Introduction: Prevalence of chronic conditions continues to rise in North America. Despite the lack of evidence supporting their use, patient contracts are commonly used by medical professionals to manage such conditions. To date, literature reviews on patient contracts has been limited to randomized controlled trials, with specific purposes and limited populations. The purpose of this study is to describe ‘for what’ and ‘how’ medical contracts are being used for the management of chronic medical conditions. Methods: In order to capture and describe the breadth of knowledge around medical contracts in the literature, a scoping review was conducted. This inclusive approach allowed for analytic reinterpretation of research activity, gaps in the literature to be identified and further avenues of inquiry to be opened. Database searches included Medline, EMBASE, AMED, PsycINFO, Cochrane, CINAHL and Nursing & Allied Health. Results: A total of 7,528 articles resulted from the original search. Seventy-six articles were included in the final review. Multiple types of studies were represented with limited follow-up durations. Extensive variety was seen for contract target population, clinical setting and co-interventions. Purposes for initiating contracts included: 1) behavior change and skill development, including goal development and problem solving; 2) altering beliefs and knowledge, including motivation and perceived self-efficacy; 3) improving interpersonal relationships and role clarification; 4) improving the quality and process of chronic care; and 5) altering objective and subjective health indices. In relationship to how contracts are used, their development, application of behavioral theory, inclusion of patient input, training for their use and implementation processes were inconsistently described. Conclusion: More research is required to determine if contracts are capable of accomplishing their intended purposes. Questions remain regarding their rationale, development and implementation. / Thesis / Master of Public Health (MPH) / Rates of chronic medical conditions continue to rise in North America. To manage such conditions, medical professionals commonly use patient contracts, defined as any type of agreement by which one or both parties agree to a set of behaviors related to the care of the patient. The purpose of this study is to describe ‘for what’ and ‘how’ medical contracts are being used for the management of chronic medical conditions. A scoping literature review was undertaken. Extensive variety was seen in the literature for contract target population, clinical setting and co-interventions. Purposes for initiating contracts included: 1) behavior change and skill development; 2) altering beliefs and knowledge; 3) improving interpersonal relationships; 4) improving the quality and process of care; and 5) altering objective and subjective health indices. Contract development and implementation processes were inconsistently described. More research is required to determine if contracts are capable of accomplishing their intended purposes. Questions remain regarding their rationale, development and implementation processes.

This thesis consists of two sections, the first of which is a systematic review of selfreport measures of mindfulness. The review aims were to evaluate the psychometric properties of each of the identified measures and examine their utility for research and clinical practice. Definitions of mindfulness were central to the differences found between measures, and as such this review also provides an overview of how mindfulness has been conceptualised in the literature. This review has been presented in the format required by the journal, Clinical Psychology Review. The second section is a meta-analysis which examines the efficacy of mindfulnessbased stress reduction (MBSR). Mindfulness-based interventions are increasingly being applied in a range of settings and the evidence base is growing. Specifically, this review aimed to determine the effectiveness of MBSR on quality of life for people suffering from chronic physical health conditions. The methods and results of the meta-analysis are described in detail, followed by a discussion of the findings. A more concise overview is then provided as a journal article, in the format required by the British Journal of Clinical Psychology. The guidelines for submission to both journals are included in Appendix 1 and 2 respectively.

Background: Whilst the experience of chronic physical conditions is well documented and has been recognised as relevant for health policy and practice little is known about notions of recovery and prognosis from the point of view of those with long-term physical health conditions. The extent to which people consider the future outcomes of their conditions is relevant to health policy which seeks to engage people in shared decision making, care plans, and self-management. This gap in knowledge about lay perceptions of recovery and prognosis becomes more pronounced when compared with literature from the mental health field in which recovery is one of the dominant foci, is comparatively well researched and in recent years has fed into policy and management approaches.Aims: The aim of the thesis is to explore perceptions of recovery and prognosis with people with long-term physical health conditions and to compare these with perspectives on recovery and prognosis apparent in the mental health field.Methodology: Using qualitative methods, a two phased approach to data collection and analysis was undertaken. Phase 1 used secondary data analysis with two existing datasets to examine whether notions of recovery and prognosis were implicit in narratives about the experience of illness. Phase 2 built on the findings from phase 1 and utilised longitudinal, primary data collection in the form of narrative interviews undertaken at two time points (baseline and 12 month follow-up). The analysis in both phases involved a cross case thematic analysis to look for commonalities and differences across individuals. Data from phase 2 were also subject to a narrative emplotment of individual stories which were used to capture the longitudinal changes in patient perspectives over time.Results: There were similarities with findings from the mental health field (recovery as a complex, nonlinear journey, the input from friends and family, notions of burden and the impact of condition on sense of self). However, there were nuanced differences in relation to physical health conditions which related to expectations about mortality, the experience of time, the extent to which narratives were future oriented and the experience of stigma. The dual focus on mental and physical health recovery proved useful for understanding those experiences of multiple morbidities. The results were used to develop a model of recovery narratives based on two dimensions (expectations and responsibility) which gave rise to four typologies of narratives. The aim of this model was to further highlight and summarise the themes arising from the data analysis.Discussion: The results of this study highlight the importance of understanding notions of recovery and prognosis in order to better understand the experience of illness and self-management. The thesis challenges the blanket use of health promotion strategies for those with and without chronic health conditions and supports a shift in policy focus from improved choice and autonomy to what Mol (2009) refers to as ‘enhanced care’.

