This project aimed to develop a digital web and mobile phone intervention for reducing Estonian adolescent and young adult alcohol and tobacco consumption. A systematic review was conducted, including a meta-analysis based on 32 randomised controlled trials, to investigate the associations with effectiveness of digital interventions in reducing adolescent and young adult alcohol and tobacco consumption. Digital interventions reduced adolescent and young adult weekly drinking (mean difference = -0.55, 95% CI (-1.04, -0.05), I2=93%) and monthly binge drinking (mean difference = -0.30, 95% CI (-0.55, -0.05), I2 = 75%). Digital interventions increased smoking cessation (risk ratio = 1.70, 95% CI (1.37, 2.11), I2= 35%). A qualitative focus group study with Estonian adolescents and young adults (N=22) indicated a lack of knowledge regarding effects of alcohol and tobacco consumption early in life and a recognition of the difficulty to change alcohol and tobacco consumption. A web and mobile phone based intervention programme was appealing to the focus group participants. The development of the first individually tailored web and mobile phone intervention targeting Estonian adolescent and young adult alcohol and tobacco consumption was undertaken. The content of this intervention was informed by the systematic review and meta-analysis, focus group study, psychological theory, and participatory design. The intervention, called MyOwnMe, is a tailored web program linked to a daily mobile phone text-messaging program. A pilot study with Estonian adolescents and young adults (N=22) indicated feasibility of implementation in Estonia and acceptability of intervention content. No difference was found between the intervention and control group in alcohol (mean difference = -0.2 95% CI (-0.9, 0.6), p = 0.62) or tobacco consumption (30-day abstinence from cigarette smoking RR = 1.25, 95% CI (0.81, 1.94)) after the 8-week study period. Results of this pilot study will be used for recommendations in this thesis on the development of individually tailored web and mobile phone interventions for Estonian adolescents and young adults.

abstract: Many individual-level behavioral interventions improve health and well-being. However, most interventions exhibit considerable heterogeneity in response. Put differently, what might be effective on average might not be effective for specific individuals. From an individual’s perspective, many healthy behaviors exist that seem to have a positive impact. However, few existing tools support people in identifying interventions that work for them, personally. One approach to support such personalization is via self-experimentation using single-case designs. ‘Hack Your Health’ is a tool that guides individuals through an 18-day self-experiment to test if an intervention they choose (e.g., meditation, gratitude journaling) improves their own psychological well-being (e.g., stress, happiness), whether it fits in their routine, and whether they enjoy it. The purpose of this work was to conduct a formative evaluation of Hack Your Health to examine user burden, adherence, and to evaluate its usefulness in supporting decision-making about a health intervention. A mixed-methods approach was used, and two versions of the tool were tested via two waves of participants (Wave 1, N=20; Wave 2, N=8). Participants completed their self-experiments and provided feedback via follow-up surveys (n=26) and interviews (n=20). Findings indicated that the tool had high usability and low burden overall. Average survey completion rate was 91%, and compliance to protocol was 72%. Overall, participants found the experience useful to test if their chosen intervention helped them. However, there were discrepancies between participants’ intuition about intervention effect and results from analyses. Participants often relied on intuition/lived experience over results for decision-making. This suggested that the usefulness of Hack Your Health in its current form might be through the structure, accountability, and means for self-reflection it provided rather than the specific experimental design/results. Additionally, situations where performing interventions within a rigorous/restrictive experimental set-up may not be appropriate (e.g., when goal is to assess intervention enjoyment) were uncovered. Plausible design implications include: longer experimental and phase durations, accounting for non-compliance, missingness, and proximal/acute effects, and exploring strategies to complement quantitative data with participants’ lived experiences with interventions to effectively support decision-making. Future work should explore ways to balance scientific rigor with participants’ needs for such decision-making. / Dissertation/Thesis / Doctoral Dissertation Exercise and Nutritional Sciences 2019

