Q3.1: Random Acts of Kindness:You may be mentally entirely healthy, and everything is fine and you’re still just an asshole. Being an asshole doesn’t mean you’re sick or need therapy, it only means you’re an asshole.Q3.2: Initiating Physical Activity:I know I’m a bit overweight, but that also means that I hear all the time that I’m supposed to do more sports. Weight loss may not be what they have in mind with this intervention, but the topic is still a major trigger for me. Some people just do not like to do sports. It’s ok not to like sports. You don’t need to do sports to be a normal healthy person.Q3.3: Chasing Happiness:Must I feel happy all the time? They seem to assume—if you aren’t happy then something surely is wrong with you, so you better try to be happier. Right? It may sound strange, but I think its ok that I don’t feel happy all the time. I may not even feel happy most of the time. If I wanted to feel happy all the time, I could just gobble up some anti-depressant meds, but that wouldn’t really mean anything, would it?Appropriateness: Our participants suggested that the appropriateness of a PPI is bound by its context and that context could provide an anchor to normalize an intervention (Q4.2 to Q4.3). Some interventions made more sense to our participants when placed in relation to special times. Although, for example, gift giving without a contextual anchor could appear strange; the birthday of a friend could constitute such an anchor and thus normalize the intervention (Q4.2). Similarly, one participant stated she would feel uncomfortable if given a Gratitude Letter out of the blue, that is, lacking a contextual anchor, and that she would feel disturbed by it (Q4.1).(4) Q4.1: Gratitude Letter:Imagine you get a letter like that—I’m just saying, out of the blue a buddy walks up to you and gives you one of those letters, I’d be seriously wondering what the hell went wrong with him. I’m always there for my friends, obviously, and sure I’m happy about the occasional “thanks,” but if someone would go through the trouble of writing a letter like that, I probably wouldn’t feel happy, more disturbed.Q4.2: Spending Money on Others:A friend of mine recently celebrated her birthday—I was feeling a bit down at the time, but I got up and got her movie tickets—and I noticed that when I gave them to her, I actually felt better. I thought that was a bit odd at the time, but now I read this, and I think, yeah, that does make perfect sense to me.Q4.3: You, At Your Best:Yeah, so, with this intervention, “You, at your best,” I actually did something like this a while back. When I finished middle school, I noticed that in many ways I wasn’t really happy with myself. So, before I started here, I sat down at home, and just sketched out how I wanted to be—probably didn’t take as much time for it as they recommend here, but essentially the same thing.Discussion section.In summary, our participants highlighted a series of issues related to tensions between their personal values and norms and those imbued in PPI. Culture and context seemed to play relevant roles in determining when an intervention would be appropriate. Wider implications of this theme are discussed in the intrinsic factors, (2) extrinsic factors, and (3) triggering of negative emotions.Our participants were concerned that many interventions harbored the potential to fail and how they would deal with the setback if that would happen. Related to this, they expressed concerns over PPI inadvertently, making them feel worse instead of better. This theme is structured into the subthemes (1) Intrinsic factors: Participants pointed out an inherent degree of difficulty of some PPIs (Q1.1 to Q1.2). They attributed this difficulty to either the intervention itself (Q1.1), own perceived shortcomings (Q1.2), or a lack of experience with PPIs (Q1.3). One participant compared PPIs with yoga exercises, in that experience is necessary for exercises to become easier but that first starting is the most difficult step (Q1.3).(1) Q1.1: Creating Flow Experiences:I also think this is difficult—this is complicated, and not necessarily something that you can do quickly. You first must understand all the steps. You almost have to study in order to understand this.Q1.2: Nonjudgmental Reflection:It would be difficult for me to not have judgmental thoughts.Q1.3: Gratitude Meditation:I mean, I’ve never done anything like this, maybe for someone who does nothing but meditating from dusk ‘til dawn—maybe then that’s easy, but seriously—do you understand this? This may be something like yoga, where you get better at doing the poses over time, but it’s really damn difficult to get started.Extrinsic factors: This subtheme relates to difficulties that are not necessarily rooted in the intervention but in some contingent elements, for example, how other people involved in the intervention may respond (Q2.1 and Q2.3) or potentially falling short of overambitious goals (Q2.2). One participant emphasized that getting a positive response from the receiver of a gift during the Spending Money on Others intervention “may actually make you feel better” (it does [(2) (it does ) but thaQ2.1: Spending Money on Others:If you get the wrong response after giving someone a gift