Workflows are a well-established concept for describing business logics and processes in web-based applications and enterprise application integration scenarios on an abstract implementation-agnostic level. Applying Business Process Management (BPM) technologies to increase autonomy and automate sequences of activities in Cyber-physical Systems (CPS) promises various advantages including a higher flexibility and simplified programming, a more efficient resource usage, and an easier integration and orchestration of CPS devices. However, traditional BPM notations and engines have not been designed to be used in the context of CPS, which raises new research questions occurring with the close coupling of the virtual and physical worlds. Among these challenges are the interaction with complex compounds of heterogeneous sensors, actuators, things and humans; the detection and handling of errors in the physical world; and the synchronization of the cyber-physical process execution models. Novel factors related to the interaction with the physical world including real world obstacles, inconsistencies and inaccuracies may jeopardize the successful execution of workflows in CPS and may lead to unanticipated situations. This thesis investigates properties and requirements of CPS relevant for the introduction of BPM technologies into cyber-physical domains. We discuss existing BPM systems and related work regarding the integration of sensors and actuators into workflows, the development of a Workflow Management System (WfMS) for CPS, and the synchronization of the virtual and physical process execution as part of self-* capabilities for WfMSes. Based on the identified research gap, we present concepts and prototypes regarding the development of a CPS WFMS w.r.t. all phases of the BPM lifecycle. First, we introduce a CPS workflow notation that supports the modelling of the interaction of complex sensors, actuators, humans, dynamic services and WfMSes on the business process level. In addition, the effects of the workflow execution can be specified in the form of goals defining success and error criteria for the execution of individual process steps. Along with that, we introduce the notion of Cyber-physical Consistency. Following, we present a system architecture for a corresponding WfMS (PROtEUS) to execute the modelled processes-also in distributed execution settings and with a focus on interactive process management. Subsequently, the integration of a cyber-physical feedback loop to increase resilience of the process execution at runtime is discussed. Within this MAPE-K loop, sensor and context data are related to the effects of the process execution, deviations from expected behaviour are detected, and compensations are planned and executed. The execution of this feedback loop can be scaled depending on the required level of precision and consistency. Our implementation of the MAPE-K loop proves to be a general framework for adding self-* capabilities to WfMSes. The evaluation of our concepts within a smart home case study shows expected behaviour, reasonable execution times, reduced error rates and high coverage of the identified requirements, which makes our CPS~WfMS a suitable system for introducing workflows on top of systems, devices, things and applications of CPS.:1. Introduction 15 1.1. Motivation 15 1.2. Research Issues 17 1.3. Scope & Contributions 19 1.4. Structure of the Thesis 20 2. Workflows and Cyber-physical Systems 21 2.1. Introduction 21 2.2. Two Motivating Examples 21 2.3. Business Process Management and Workflow Technologies 23 2.4. Cyber-physical Systems 31 2.5. Workflows in CPS 38 2.6. Requirements 42 3. Related Work 45 3.1. Introduction 45 3.2. Existing BPM Systems in Industry and Academia 45 3.3. Modelling of CPS Workflows 49 3.4. CPS Workflow Systems 53 3.5. Cyber-physical Synchronization 58 3.6. Self-* for BPM Systems 63 3.7. Retrofitting Frameworks for WfMSes 69 3.8. Conclusion & Deficits 71 4. Modelling of Cyber-physical Workflows with Consistency Style Sheets 75 4.1. Introduction 75 4.2. Workflow Metamodel 76 4.3. Knowledge Base 87 4.4. Dynamic Services 92 4.5. CPS-related Workflow Effects 94 4.6. Cyber-physical Consistency 100 4.7. Consistency Style Sheets 105 4.8. Tools for Modelling of CPS Workflows 106 4.9. Compatibility with Existing Business Process Notations 111 5. Architecture of a WfMS for Distributed CPS Workflows 115 5.1. Introduction 115 5.2. PROtEUS Process Execution System 116 5.3. Internet of Things Middleware 124 5.4. Dynamic Service Selection via Semantic Access Layer 125 5.5. Process Distribution 126 5.6. Ubiquitous Human Interaction 130 5.7. Towards a CPS WfMS Reference Architecture for Other Domains 137 6. Scalable Execution of Self-managed CPS Workflows 141 6.1. Introduction 141 6.2. MAPE-K Control Loops for Autonomous Workflows 141 6.3. Feedback Loop for Cyber-physical Consistency 148 6.4. Feedback Loop for Distributed Workflows 152 6.5. Consistency Levels, Scalability and Scalable Consistency 157 6.6. Self-managed Workflows 158 6.7. Adaptations and Meta-adaptations 159 6.8. Multiple Feedback Loops and Process Instances 160 6.9. Transactions and ACID for CPS Workflows 161 6.10. Runtime View on Cyber-physical Synchronization for Workflows 162 6.11. Applicability of Workflow Feedback Loops to other CPS Domains 164 6.12. A Retrofitting Framework for Self-managed CPS WfMSes 165 7. Evaluation 171 7.1. Introduction 171 7.2. Hardware and Software 171 7.3. PROtEUS Base System 174 7.4. PROtEUS with Feedback Service 182 7.5. Feedback Service with Legacy WfMSes 213 7.6. Qualitative Discussion of Requirements and Additional CPS Aspects 217 7.7. Comparison with Related Work 232 7.8. Conclusion 234 8. Summary and Future Work 237 8.1. Summary and Conclusion 237 8.2. Advances of this Thesis 240 8.3. Contributions to the Research Area 242 8.4. Relevance 243 8.5. Open Questions 245 8.6. Future Work 247 Bibliography 249 Acronyms 277 List of Figures 281 List of Tables 285 List of Listings 287 Appendices 289