BACKGROUND. Unhealthy lifestyle behaviours such as physical inactivity are global risk factors for chronic disease. Despite this, a substantial proportion of the UK population fail to achieve the recommended levels of physical activity. This may partly be because the health messages presently disseminated are not sufficiently potent to evoke behaviour change. There has been an exponential growth in the availability of digital health technologies within the consumer marketplace. This influx of technology has allowed people to self-monitor a plethora of health indices, such as their physical activity, in real-time. However, changing movement behaviours is difficult and often predicated on the assumption that individuals are willing to change their lifestyles today to reduce the risk of developing disease years or even decades later. One approach that may help overcome this challenge is to present physiological feedback in parallel with physical activity feedback. In combination, this approach may help people to observe the acute health benefits of being more physically active and subsequently translate that insight into a more physically active lifestyle. AIMS. Study One aimed to review existing studies employing fMRI to examine neurological responses to health messages pertaining to physical activity, sedentary behaviour, smoking, diet and alcohol consumption to assess the capacity for fMRI to assist in evaluating health behaviours. Study Two aimed to use fMRI to evaluate physical activity, sedentary behaviour and glucose feedback obtained through wearable digital health technologies and to explore associations between activated brain regions and subsequent changes in behaviour. Study Three aimed to explore engagement of people at risk of type 2 diabetes using digital health technologies to monitor physical activity and glucose levels. METHODS. Study One was a systematic review of published studies investigating health messages relating to physical activity, sedentary behaviour, diet, smoking or alcohol consumption using fMRI. Study Two asked adults aged 30-60 years to undergo fMRI whilst presented personalised feedback on their physical activity, sedentary behaviour and glucose levels, following a 14-day wear protocol of an accelerometer, inclinometer and flash glucose monitor. Study Three was a six-week, three-armed randomised feasibility trial for individuals at moderate-to-high risk of developing type 2 diabetes. The study used commercially available wearable physical activity (Fitbit Charge 2) and flash glucose (Freestyle Libre) technologies. Group 1 were offered glucose feedback for 4 weeks followed by glucose plus physical activity feedback for 2 weeks (G4GPA2). Group 2 were offered physical activity feedback for 4 weeks followed by glucose plus physical activity feedback for 2 weeks (PA4GPA2). Group 3 were offered glucose plus physical activity feedback for six weeks (GPA6). The primary outcome for the study was engagement, measured objectively by time spent on the Fitbit app, LibreLink app (companion app for the Freestyle Libre) as well as the frequency of scanning the Freestyle Libre and syncing the Fitbit. RESULTS. For Study One, 18 studies were included in the systematic review and of those, 15 examined neurological responses to smoking related health messages. The remaining three studies examined health messages about diet (k=2) and physical activity (k=1). Areas of the prefrontal cortex and amygdala were most commonly activated with increased activation of the ventromedial prefrontal cortex predicting subsequent behaviour (e.g. smoking cessation). Study Two identified that presenting people with personalised feedback relating to interstitial glucose levels resulted in significantly more brain activation when compared with feedback on personalised movement behaviours (P < .001). Activations within regions of the prefrontal cortex were significantly greater for glucose feedback compared with feedback on personalised movement behaviours. Activation in the subgyral area was correlated with moderate-to-vigorous physical activity at follow-up (r=.392, P=.043). In Study Three, time spent on the LibreLink app significantly reduced for G4GPA2 and GPA6 (week 1: 20.2±20 versus week 6: 9.4±14.6min/day, p=.007) and significantly fewer glucose scans were recorded (week 1: 9.2±5.1 versus week 6: 5.9±3.4 scans/day, p=.016). Similarly, Fitbit app usage significantly reduced (week 1: 7.1±3.8 versus week 6: 3.8±2.9min/day p=.003). The number of Fitbit syncs did not change significantly (week 1: 6.9±7.8 versus week 6: 6.5±10.2 syncs/day, p=.752). CONCLUSIONS. Study One highlighted the fact that thus far the field has focused on examining neurological responses to health messages using fMRI for smoking with important knowledge gaps in the neurological evaluation of health messages for other lifestyle behaviours. The prefrontal cortex and amygdala were most commonly activated in response to health messages. Using fMRI, Study Two was able to contribute to the knowledge gaps identified in Study One, with personalised glucose feedback resulting in a greater neurological response than personalised feedback on physical activity and sedentary behaviour. From this, Study Three found that individuals at risk of developing type 2 diabetes were able to engage with digital health technologies offering real-time feedback on behaviour and physiology, with engagement diminishing over time. Overall, this thesis demonstrates the potential for digital health technologies to play a key role in feedback paradigms relating to chronic disease prevention.