then that doesn’t really help you. But if you get a positive response—A positive response may actually make you feel better, but it could end up being disappointing otherwise.Q2.2: Self-Contract:This “self-contract” thing sounds like new year’s resolutions to me—I’ve been through that with my dad. We planned which grade I should reach in which subject, and then that didn’t work out. And then that was just really depressing. So, what happens if I can’t fulfill the contract? Then I’m just standing there, disappointed.Q2.3: Three Loving Connections:For me, I’d be worried about getting rejected, if I’m honest. I may not be the most social person, and in principle that’s ok for me, but if the goal of this intervention is to meet more people—it says nothing what to do if the people don’t want to meet you though.Triggering negative emotions: This subtheme relates to PPIs being a potential cause, that is, trigger, for negative emotions. Both a focus on negative (Q3.1) and positive (Q3.2) memories could, according to our participants, become a trigger for them. Additional risk was identified in relation to Daily Motivational Awareness, an activity that asks people to reflect on what drives them. One of our participants worried how to reconcile if nothing motivated her, saying that “realizing that would be really depressing for me” (Q3.3). Explicit reference to a PPI being depressing also came up in response to My Gravestone, where people are tasked to reflect on what they would want to be remembered for. The participant noted that this PPI would “put all the focus on dying,” saying that they “don’t want to think about that” (Q3.4).(3) Q3.1: Healing Through Writing:What hurt me? That sounds contra-productive. You are supposed to really think deeply about something that hurt you, and really immerse yourself in that pain? Fuck that shit. I don’t want that—I really don’t want to put a magnifying glass on that. If someone would say, ok, please write this down, then I’d say, piss off, easy as that.Q3.2: The Best Possible Self:I’m just feeling that my memory of my “best self” from the past could lead to the thought that this good time is now over and that I’ve lost something positive. If the response to that would be a clinging to the past, then I don’t think that would be good.Q3.3: Daily Motivational Awareness:What if nothing motivates me? So, what if I do things only because I must do them, but beyond that I cannot find a reason for it? Realizing that would be really depressing for me.Q3.4: My Gravestone:It’s as depressing as it sounds. You put all the focus on dying. I don’t want to think about that. I mean, I understand—it’s supposed to create perspective, ok, but—what I would end up thinking about is dying—and that’s just depressing.Discussion section.In summary, our participants discussed the risk of interventions failing them, either because the intervention itself may be too complicated or because other factors outside of the intervention may not manifest as they should. They also spoke about the issue of negative emotions being triggered by PPIs. Wider implications of this theme are discussed in the impact of personality differences on PPIs and (2) role of modalities within those interventions.This theme deals with individual factors in relation to PPI, that is, factors that are highly subjective, differ between people, and are rooted in tastes and preferences. There are 2 subthemes: (1) Impact of personality differences: Young people are no homogenous group with regards to their interests and preferences, and their individual differences impact how they respond to PPIs (Q1.1 to Q1.4). In some instances, this was explained with reference to personality traits, such as a tendency toward anxiety (Q1.1) or lack of patience (Q1.3). In other instances, participants just noted that an activity would be uninteresting for them, without going into details as to why (Q1.2). One participant who said she was too anxious for meditation referenced an alternative activity that would work better for her, playing soccer (Q1.1). Another participant reflected on a writing-based PPI, saying that she did not have “a talent to write stories like that” (Q1.3). Participants commented positively on PPI, which allowed them to use what they saw as personal strengths (Q1.4).(1) Q1.1: Gratitude Meditation:I personally don’t think this intervention fits to me because I personally am too anxious for meditation. I mean, the goal is to relax, right? I can relax better when playing soccer, or something like that, afterwards I am calm, relaxed.Q1.2: Nonjudgmental Reflection:You know me (name redacted), I don’t need to try this to know that I wouldn’t enjoy this crap at all. Nothing about this is even remotely interesting for me.Q1.3: You, At Your Best:I didn’t particularly like this, because not everyone got a talent to write stories like that; I mean, to formulate this properly (...) I wouldn’t have the patience to sit down, pick something and write it out. For other people this could work, if they had the time and inclination, but for me, or even for most people maybe, this wouldn’t work.: Gratitude Journal:Q1.4Reading an intervention and seeing that it plays off something I’m already good at definitely makes it more