Development of the web application My Stress Control—Integrating theories and existing evidence

Figures & data

Figure 1. Flowchart of the development process.

Figure 2. A paper version of the programme designed in Power Point (an example showing the psychoeducation section) (in Swedish). In the left column, a menu for personal information. In the right column, divided into two tabs, my stress (Min Stress) and my exercises (Min Träning).

Table 1. Structure of My Stress Control (MSC) and content regarding how information is presented, stress management strategies, life-style change and behaviour change techniques included as well as coding according to the behavior change technique taxonomy (v1) (Michie et al., 2013)

Structure of MSC	Content	The included behaviour change techniques and coding	Clarification of content
Log in and security	The log in page informs the users of the origin, affiliation, ownership of MSC, as well as last update. All communication to and from the application is encrypted using Secure Sockets Layer (SSL). IP addresses failing to log in to the system are banned after a certain number of failures.	Credible source (9.1).	A university is presented as the “owner” of the MSC which could account as a credible source.
Targeting	Stress-level is screened with the Perceived Stress Scale 14 (PSS-14) (Cohen et al., 1983; Cohen & Williamson, 1988). Depression and anxiety are screened with the Hospital Anxiety and Depression Scale (HADS) (Zigmond & Snaith, 1983)	None.
Introduction	Film: How to navigate in MSC. Film: Introduction to MSC (rationale for the MSC). The Symptoms of Stress Survey (SySS)	Credible source (9.1).	The research team is presented as the programme developers. The rationale for the MSC states how much time is demanded, information about surveys, e-mail reminders, feedback and confidentiality. The information is provided to the users in text, films and audio. In the end of the introduction the users will get access to the SySS. When completed first time the survey steers the user to the Advices on Sleep Module if needed later in the programme, and also provides a baseline for feedback on how symptoms of stress changes during the programme.
Psychoeducation (Van Daele, Hermans, Van Hudenhove, & Van Den Bergh, 2012)	Film: What is Stress? Film: The ABC-model and how it can help the user understand her/his stress. Document: Examples of how to formulate an ABC-model Assignment: Formulate an own ABC-model (Kushnir, Malkinson, & Ribak, 1998) The Symptoms of Stress Survey (SySS)	Self-monitoring of current behaviour (2.4). Information about antecedents (4.2). Information about health consequences (5.1). Salience of consequences (5.2). Information about emotional consequences of stress (5.6).	Includes what stress is, how it develops, risks with long term stress and possibilities to reduce stress. The users are taught how to analyse their own stress related behaviour according to the ABC-model. After completing the ABC-model the users once again will complete the SySS stating (Yes or No) regarding symptoms in relation to the ABC-model. The Yes-statements can be sorted with the one most troubling first.
Tailoring (Kreuter et al., 1999)	The tailoring for each individual is based on the user’s choices is in three different parts: 1. As a result from the first SySS the module Advices to sleep better will or will not be recommended. 2. From the second SySS different stress management strategies are recommended in relation to the presented symptoms and in relation to the ABC-model. The users will be recommended some strategies but will have access to all. 3. Within the modules for the stress management strategies, the user’s state whether they are ready to change their behaviour according to SoC regarding the specific stress management strategy.	None.	Stress management strategies connected to the Yes statements in SySS will determine the recommendation of strategies. Regarding the SoC the users will answer questions on how ready they are to start the specific strategy. The programme can steer the user in three directions. They can be led to an ambivalence module, start the module or, if they are in maintenance stage for the current stress management strategy, to continue further in the programme.
Ambivalence (Norcross, Krebs, & Prochaska, 2011)	Film: Ambivalent towards changing Assignment: To reflect over pros and cons for change of the own behaviour.	Information about health consequences (5.1). Compare pros and cons for starting practicing (9.1). Comparative imagining of future outcomes (9.3). Identity associated with changed behaviour (13.5).	This module appears for users stating not ready for starting with a stress management technique.