Avec l’essor des technologies de l’information et de la communication, la société et les organisations se transforment, serecomposent tous secteurs confondus. On appelle communément disruption, le changement de paradigme économique etorganisationnel lié aux TIC, plus précisément, à la digitalisation des processus.Les modes d’échanges entre les hommes ont évolué. Notre mémoire de master 2 (Numérique, recomposition organisationnelles et appropriation des TIC, Gravereaux, 2013) nous aura permis de comprendre que les véritables changements qui opèrent en organisation se situent au-delà des usages des espaces numériques de travail et des outils TIC.Notre thèse s’inscrit dans la continuité de ce travail préliminaire qui nous avait offert de questionner, de manière introductive, quelle pouvait être la portée de la dimension politique dans l’appropriation des technologies numériques.Cette thèse de doctorat a pour but de saisir, d’identifier, d’analyser et de conceptualiser, tant sur le plan théorique que pratique, le processus de transition organisationnelle qui opère dans les établissements de santé traversés par l’informatisation du dossier de soin et par la maturation des Systèmes d’Information Hospitalier. Après avoir compris qu’il fallait dépasser les usages pour comprendre l’appropriation des TIC, nous orienterons nos réflexions et enquêtes de façon à confronter ce point de vue et à lui donner une portée opérationnelle.Les phénomènes communicationnels liés aux changements et aux transformations en organisations constituent un élément central de ces recompositions. Le chercheur doit enquêter pour questionner et saisir ces phénomènes à l’aune de la compréhension particulière d’un établissement de santé.Le regard communicationnel porté sur un espace, un vécu, en transition, tentera de mettre à jour les conditions qui participent de l’appropriation des nouveaux outils liés à la traçabilité des soins : la forme informatisée du dossier patient.Notre thèse de doctorat se propose d’apporter une contribution à des problématiques de recherches actuelles en questionnant l’individu au travail au regard des questions politico-organisationnelles liées à l’appropriation du dossier patient informatisé.Ces acteurs que nous sommes venus « étudié », soignants, médecins, personnels administratif, sont au coeur, vivent, en même temps que l’organisation, ce phénomène de disruption qui affecte l’intégralité du dispositif organisationnel.À partir d’une rupture disruptive, de nouvelles formes d’organisation du travail, liées aux changements de pratiques del’information médicale, apparaissent, émerge des dissonances. De la même façon, pour accompagner cette organisation émergente, les formes et normes de management en santé, sont amenées à se recomposer et donc à se spécialiser.Nous assistons à une recomposition globale de la Santé, dont les composantes du dispositif tendent à faire de la contribution, de la collaboration, de l’autonomie et de la traduction, les nouveaux fondamentaux du management en organisations de santé accompagnant la métamorphose digitale des routines des acteurs. / With the growth of information and communication technologies, society and organizations are transforming, recomposing all sectors combined. The common paradigm shift is to change the economic and organizational paradigm linked to ICT, more precisely, to the digitalization of processes.The modes of exchange between men have evolved. Our Master 2 thesis (Digital, Organizational Reorganization andAppropriation of ICTs, Gravereaux, 2013) allowed us to understand that the real changes that operate in organization arebeyond the use of digital workspaces and ICT tools.Our thesis is part of the continuation of this preliminary work which offered us to question, in an introductory way, what could be the scope of the political dimension in the appropriation of digital technologies.This doctoral thesis aims at capturing, identifying, analyzing and conceptualizing, both theoretically and practically, the process of organizational transition that operates in the healthcare institutions through which the computerization of the care file And by the maturation of Hospital Information Systems. Having understood that we need to go beyond the uses to understand ICT appropriation, we will orient our reflections and investigations in order to confront this point of view and to give it an operational scope.The communicationa phenomena linked to changes and transformations in organizations are a central element of theserecompositions. The researcher must investigate and question these phenomena in terms of the particular understanding of a healthcare institution.The communicative look at a space, a experience, in transition, will try to update the conditions that participate in the appropriation of the new tools related to the traceability of care: the computerized form of the patient record.Our doctoral thesis proposes to make a contribution to current research questions by questioning the individual at work withregard to the politico-organizational issues related to the appropriation of the computerized patient record.These actors, who have come to be "studied", caregivers, doctors and administrative staff, are at the heart of this phenomenon of disruption, which affects the entire organizational system, at the same time as the organization.From a disruptive rupture, new forms of work organization, linked to changes in the practices of medical information, emerge, emerging from dissonances. In the same way, to support this emerging organization, the forms and standards of health management, are led to recompose and therefore to specialize.We are witnessing a global recomposition of health, whose components of the system tend to make contribution, collaboration, autonomy and translation, new fundamentals of management in health organizations accompanying the digital metamorphosis of routines actors.

