Encouraging breath: increasing out-of-session DMHI engagement using a shape-changing biofeedback physicalization within a longitudinal RCT

Abstract

Out-of-session or “homework” engagement is a primary limiting factor in clinical mental health outcomes. Despite weekly practitioner contact, adherence to prescribed Digital Mental Health Interventions (DMHIs) typically drops by 96.1% within two weeks. We evaluate Ankor, a handheld shape-changing biofeedback physicalization, as an adjunct to standard audio-guided mindfulness. In a longitudinal randomized controlled study (N=69), participants were assigned to Ankor+audio or audio-only control across six weekly 15-minute laboratory sessions, with optional DMHI use between sessions. Relative to control, Ankor yielded a 351% increase in total DMHI practice initiations and, by week 2, maintained 29.4% active users versus 2.9% in control, indicating substantially higher out of-session engagement and reduced early disengagement. These findings demonstrate the capacity of shape-changing biofeedback physicalizations to extend adherence to DMHIs, highlighting kinaesthetic interactions as a promising design pathway for sustainingengagement in mental health interventions.

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ORCID for Ben Ainsworth: orcid.org/0000-0002-5098-1092

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