Obesity is a dangerous health condition affecting approximately 30% of all Americans and can be attributed to 300,000 deaths a year. Obesity has been found to disproportionately affect Blacks, Latinos, and those with lower SES. Although obesity is a problem for all age groups, its prevalence is highest among those 60-74 years of age. Studies have shown that there is an association between obesity and chronic conditions such as cardiovascular disease, arthritis, cancers, and type-2 diabetes. According to the Centers for Disease Control, chronic health conditions affect 80% of all elderly persons, many times limiting function and decreasing quality of life. This study attempted to find a relationship between obesity and chronic conditions among 1,053 elderly living in Philadelphia and 1,648 elderly living in Bucks, Chester, Delaware, and Montgomery counties. This study also examined the risk for having a chronic condition associated with living in Philadelphia compared to living in the four surrounding counties. Data from the 2002 Household Survey conducted by the Philadelphia Health Management Corporation was used to examine the relationship between obesity and chronic conditions and it was found that obesity was significantly related to having a chronic condition among elderly in both the city and suburbs. Specifically, obesity was related to diabetes, asthma, arthritis, and heart conditions for persons over 60 living in the city and suburbs with an additional association with allergies for elderly living in the city. It was also found that living in the city of Philadelphia was significantly associated with a 50% increased chance for diabetes among persons 60 and over. Future research should first be conducted to design a BMI scale that reflects the decrease in muscle and bone mass associated with aging. After a new scale is devised, research should continue to further investigate the association between obesity and various chronic conditions in the elderly.

Indiana University-Purdue University Indianapolis (IUPUI) / Medication nonadherence among middle-aged to older adults with chronic conditions often stems from forgetting to take or fill medications as prescribed. A pilot study indicated the feasibility of technology acceptance model (TAM)-based smartphone medication reminder app (SMRA) training as a way to promote their app use and medication adherence. This dissertation assesses the viability and effect size of the modified TAM-based SMRA training in promoting app use and medication adherence, as well as its delivery design in preparation for a larger efficacy study. A two-group pretest-posttest design was employed. Twenty-nine adults aged over 40 years and taking medications for chronic condition management were recruited from Midwestern university and community sites. The training group (n = 15) received the modified TAM-based SMRA training; whereas the non-training group (n = 14) self-navigated app features. The training group reported significantly higher levels of perceived usefulness, perceived ease of use, positive subjective norm, and intention to use the app. In addition, the training group reported a higher proportion of active app use than the non-training group. Modified TAM-based SMRA training was not viable in increasing the levels of medication adherence variables. Effect sizes suggested at least 52 participants as a sample size for a larger efficacy study. Participants suggested that training could be improved by scheduling separate group training for iPhone and Android phone users, providing a live online training option, providing small group training with peer helper, tailoring training length to participant preference, and working with family members and healthcare providers as co-trainees and co-trainers.