Type 2 diabetes is a life-threatening condition, and it is rapidly growing in the world. If patients receive adequate education and support, they can manage their diabetes-related tasks effectively and reduce the severe complications of this disease. However, traditional self-management education and practices were not very effective in stimulating behaviour change and addressing patients’ diversified needs and expectations. Mobile text messaging is a promising method for type 2 diabetes self-management as it can provide continuous and customized support to these patients. However, there is a lack of knowledge about the optimal approach to designing and delivering mobile text messages. Hence, this dissertation aimed to define effective message strategies for mobile text messaging interventions targeting type 2 diabetes self-management. This manuscript-based dissertation consists of three complementary studies. The first manuscript includes a systematic review and a meta-analysis of tailored mobile text messaging interventions on type 2 diabetes self-management. It examines the tailoring strategies, message content, and structure and identifies the moderators of effectiveness in these interventions. The second manuscript includes a systematic review and a meta-synthesis of qualitative evidence on patients’ experiences and perspectives of mobile text messaging studies. The third manuscript consists of a prospective qualitative study to explore the text messaging design and delivery preferences of patients. In the first and second studies, the comprehensive search strategy included major electronic databases, key journal searches, and hand searches of the reference lists of related systematic reviews and meta-analyses. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines and Cochrane Collaboration's guidelines and recommended tools were used for data extraction, risk of bias and critical appraisal assessments, data analysis and reporting. Within a social marketing framework, the third study included semi-structured interviews and a thematic analysis of the main findings. In the first manuscript, 13 eligible trials were included for the systematic review and 11 eligible trials were further analyzed in the meta-analysis. This study concluded that tailored mobile text messaging interventions could improve glycemic control in patients with type 2 diabetes. The subgroup analyses revealed the importance of some moderators such as message delivery, message direction, message frequency, and using multi-modalities. In the second manuscript, the systematic review included 14 eligible studies, and the thematic synthesis included 13 eligible studies. Patients emphasized the importance of tailored text message design and delivery. They felt “supported” by using text messaging and improved their communication with family/friends and care providers. Mobile text messaging increased patients’ self-awareness, knowledge and control of diabetes. The third study explored that mobile text messages could be more effective if they are gain-framed and written in a standard format. Patients favoured the text messages that included simple and direct tone and provided statistical evidence. The findings demonstrated patients’ needs and expectations for advanced tailoring strategies in both message content and delivery. Together, the manuscripts fill a significant gap and inform research and practice for the development of more effective message strategies that could lead to reducing the spread of type 2 diabetes worldwide. / Graduate / 2022-05-12