Stress management strategies	The programme includes the following stress management strategies: Relaxation (Jacobson, 1987; Ponce et al., 2008) Time-management (Häfner & Stock, 2010) Cognitive restructuring (Welbourne, Eggerth, Hartley, Andrew, & Sanches, 2007; West, Horan, & Games, 1984) Pleasant activity scheduling (Mazzucchelli et al., 2010) Assertiveness training (Galassi & Galassi, 1978; Imamura et al., 2014) All the stress management strategies include: Short rationale of the module in text Readiness for change questions Film: A short film/animation with information on how to perform the behaviour and an extended rationale for each stress management technique Goal setting and a plan for the assignments Specific assignments associated with each strategy: Some assignments are time-locked for a predetermined number of days before next assignment opens up. SySS	Goal-setting for the behaviour (1.1). Problem solving (1.2). Action planning (1.4). Self-monitoring (2.3). Self-monitoring of outcome(s) of behaviour (2.4). Instruction on how to perform a behaviour (4.1). Information about health consequences (5.1). Information about social and environmental consequences (5.3). Monitoring of emotional consequences (5.4). Graded tasks (8.7). Self-incentive (10.7). Self-reward (encouraged) (10.9). Reduce negative emotions (11.2). Self-monitor outcome of body changes (relaxation) (12.6).	What to expect regarding estimated time for the module, assignments included and how the technique is related to stress management strategies are described. After taking part of the description the users will take a stand to each recommended stress management strategy according to SoC. The repeated measures of stress related symptoms provide feedback on outcomes in a line chart. All behaviour change techniques are not included in every stress management strategy.
Ambivalence for lifestyle change	See ambivalence.	See ambivalence.	This module appears for users stating not ready for starting with a lifestyle change
Lifestyle change relevant for stress related problems	The programme includes the following lifestyle changes related to stress management: Advices for better sleep, and sleep restriction (Thiart, Lehr, Ebert, Berking, & Riper, 2015) Physical activity (Lindegård, Jonsdottir, Börjesson, Lindwall, & Gerber, 2015; Lindwall, Gerber, Jonsdottir, Börjesson, & Ahlborg, 2013) Both lifestyle change strategies include: Short rationale of the module in text Readiness for change questions Film: A short film/animation with information on how to perform the behaviour and an extended rationale Goal setting and a plan for each module Specific assignments associated with each strategy: Some assignments are time-locked for a predetermined number of days before next assignment opens up. SySS	Goal-setting for the behaviour (1.1). Problem solving (1.2). Goal setting (outcome) for sleep (1.3). Action planning (1.4). Self-monitoring (2.3). Self-monitor outcome of the behaviour (2.4). Instruction on how to perform a behaviour (4.1). Information about health consequences (5.1). Information about social and environmental consequences (5.3). Demonstration of behaviour (physical exercise) (6.1). Graded tasks (8.7). Self-incentive (10.7). Self-reward (encouraged) (10.9). Reduce negative emotions (stress management) (11.2). Body changes (physical exercise) (12.6).	The modules for lifestyle changes follow the same structure as the stress management strategies. See Stress management strategies. All users will receive the physical activity module.
Maintenance module (Norcross et al., 2011)	Film: To maintain good habits Assignment: Summary of the own work in MSC Film: The meaning of social support in stress management training (Paech, Luszczynska, & Lippke, 2016) Assignment: Problem solving to obtain social support Assignment: Behavioural contract Assignment: My own recipe for stress management when/if stress-related problems returns Assignment: Planning for maintenance (Paech et al., 2016) PSS-14 SySS Evaluation of satisfaction with the programme	Behavioural contract (1.8). Social support (unspecified) (3.1). Social support (practical) (3.2). Social support (emotional) (3.3).	The films include rationale for the last part of the programme respectively how to seek social support is related to stress management rehearsal. Evaluation of satisfaction is graded on an 11-point Likert Scale. Low satisfaction leads to advice where to find more support for stress-related problems.
Feedback	Feedback is integrated in the whole programme Feedback depending on frequency of logins are provided Feedback on outcome at the end of every stress management strategy and life-style changes with SySS through diagrams and flowcharts Feedback on outcome at the end of the programme with PSS. Booster e-mail is sent to the user four weeks after the completed programme.	Problem solving (1.2). Feedback on behaviour (2.2). Self-monitoring of outcome (2.4). Feedback on outcome (2.7).

Abbreviations: MSC, My Stress Control; PSS, Perceived Stress Scale; HADS, Hospital Anxiety and Depression Scale; SySS, Symptoms of Stress Survey; SoC, Stages of Change

Figure 3. A screen dump from the change negative thinking module as an example of the structure (in Swedish). In the left column, the two tabs my stress and my exercises are placed under two menus. Overview function of current module in the centre. Personal information in a drop-down menu in the top right corner. This screen dump shows the introduction and psychoeducation under my stress (Min Stress) and shows the available stress management strategies under my exercises (Min Träning).

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