As the population of older adults in the US increases so do their rates of chronic disease (CDC, 2020). There is limited availability of occupational therapy led health promotion programs for older adults despite being shown to prevent and/or manage chronic disease while helping them thrive (Berger et al., 2018; Cassidy et al., 2017; Clark et al., 2012; Smallfield & Lucas Molitor, 2018b). Factors contributing to limited programming include lack of training for occupational therapy practitioners in preventive health (Metzler et al., 2012), occupational therapy having little recognition as a provider in preventive care amongst health professionals (Halle et al., 2018), and lack of referrals and reimbursement for occupational therapy services in preventive care (Hildenbrand & Lamb, 2013; Metzler et al., 2012). ageWISE is an innovative evidence-based preventive occupational therapy program developed to improve the mental and physical health of older adults. The six-month program develops participant efficacy in optimizing self-selected health behaviors through topics including fall prevention, sleep and rest, ADL performance, socialization, and navigating healthcare technology by utilizing a blend of didactic lecture, experiential learning, peer discussion, goal-setting, and journaling. Comprised of eight in-person group-based sessions and two telephone-based individual sessions, all ageWISE sessions are led by an occupational therapy practitioner and supported by an occupational therapy doctoral student. ageWISE is positioned to not only improve the health of older adults but to expand the reach of occupational therapy in a setting where its value is a necessity…preventive care.

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Chronic Obstructive Pulmonary Disease (COPD) and Congestive Heart Failure (CHF) are conditions that represent significant and ongoing medical costs, including frequent emergency department (ED) visits, hospitalizations, work absences, and disability. This retrospective cross-sectional study, examined the effects of the frequent ED visits due to COPD and CHF on the beneficiaries of Medicare and Medicaid in Maryland. The goal was to identify the factors that led these patients to visit the ED, the impact of these visits on Medicare utilization and costs across Maryland, and preventative intervention strategies to control this population's costs of care. Secondary data were analyzed from 2010-2012 using the Administrative Claims Data in Chronic Condition Warehouse (CCW). The results for the first research question revealed that an increase in the number of primary care physicians was correlated with a decrease in ED visits; thus, persons living in areas with higher PCPs also had lower ED visits therefore the first null hypothesis was rejected (Ï?2 = 3.85, p=.05) . The results for the second research question revealed that ED visits had no significant relationship with death in a given year; thus, patients may be diverted to less expensive care sites to minimize cost and ED overcrowding, therefore the second null hypothesis was not rejected (Ï?2 = 0, p=.98). In both cases, the confounding variables of gender, age, and race had significant effects upon the relationship. Health Professionals and policy makers may use the findings to develop strategies to increase supply of PCPs, adapt patient centered interventions and modify existing chronic disease care strategies to minimize or prevent lifestyle and environmental factors that affect chronic disease outcomes. Such improvements could contribute to positive social change by eliminating or reducing the overcrowding that occurs in emergency departments in Maryland and other states.

Children with chronic conditions often participate in therapy, but there is little information about how often or for how long therapy services should be provided. Participatory action research (PAR) methods were utilized in this study and, therefore, involved both parents and occupational and physical therapists throughout the study. Parental interviews were conducted to understand parent perception of self-management and how parents felt their child’s therapist was doing or could do to facilitate self-management, particularly as it related to discharge planning or having their child take a break from ongoing therapy. Through analysis of parent interviews completed by the therapist team and additional parent feedback on priorities for change, there were several concerns parents identified as being important to them when thinking about long-term therapy planning. A shared decision making tool and supporting documents were subsequently developed and tested as a method for enhancing collaborative conversations between the parent and therapist regarding a long-term therapy plan for the child. During follow-up parent interviews, parents were able to clearly voice long-term goals or a long-term plan for their child’s therapy, and they had a more positive reaction to the idea of taking a break from ongoing therapy services. Use of PAR methodology in this study was effective in allowing parents and therapists to co-create a change that both parents and therapists identified as an improvement (during follow-up interviews with parents and a focus group with therapists).