Bakgrund: Hjärtsvikt är en kronisk sjukdom som är bland den vanligaste orsaken till sjukhusinläggning i Sverige. Egenvård är en viktig del av behandlingen vid hjärtsvikt. Syftet med egenvården är att underhålla eller återhämta hälsa och livskvalitet samt att förebygga försämring och hantera sjukdomen. Syfte: Syftet med studien var att undersöka om egenvårdsutbildningar förbättrar livskvaliteten för personer med hjärtsvikt. Metod: Totalt inklulderades tio empiriska artiklar med kvantitativ metod. Databassökningen för artiklarna genomfördes i Cinahl och Pubmed. Efter sökningen kvalitetsgranskades, analyserades och sammanställdes dessa.   Resultat: Litteraturstudiens resultat visade att i åtta av tio studier hade deltagarna en signifikant förbättrad livskvalitet efter genomförd utbildning. Studierna mätte effekten av interventionerna med hjälp av olika mätinstrument för livskvalitet och studien varade mellan tre till tolv månader. Majoriteten av egenvårdsutbildningarna som inkluderade en sjuksköterska hade en signifikant förbättring på livskvaliteten.  Konklusion: Enligt litteraturstudien kan olika egenvårdsutbildningar förbättra livskvaliteten för en person som lever med hjärtsvikt. Sjuksköterskan har en viktig roll när det handlar om att sprida kunskap, information och ge råd för att hjärtsviktspatienter ska kunna förbättra egenvården. Framtida forskning bör utföras på längre interventioner för att utvärdera hur livskvaliteten påverkas på lång sikt. / Background: Heart failure is a chronic disease and is one of the main reasons for hospitalization in Sweden. Self-care is an essential part of the treatment for people with heart failure. The purpose of self-care is to maintain or restore health and quality of life and also to prevent deterioration and handle the disease. Aim: The purpose of this study was to explore if self-care programs improved quality of life for people with heart failure. Methods: A total of ten empirical articles with a quantitative method were included. The database search was conducted in Cinahl and Pubmed. The articles were quality reviewed, analyzed and compiled after the search. Results: The result of the study showed that the participants had a significant improvement in quality of life, after the intervention, in eight out of ten studies. The effects of the interventions were calculated by different measurements for quality of life and the study lasted for three to twelve months. Most of the studies that included a nurse improved quality of life significantly.  Conclusion: According to the study, different self care educations can improve quality of life for people living with heart failure. Nurses have an important role when it comes to spread knowledge, give information and advice to heart failure patients to improve self-care. Future studies should be performed on longer interventions to evaluate the long-term effects on quality of life.

Objective: Transfer from pediatric care into the adult health care system is known to be a vulnerable phase in the lives of youth with special health care needs (YSHCN). Recommendations from the literature favor assessment of transition readiness rather than simply pass over YSHCN from pediatric to adult-centered care by the age of 18. Nevertheless, no validated and disease neutral assessment instrument in German exists to date. Hence, our aim was to cross-culturally adapt and to pilot-test a German version of the Transition Readiness Assessment Questionnaire (TRAQ 5.0). We wanted to provide a tool that can be applied broadly during the health care transition (HCT) process of YSHCN. Methods: The development included translating and adapting TRAQ 5.0 to German and conducting a pilot-study with 172 YSHCN between the ages of 14 and 23. Results: Cross-cultural adaptation resulted in the TRAQ-GV-15. Exploratory factor analysis led to a 3 factor-structure. Internal consistency for the overall score was good with a Cronbach’s alpha of 0.82. Age, in contrast to sex, had a significant effect on the TRAQ scoring. The administration of the TRAQ-GV-15 was well received and demonstrated good feasibility. Conclusion: The TRAQ-GV-15 is an easily applicable and clinically usable instrument for assessing transition readiness in German speaking YSHCN prior to HCT.

Bakgrund Ungdomstiden är en utmanande period då identiteten skapas. Att leva med typ 1 diabetes (T1D) och utföra egenvård under denna period i livet kan upplevas påfrestande. Sjuksköterskan har således en betydande roll som stöd för ungdomar vid egenvård. Syfte Att beskriva ungdomars upplevelse av egenvård vid typ 1 diabetes. Metod Litteraturöversikten har baserats på tolv vetenskapliga artiklar hämtade från databaserna CINAHL och PubMed. Artiklarna har kvalitetsgranskats enligt granskningsmall och dataanalys har genomförts. Analysen resulterade i två huvudkategorier; Att utföra egenvård självständigt; Omgivningens påverkan på egenvård. Resultat Ungdomar upplever att utförandet av egenvård ofta resulterar i psykiska och fysiska påfrestningar. Egenvård är speciellt utmanande i sociala kontexter då de är rädda för omgivningens reaktioner. Ungdomar vill ta ansvar och utföra egenvård självständigt utan hjälp från familjen och sociala nätverk. Dock uppskattar de att få stöd vid speciellt utmanande situationer. Slutsats Ungdomar upplever en konstant rädsla för att anses vara ”onormal” vilket är en stor anledning till att egenvården brister. Ungdomar vill utföra egenvård självständigt men upplever att de behöver mer kunskap. Omgivningen behöver skapa sig en uppfattning om ungdomens livssituation för att kunna ge stöd och främja god egenvård. / Background The adolescence is a challenging period in life when the personal identity is created. To live with type 1 diabetes and practice self-management of blood sugar levels during this period can be stressful. Nurses therefore plays an important role as support for adolescents’ when practicing self-management. Aim To describe adolescents’ experience of self-management in type 1 diabetes. Method The result of this literature review is based on twelve scientific articles downloaded from the databases CINAHL and PubMed. Article underwent a quality assessment before dataanalysis took place. The analysis resulted in two main categories; To practice selfmanagement independently; Relationships influence on self-management. Results Adolescents’ experience psychological and physical distresses when practicing selfmanagement. Practicing self-management in social contexts are especially challenging since adolescents might fear the reactions from the surroundings. Adolescents’ wants to take responsibility and practice self-management independently, although they appreciate support from their social network during challenging situations. Conclusions Adolescents´ lives with a constant fear of being different, which is a significant reason why self-management fails. Adolescents´ wants to practice self-management independently but experiences that they need more knowledge. Surrounding people need to get informed of the adolescents’ life circumstances to be able to support and promote self-management.