likely for me to try it out. The intervention itself may already be difficult, without me having to deal with something I’m bad at on top of that. For example, I just don’t like to write, I’m not good at it, and it frustrates me. So why would I pick an intervention that forces me to write, instead of doing something I’m good at and enjoy?Role of modalities: Participants commented predominantly negatively on writing-based activities, stating that they would rather avoid this modality if possible (Q2.1 to Q2.2). Conversely, music (Q2.2) and photography (2.3) were commented on positively. In relation to music, one participant stated that “when (she) feels bad, (she) listens to music anyway” (Q2.2). In relation to photography, it seemed more important to one participant that there would be some visual options, “doesn’t matter if photos or videos, but something visual would be great for me” (Q2.3).(2) Q2.1: Reframing Critical Self-Talk:What I like about this one—at least you do not have to write anything—always all this writing with these exercises. This shows, it doesn’t have to be writing all the time, you only need to think about it in this exercise, that’s much more pleasant—and if I want to write it down, then I can still do that.Q2.2: Using Music to Express Feelings:Finally, an intervention that fits to me—When I feel bad, I listen to music anyway—and usually it ends up helping me. I was asking myself when finally, an intervention comes up that I like, most things are just about writing.Q2.3: Using Photography to Increase Savoring:Photography would be fun for me—that seems like a great way to store positive memories—doesn’t matter if photos or videos, but something visual would be great for me.In summary, attitude toward PPIs seemed predicated on personal preferences and strengths, partially in relation to personality and partially in relation to which modalities were dominant in a PPI. Writing components were especially criticized.As described in the beginning, previous research had identified a lack of engagement from young people with digital instantiations of PPI and proposed to explain this through how PP principles are usually instantiated digitally, that is, with an overreliance on static context, such as written text. We investigated whether the lack of engagement of young people with digital instantiations may also be rooted in the underlying intervention principles, from which the digital instantiations PPI are derived. The findings of this study support this assumption; we will now discuss the findings in more detail.Steps 1 and 2 of the workshop both explored participants’ attitude toward PPI, part of which was the quantitative rating of interventions and part of which were the qualitative statements about interventions. Both lines of inquiry converged toward the following notable insights.normal behavior. Our data suggest that young people should have a significant choice when it comes to when to apply which PPI, including how to shape the PPI to make it more appropriate for their context.Youth cultures may inform participants’ attitudes toward a PPI, which became visible when values and norms of our participants came into conflict with values and norms embedded in a PPI. Special concern was given to authenticity and a notable aversion toward PPIs that enforced docile behavior or that pathologized what our participants categorized as Young people may see PPIs as potential sources of negative emotions. If they feel that a PPI is too difficult—either inherently or made too difficult by too ambitious goals—then that may become a red flag that keeps young people from engaging with the activity. Further, components in some PPIs may become triggers for negative emotions, for example, a reflection PPI that may bring up negative memories. PPI instructions so far do not seem to take this possibility into account, at least not to a degree that our participants saw as sufficient. Research into how to safeguard PPIs from inadvertently becoming triggers for negative emotions—that is, which kinds of components most likely could become triggers—seems necessary. If we knew which interventions have a higher likelihood of triggering negative emotions, we could, for example, amend them with a suitable warning or not give them out to young people who are, at that point, not stable enough.Individual preferences had a major impact on young people’s attitudes toward interventions. When talking about what they thought about interventions, our participants did so mostly in relation to their own preferences and interests. Although some preferences or aversions were more prevalent than others—for example, a general disdain for writing-based activities and preference for visual- and audio-based instantiations—there was an overall notable diversity in what young people felt appropriate for themselves. This diversity means that there cannot be a one-size-fits-all approach to youth mental health promotion. Instead, choice and customization may be the most relevant goals in any attempt to proliferate digital instantiations of PPI among young people. This may be especially relevant as the cultural context in which an intervention is first validated may not translate to another context, for