Complex diseases such as cancer, cardiovascular diseases and diabetes are often diagnosed too late, which significantly impairs treatment options and, in turn, lowers patient’s survival rate drastically and increases the costs significantly. Moreover, the growth of medical data is faster than the ability of healthcare systems to utilize them. Almost 80% of medical data are unstructured, but they are clinically relevant. On the other hand, technological advancements have made it possible to create different  igital health solutions where healthcare and ICT meet. Also, some individuals have already started to measure their body function parameters, track their health status, research their symptoms and even intervene in treatment options which means a great deal of data is being produced and also indicates that patient-driven health care models are transforming how health care functions. These models include quantified self-tracking, consumer-personalized-medicine and health social networks. This research aims to present an open innovation digital health platform which creates value  y using the overlaps between healthcare, information technology and artificial intelligence. This platform could potentially be utilized for early detection of complex diseases by leveraging Big Data technology which could improve awareness by recognizing pooled symptoms of a specific disease. This would enable individuals to effortlessly and quantitatively track and become aware of changes in their health, and through a dialog with a doctor, achieve diagnosis at a significantly earlier stage. This thesis focuses on a case study of the platform for detecting breast cancer at a  ignificantly earlier stage. A qualitative research method is implemented through reviewing the literature, determining the knowledge gap, evaluating the need, performing market research, developing a conceptual prototype and presenting the open innovation platform. Finally, the value creation, applications and challenges of such platform are investigated, analysed and discussed based on the collected data from interviews and surveys. This study combines an explanatory and an analytical research approach, as it aims not only to describe the case, but also to explain the value creation for different stakeholders in the value chain. The findings indicate that there is an urgent need for early diagnosis of complex diseases such as breast cancer) and also handling direct and indirect consequences of late diagnosis. A significant outcome of this research is the conceptual prototype which was developed based on the general proposed concept through a customer development process. According to the conducted surveys, 95% of the cancer patients and 84% of the healthy individuals are willing to use the proposed platform. The results indicate that it can create significant values for patients, doctors, academic institutions, hospitals and even healthy individuals.

Digital consultations in primary care have the advantage of offering equal healthcare for people residing in the countryside. While it is gaining acceptance among young- and middle-aged people, the elderly are reluctant to use it. The aim of this study was hence to identify reasons for non-use among elderly in the countryside and describe perceived possible challenges and opportunities with digital consultations. Semi-structured interviews were conducted with 13 persons over 65 years old residing in the Swedish countryside. There was a mistrust for services offered by private companies and their public funding, a lack of knowledge of available services, and a lack of perceived usefulness. Personal interaction and continuity was more important than time or travel conveniences, although these advantages were recognized. To prevent digital exclusion, caregivers need to offer information, encouragement, or tools for the elderly. Digital primary care also needs to offer familiarity, with continuity and personal connections.