For children with hearing loss, spoken language development often requires the use of hearing aids. Young children often have to rely on their parents or other adults to confirm that their hearing aids are functioning correctly; however, less than 50% of parents check their child’s hearing aids every day. Because of the significant likelihood that a hearing aid malfunction could go unnoticed, it is recommended that children learn hearing aid self-management skills in elementary school and become independent with these skills by middle school. Using the ICF Model of disability, self-management skills should include more than just hearing aid skills, but also skills such as self-advocacy; these can be grouped under one umbrella as “hearing loss self-management skills”. Pediatric self-management skills are associated with improved outcomes for other complex health conditions and have been shown to be responsive to pediatric-focused interventions. While there have been studies to design engaging ways of increasing these hearing loss self-management skills in adults, few have involved children. This study seeks to answer the following two research questions: the first, “What are the baseline hearing loss self-management skills in middle school-aged children?”; the second, “Are educational videos an effective way to increase hearing loss self-management skills in middle school-aged children?”. To answer the first question, children between the ages of 11 and 14 who use at least one hearing aid were asked to answer questions based on the Audiology Self-Advocacy Checklist – Middle School (ASAC-MS) on a scale of “Never/Rarely/Sometimes/Almost all the Time”, to observe their baseline self-reported skills. To answer the second question, a playlist of seven narrated videos with subtitles and visible faces for lipreading was created to address the different topics of the ASAC-MS. The participants were asked to watch these videos and answer the ASAC-MS again. While data collection is not complete, the research team anticipates that most participants will rate their skills in the Rarely or Sometimes categories in the pre-intervention ASAC-MS, and anticipates that the post-intervention ASAC-MS scores will be higher than the pre-intervention ASAC-MS scores. Answering these two research questions is an important step in identifying the needs of current young hearing aid users and identifying ways to meet these needs. Improved hearing loss self-management skills may result in improved speech and language for children with hearing loss in the future.

This study examines physical activity intervention outcome measures in children with Type 1 Diabetes (T1D). Additionally, it explores medical and psychosocial outcomes. Five databases (CINAHL, PsycINFO, MEDLINE, PubMed, Scopus) were used in this study. The selection of articles was done by using exclusion and inclusion criteria. The articles chosen for this study were restricted to those written in English and had to be peer-reviewed and published between 2012 and 2023. Besides, the focus was on quantitative studies. Six articles were eligible to be used in this study. Intervention types, durations, and outcome measurements have been reported. Results showed that the length of intervention should be more than twelve weeks to see the actual effect of interventions.  Additionally, while an effect of physical activity on glycemic control was observed, generalizable psychosocial outcomes could not be obtained. In future research, to reach generalizable conclusions, the sample of this study should be expanded. Also, in addition to clinical data, getting psychosocial data can provide helpful insights. It can offer tips to improve participants' quality of life.

Classroom management is a common challenge in middle schools. Class-wide Function-Related Intervention Teams (CW-FIT) is a multi-tiered intervention designed to decrease problem behaviors at the classroom level (Wills et al., 2010). It is comprised of evidence-based practices such as teaching classroom expectations, increasing teacher praise, and using positive reinforcement in an interdependent group contingency. CW-FIT has shown promise in a variety of school settings, but it has not been tested in middle school art classrooms. This was initial investigation examining the effects of CW-FIT using a single-subject ABAB design in two middle school art classrooms. Results indicated that class on-task behavior increased by more than 25% and teacher praise-to-reprimand ratios more than doubled during CW-FIT implementation, compared to baseline levels. Results also indicated that on-task behavior for students identified as at-risk for emotional/behavioral disorders improved by more than 18% during the intervention. Teachers and students found the intervention to be socially valid. Results indicate promising implications for using CW-FIT in other middle school art classrooms.

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