example, Gratitude interventions have not yet been validated with German youth.players or gamers, that is, those from whom fun had the highest priority; engagers, that is, those for whom support to their well-being had the highest priority but who are open to gamified approaches; skeptics, that is, those who do not see value in digital interventions; and Straight-talkers, that is, those who explicitly do not want any gamified content in their mental health applications. Building on taxonomies like this would allow the creation of more focused strategies, such as how to best address engagers, instead of just aiming at young people in general.One promising way of approaching the complexities of individually varying interests and preferences may be found at the intersection of mental health and games research. Fleming et al  have devSeveral issues brought up by our participants further intersect with ongoing discussions of PPI and underlying intervention principles; we have addressed these issues in the following sections.Our participants were concerned about PPIs potentially making them feel worse, not better. Three possible reasons for this were given: the intervention itself being too difficult, for example, having too many steps; other people responding negatively, for example, an apology being rejected; and interventions triggering negative emotions, for example, by invoking problematic memories.backfiring, as other researchers have called it [Healing Through Writing—asks the person to reflect on a particularly painful memory. However, a 2009 study in the Journal of Abnormal Child Psychology has demonstrated that these types of memories are potential triggers for suicidal ideations in urban youth [The literature on a PPI alled it , is sparalled it . There halled it . One PPIan youth .backfiring. There are 2 possible reasons for this lack of research. First, it could be that PPI rarely go wrong and that our participants were overly cautious of something that in reality does not significantly factor into the application of PPI. If so, then our data at least suggest that the concern of PPIs backfiring is present among young people, which in turn means that PPI instructions should address it. Alternatively, the lack of research into PPI failing may also be an artifact of publication bias; it is possible that PPI studies that encounter significant issues only rarely make it to print. We are not able to say which of those is the case but suggest that it warrants further investigation.Beyond that, there is limited research on PPI The shortcomings of PPIs with regard to individual preferences and modalities line up with the aforementioned study on PP apps for young people , which sperson features, such as preferences and strengths, and intervention features, such as dosage and variety, impact how well a PPI is performed, which in turn impacts the subsequent well-being increase [The impact of personal preferences on effectiveness is increasingly recognized in PP research. The Person-Activity Fit (PAF) model describes how the overlap between increase . Both princrease  and our Gratitude Journal; replace its writing components with audio; and assume that its existing evidence base is not impacted by this translation.Instantiating conventionally text-based PPI for a digital platform could mean an opportunity to reinterpret these interventions to better fit with expectations and needs of young people across various cultures and subcultures. Activities in conventional PPI are mostly predicated on paper, pens, and the material constrictions they come with. For example, a conventional diary entry would not allow a young person to just sit in front of a piece of paper and talk about what is on their mind. For a digital diary, however, accommodating verbal speech is trivial, opening the diary activity to young people who have less affinity to writing. Furthermore, worksheets accompanying PPIs usually present one way of approaching an activity, for example, providing a table and asking the person to fill it in. Digitally, it is possible to provide a range of options to accommodate differences between young people and allow them to choose. As stipulated by Michel et al , there iinside the field [outside of it [Gratitude Letter is the most effective intervention within PP [Gratitude Letter is a widely used successful intervention, we do not know enough about it to confidently instantiate it digitally without losing its effectiveness.The reason why addressing individual preferences and modalities in the context of new digital instantiations of PPI for young people is nontrivial is intimately entangled with one of the most significant gaps in PP research, as has been pointed out from he field  and fromde of it : a lack de of it . For exaithin PP ; the actOverall, to address the issue of young people’s lack of engagement with digital instantiations of intervention strategies, extensive further research is necessary. This includes facilitating the creation of culturally appropriate intervention strategies, exploring risks, and safeguarding strategies relating to PPI and further research into the MOA of the PPI, for example, via microrandomized trials . This wiTyranny of the Positive Attitude [second wave made