Hearing loss is considered a global health concern with 466 million people affected worldwide. Current hearing health care delivery models are based on several consecutive face-to-face consultations that occur in-person. Information and communications technology, and especially mobile technology, can be used to support or enhance health care delivery. This can be employed in addition, or as an alternative to, current patient treatment pathways. This project developed a hybrid hearing health care approach by combining online and face-to-face services. The services were offered using a five-step approach: (1) online hearing screening, (2) motivational engagement by voice/video calling, messaging, or emailing, (3) diagnostic hearing testing in a face-to-face appointment, (4) counseling, hearing aid trial and fitting using face-to-face and online methods, and (5) online aural rehabilitation, counseling and ongoing coaching using face-to-face and online methods. Three studies were conducted. Study I investigated the readiness, characteristics and behaviors of patients who sought hybrid hearing health care. Over three months (June–September 2017), 462 individuals completed the online hearing screening test: 59% (271/462) of those failed (age M = 60; SD = 12), indicating that further assessment and treatment might be required. These patients had been aware of their hearing loss for a period of between 5 to 16 years. A significant positive correlation was observed between age and speech reception threshold (r = 0.21; p < .001), where older participants presented with poorer scores. Five participants completed readiness measurement scales and attended a face-to-face diagnostic hearing evaluation during this time. Study II investigated patient uptake, experience and satisfaction with hybrid hearing health care using a process evaluation. The process evaluation study was conducted over a three-month period for patients who sought services from the clinic over a period of 19 months (June 2017–January 2019). A total of 46 patients seen at the clinic were invited to complete an online questionnaire regarding their experiences and satisfaction with the steps completed and services provided. Of those, 31 (67%) patients responded (age M = 66; SD = 16). Of the 61% of patients who had previously sought hearing services, 95% reported the hybrid clinic services as superior. Two main themes emerged from the patient’s comparison of their experience with the hybrid clinic versus previous experiences: clinician engagement (personal attention, patience, dedication, thorough explanations, professional behavior, exceeding expectations, friendliness and trust) and technology (latest technology, advanced equipment and hearing aid trial). Patients who completed all five steps, including acquiring hearing aids and taking part in an online aural rehabilitation program (continued with hearing health care), were significantly older and had significantly poorer speech reception thresholds compared to those who did not acquire hearing aids after the diagnostic hearing test and hearing aid trial (discontinued hearing health care). A significant positive correlation was found between age and the number of face-to-face appointments attended per patient (r = 0.37; p = .007). Study III investigated whether digital proficiency (proficiency with mobile devices and computers) was a predictor of the uptake of hybrid hearing health care. A total of 931 individuals failed the online hearing screening test and had submitted their details to the clinic for further care over a 24-month period (June 2017–June 2019). Of the 931 online test takers, 53 persons (age M = 64; SD = 15) who attended a face-to-face diagnostic hearing testing completed a mobile device and computer proficiency questionnaire. An exact regression model identified age as the factor associated with patients completing all five steps, including acquiring hearing aids and taking part in an online aural rehabilitation program (continued with hearing health care) from a hybrid model (β = .07; p = .018). Older patients were more likely to continue to seek hearing health care. Digital proficiency was not significantly associated with adults with hearing loss taking up services through a hybrid hearing health care model. The results from these three studies demonstrate that asynchronous internet-based services such as an online hearing screening test can be used to create awareness of hearing health care. It is possible to provide online support to patients during the initial stages of seeking hearing health care online prior to the first face-to-face visit. Patient uptake, satisfaction and experience of using hybrid hearing health care services are positive when compared to traditional methods of service delivery. Hearing health care models that combine face-to-face and online methods hold promise for audiologists willing to incorporate online modalities into current treatment pathways. This research project highlights the opportunity for audiologists to provide services and personalized support to patients using a combination of face-to-face and online modalities. / Thesis (PhD)--University of Pretoria, 2020. / This work was supported by the National Research Foundation (NRF) of South Africa under the grant number 107728. / Speech-Language Pathology and Audiology / PhD (Audiology) / Unrestricted

In in low-and middle-income countries (LMIC), where there are very few trained physicians and nurses, community health workers (CHWs) are often the only providers of healthcare to millions of people. Such LMIC are countries that are classified, based on their geographic region and Gross National Income (GNI), as low-middle income by the World Bank Group, the worlds largest development bank. Research has shown digital health tools to be an effective strategy to improve the performance of frontline line health workers. The aim of this review was to systematically examine the literature on digital health tools that are used for decision support in LMIC and describe what we can learn from studies that have used these tools. As part of a larger parent study the following databases were searched: PubMed, Embase, Scopus, CINAHL, Global Health Ovid, Cochrane and Global Idex Medicus, to find ariticles in the following domains: training tools, decision support, data capture, commodity tracking, provider to provider communication, provider to patient communication and alerts, reminders, health information content. These domains were selected based on the World Health Organisation (WHO) framework for classifying digital health interventions. Content from all seven of these domains informed a series of reviews however this review focuses on how digital tools are used to provide decision support to FLHWs. Included studies were conducted in LMIC in Africa, Asia, North America and South America with the most common users of the tools being CHWs. Most tools for FLHW decision-support used in the interventions described in included articles were in either the pilot or prototype phases, and offered maternal and child health care services. Although decision support was the primary digital health function of all these studies, there was considerable variation in the number of digital health functions of each tool with most studies reporting decision support and data capture as their primary and secondary functions respectively. All the studies found their intervention to have beneficial effects on one or more of the following outcomes: beneficiary engagement, provider engagement, health effects and process/outputs. These findings show great potential for the use of decision support digital health tools as a means of improving the outcomes of health systems through; reducing the work load of FLHWs, reducing the costs of health care, improving the efficiency of service delivery and/or improving the overall quality of care.