Population ageing has been taking place all over the world, being estimated that 2.1 billion people will be aged 60 or over in 2050. Healthcare Supportive Home (HSH) Systems have been proposed to overcome the high demand of remote home care for assisting an increasing number of elderly people living alone. Since a heterogeneous team of healthcare professionals need to collaborate to continually monitor health status of chronic patients, a cooperation of pre-existing e-Health systems, both outside and inside home, is required. However, current HSH solutions are proprietary, monolithic, high coupled, and expensive, and most of them do not consider their interoperation neither with distributed and external e-Health systems, nor with systems running inside the home (e.g., companion robots or activity monitors). These systems are sometimes designed based on local legislations, specific health system configurations (e.g., public, private or mixed), care plan protocols, and technological settings available; therefore, their reusability in other contexts is sometimes limited. As a consequence, these systems provide a limited view of patient health status, are difficult to evolve regarding the evolution of patients health profile, do not allow continuous patients monitoring, and present limitations to support the self-management of multiple chronic conditions. To contribute to solve the aforementioned challenges, this thesis establishes HomecARe, a reference architecture for supporting the development of quality HSH systems. HomecARe considers HSH systems as Systems-of-Systems (SoS) (i.e., large, complex systems composed of heterogeneous, distributed, and operational and managerial independent systems), which achieve their missions (e.g., improvement of patients quality of life) through the behavior that emerges as result of collaborations among their constituents. To establish HomecARe, a systematic process to engineer reference architectures was adopted. As a result, HomecARe presents domain knowledge and architectural solutions (i.e., architectural patterns and tactics) described using conceptual, mission, and quality architectural viewpoints. To assess HomecARe, a case study was performed by instantiating HomecARe to design the software architecture of DiaManT@Home, a HSH system to assist at home patients suffering of diabetes mellitus. Results evidenced HomecARe is a viable reference architecture to guide the development of reusable, interoperable, reliable, secure, and adaptive HSH systems, bringing important contributions for the areas of e-Health, software architecture, and reference architecture for SoS. / O envelhecimento da população é um fenômeno mundial e estima-se que no ano 2050, 2,1 bilhões de pessoas terão 60 anos ou mais. Sistemas de casas inteligentes para o cuidado da saúde (em inglês Healthcare Supportive Home - HSH systems) têm sido propostos para atender a alta demanda de serviços de monitoramento contínuo do número cada vez maior de pacientes que vivem sozinhos em suas residências. Considerando que o monitoramento do estado de saúde de pacientes crônicos requer a colaboração de equipes formadas por profissionais de várias especialidades, é fundamental que haja cooperação entre sistemas eletrônicos de saúde (por exemplo, sistemas de prontuário eletrônico ou sistemas de atenção de emergência), sendo eles externos ou internos à residência. Entretanto, as soluções de HSH existentes são comerciais, monolíticas, altamente acopladas e de alto custo. A maioria delas não considera a interoperabilidade entre sistemas distribuídos e exteriores ou internos à residência dos pacientes, como é o caso de robôs de companhia e monitores de atividade. Além disso, os sistemas de HSH muitas vezes são projetados com base em legislações locais, na estrutura do sistema de saúde (por exemplo, público, privado ou misto), nos planos de cuidados nacionais e nos recursos tecnológicos disponíveis; portanto, a reusabilidade desses sistemas em outros contextos é não é uma tarefa trivial. Em consequência, os sistemas de HSH existentes oferecem uma visão restrita do estado de saúde do paciente, são difíceis de evoluir acompanhando as mudanças no perfil de saúde do paciente, impossibilitando assim seu monitoramento contínuo e limitando o suporte para o paciente na autogestão de suas múltiplas condições crônicas. Visando contribuir na resolução dos desafios apresentados, esta tese estabelece a HomecARe, uma arquitetura de referência para apoiar o desenvolvimento de sistemas de HSH de qualidade. A HomecARe considera os sistemas de HSH como Sistemas-de-Sistemas (do inglês Systems-of-Systems - SoS) (ou seja, sistemas grandes e complexos formados por outros sistemas heterogêneos, distribuídos e que apresentam independência em seu gerenciamento e operação), que cumprem suas missões (por exemplo, melhoria da qualidade de vida do paciente) mediante o comportamento que emerge resultante da colaborações entre seus sistemas constituintes. Para estabelecer a HomecARe, foi adotado um processo sistemático que apoia a engenharia de arquiteturas de referência. Como resultado, a HomecARe contém o conhecimento do domínio, bem como soluções arquiteturais (por exemplo, padrões arquiteturais e táticas) que são descritas usando os pontos de vista conceitual, de missão e de qualidade. A HomecARe foi avaliada por meio da condução de um estudo de caso em que a arquitetura de referência foi instanciada para projetar o DiaManT@Home, um sistema de HSH que visa apoiar pacientes diagnosticados com diabetes mellitus na autogestão de sua doença. Os resultados obtidos evidenciaram que a HomecARe é uma arquitetura de referência viável para guiar o desenvolvimento de sistemas de HSH reusáveis, interoperáveis, confiáveis, seguros e adaptativos, trazendo importantes contribuições nas áreas de saúde eletrônica, arquitetura de software e arquiteturas de referência para SoS.