an explicit effort to conceptually integrate negative emotions, trauma, suffering, mortality, and adversity into a larger positive framework [Healing Through Writing, were criticized as potentially triggering negative emotions (theme 2). Preference toward one or the other may be a matter of individual differences. We suggest that similar future studies with young people include an explicit discussion of happiness to prime aspects of the (presumably) less intuitive notion of eudemonic happiness.Some criticism during the workshop was directed at what our participants felt was too much focus on positive emotions within the PPI they were shown. This criticism mirrors a larger discussion of what has been coined Attitude ,34, a peAttitude  wrote abramework . Thus, tWe will now address some limitations of this study, with regard to the role of our setting , our participants , and how we exposed them to PPI .This paper is based on one workshop with 30 young people from a specific area in Germany; both the number of participants and their cultural context limit the extent to which our findings generalize. Instead, our data serve as a starting point for future explorations into other groups and cultures of young people.Our specific setting  may have been impacted by peer pressure, for example, of not speaking too positively about some kinds of PPI. As the individual ratings from step 1 aligned with opinions expressed during the group discussion in step 2, we do not expect peer pressure to have had a big impact; however, it could have skewed the group discussions. Responses to intervention principles such as kindness, gratitude, and forgiveness, while being around classmates, could have been skewed by teenagers attempting to manage their identity within their social group, for example, trying to conform to gender stereotypes. To alleviate the impact of this, we started with participants responding to PPI individually and in writing, but the setting may have still influenced their responses.Furthermore, although PP is generally considered useful for anyone regardless of underlying mental health problems, previous experience with mental health problems may skew someone’s opinion toward PP. We did not evaluate the mental health status of our participants. As they all have been from the same class and thus share an environment for long periods, it is possible that shared stress factors may have impacted their attitude as a whole in a way that would not show up in another sample from another school.In addition, we noticed during the analysis that many of our participants criticized interventions for not taking negative emotions into account. PP overall recognizes the importance of negative emotions, and when we introduced the topic to our participants, we explained this. However, they still evidently felt that the specific interventions they discussed did not sufficiently account for negative emotions. A different selection of interventions with an explicit focus on negative emotions may have resonated better with our participants.Finally, our participants responded to instructions for PPI, not to first-hand experiences of applying the PPI. It is almost certain that actively applying the PPI would have impacted our participants’ opinions, although it is less certain in which way. For example, when our participants reflected on whether they expected a PPI to help them, their answers were speculative and not necessarily rooted in experience. The attitudes they expressed may not predict if and how they would perceive these interventions in a real-world setting; they might, however, indicate the willingness to try or reject similar intervention strategies outright.To make PP useful for young people, we need to find ways to present the interventions as being suitable for the culture and context of young people, be aware of their degree of difficulty, and find ways of aligning interventions with young people’s personalities and strengths. These adjustments seem to be necessary if we expect young people to engage with digital instantiations of PPI principles. Across all our findings, there was a need for customization and choice. It is possible for young people to select and choose which interventions they feel are most useful to them and to further shape these interventions to their own needs, strengths, interests, backgrounds, values, and context in general. Digital technologies are uniquely suitable to facilitate this kind of freedom; but, as past research has shown, they are not yet delivering on it. Future research needs to identify on a more granular level how components of PPI interact with different types of young people’s personalities, interests, and strengths, to allow the design of useful and engaging platforms, which offer young people both the necessary freedom and scaffolding to create individually ideal PPIs. Specifically, we would like to see more research identifying the MOA of interventions and how these mechanisms may be expressed on digital platforms. If these insights would exist, it would become possible to systematically create digital interpretations of interventions, flexible to individual needs and preferences of young people, while preserving their validated effectiveness.