The World Health Organization (WHO) has forecast a global shortage of health workers by 2030, predominantly affecting low- and middle-income countries (LMICs). This sits in tension with the United Nations’ (UN) Sustainable Development Goal 3 (healthy lives and well-being) through universal health coverage (UHC). To address this problem, the WHO encourages task shifting, recruitment, training, and deployment of health workers. In lowand middle-income countries (LMICs), frontline health workers (FLHWs) are responsible for expanding the reach of the health system and providing crucial reproductive, maternal, newborn and child health (RMNCH) services. Adequate and appropriate training is fundamental to the success of FLHWs, particularly in contexts where their scope of work may evolve or expand over time. Digital health solutions (defined as the use of digital, mobile and wireless technologies to support the achievement of health objectives) are increasingly being used to support the training of FLHWs. Strategies may rely on use of digital tools, including mobile phones, as the primary modality for training or as tools which augment traditional face-to-face instruction. Digital health has potential for FLHW training as it allows for listening, learning and teaching through interactive health content accessible even on basic mobile phones. This dissertation explored the literature on FLHWs in LMICs, digital health in LMICs, digital health used by FLHWs, and digital health used for training of FLHWs in LMICs. The journal “ready” component is a systematic review which discusses the various aspects of digital training for FLHWs in LMICs. For the purposes of the systematic review, seven electronic databases were searched for articles published in English from 2008-2018. Combinations of medical subheadings (MeSH) that were used were: “mHealth”, “health worker”, “community health worker” and “low- and middle-income country”. From a total of 2628 identified studies, abstracts were screened with four filters to identify studies about “training”, and eventually a total of 16 studies were included. The included studies were critically appraised and coded descriptively to enable a narrative synthesis of findings. Of the sixteen studies, twelve used mobile and/or smartphones for FLHW training. A wide range of digital platforms were used to provide information (and where relevant enable interaction). Duration of training programs varied from five days to six months. Training content was relevant to the various health services and practice areas the FLHWs worked in. Training focused on continuing education through in-service training of new content or in-service refresher courses. Three training pedagogies were used: 1) didactic training techniques – in four studies information was provided passively without an interactive component; 2) interactive training techniques – six studies used platforms to provide information along with an interactive component via multi-media; and, 3) blended-learning approach – six studies delivered training via didactic and interactive approaches by combining live and distance training. Consistent with the literature review, all studies reported increased knowledge and positive perceptions of digital health for FLHW training. Interactive and blended learning approaches, especially when accessed through mHealth technologies, are feasible, effective, appropriate, cost effective and scalable in LMICs. The conclusion from the literature and systematic reviews were that long-term effects (e.g. change in behaviour, improved service provision) need to be researched further.

Healthcare is facing a major transformation driven by digitalization and the shift of responsibility to the individual patient level. Digital health enables significant improvements in terms of efficiency, effectiveness and quality of healthcare. This dissertation provides a framework, which underlines the relevance of combining innovation and process management in the healthcare system. The current and future state of research and practice of promising technologies, their benefits and their challenges were elaborated. Moreover, approaches for integrating suitable and emerging digital health technologies in existing healthcare infrastructure were investigated, in particular the motivation and acceptance of different stakeholders and users. The dissertation contributes recommendations for science, government, and healthcare actors by elaborating the concept of patient-centricity and process improvement.