Over 43.5 million Americans provide informal care to a fast-growing elderly population in the United States. Informal care allows care-recipients to remain functional members of society. However, research suggests that the demands of informal care can negatively impact the health of caregivers. For example, caregiver burden increases the risk for poor health in caregivers compared to non-caregivers. Caregiving research is on the rise, but the dynamics of informal care in active retirement communities remains widely unexplored. To provide adequate services to lessen caregiver burden and improve the Quality of Life (QoL) of informal caregivers, the various settings in which informal care is delivered must be evaluated. Aiming to understand the needs of informal caregivers and the protective factors against caregiver burden in active retirement communities, data from the USF Health and The Villages study, conducted from October 2011 and March 2013, were analyzed. Data from twenty-nine focus groups (N=144) was used to explore the challenges faced by seniors in a caregiver role and the availability of resources that decrease caregiver burden. The primary focus was informal care and the challenges associated with the caregiver role; findings revealed a great need for caregiver relief and limited information on existing resources is available to informal caregivers. Consistent with existing literature on caregiver burden, having no personal time, financial burden, physical demands, and poor health were commonly identified as the biggest caregiving challenges. However, findings strongly suggest that the unique structure of The Villages community encourages high social support that may be the strongest protective factor against caregiver burden in the community.

Research endeavors on spoken dialogue systems in the 1990s and 2000s have led to the deployment of commercial spoken dialogue systems (SDS) in microdomains such as customer service automation, reservation/booking and question answering systems. Recent research in SDS has been focused on the development of applications in different domains (e.g. virtual counseling, personal coaches, social companions) which requires more sophistication than the previous generation of commercial SDS. The focus of this research project is the delivery of behavior change interventions based on the brief intervention counseling style via spoken dialogue systems. Brief interventions (BI) are evidence-based, short, well structured, one-on-one counseling sessions. Many challenges are involved in delivering BIs to people in need, such as finding the time to administer them in busy doctors' offices, obtaining the extra training that helps staff become comfortable providing these interventions, and managing the cost of delivering the interventions. Fortunately, recent developments in spoken dialogue systems make the development of systems that can deliver brief interventions possible. The overall objective of this research is to develop a data-driven, adaptable dialogue system for brief interventions for problematic drinking behavior, based on reinforcement learning methods. The implications of this research project includes, but are not limited to, assessing the feasibility of delivering structured brief health interventions with a data-driven spoken dialogue system. Furthermore, while the experimental system focuses on harmful alcohol drinking as a target behavior in this project, the produced knowledge and experience may also lead to implementation of similarly structured health interventions and assessments other than the alcohol domain (e.g. obesity, drug use, lack of exercise), using statistical machine learning approaches. In addition to designing a dialog system, the semantic and emotional meanings of user utterances have high impact on interaction. To perform domain specific reasoning and recognize concepts in user utterances, a named-entity recognizer and an ontology are designed and evaluated. To understand affective information conveyed through text, lexicons and sentiment analysis module are developed and tested.

This ethnographic study was conducted among the riverine people, also known as Ribeirinhos, in the state of Amazonas, Brazil, during four months of field research. The study focused on learning from Ribeirinhos’ experiences and practices of malaria. In this thesis, I argue that paying attention to Ribeirinhos’ experiences and diagnostic, treatment, and control practices of malaria can provide useful insights into blind spots in the current interventions to control the disease in Brazil. As this is a thesis by publications, the findings are presented in three manuscripts. The first manuscript focuses on how malaria is experienced by Ribeirinhos. It explores the embodiment of malaria, empirical strategies to distinguish it from other febrile sicknesses, misalignment between bodies and current biomedical diagnosis methods, “becomings” of bodies and experiences, and the vicissitudes of having the disease. The second manuscript examines experiences and treatment practices for vivax malaria highlighting the uses of pharmaceuticals, side effects of antimalarial drugs, and traditional treatments for malaria. The third manuscript describes Ribeirinhos’ perceptions of malaria-carrying mosquitoes, their everyday practices to manage these beings, and their experiences with control interventions, such as time monitoring recommendations (TMR), indoor residual spraying (IRS), and insecticide-treated nets (ITN). The three manuscripts clearly show that Ribeirinhos' lives are thoroughly entangled with Amazonian rivers and forests; malaria also takes part in these entanglements. Learning from their experiences and practices of malaria has provided information about the nuances, improvisations, and continuous negotiations required to coexist with the parasite and disease vectors.

Aim: To determine if a significant relationship exists between a) nurse-driven interventions to foster collaborative psychiatric and oncology care and b) higher rates of cancer treatment adherence and lower healthcare utilization rates in patients with serious mental illness (SMI) and cancer. Background: It is not uncommon for patients with SMI to suffer from treatment noncompliance and present in the acute care setting, such as the emergency department. Patients with cancer and SMI pose a unique challenge to nurses and providers due to the psychological effect of a cancer diagnosis as well as side effects experienced from psychotropic medications and oncology treatments alike. As a result, these patients are less likely to maintain cancer treatment regimens and present with advances stages of cancer in the acute care setting. Methods: An extensive electronic literature search in the CINAHL Plus and APA PsycINFO databases was completed and included the keywords: cancer, neoplasms, carcinoma, serious mental illness, chronic mental illness, mental disorders, mental disorders, chronic, psychiatric illness, psychiatric disability, cognitive behavioral therap*, intervention*, mindful*, and mental health. Inclusion criteria included: published in the years 2012-2022. The available literature was carefully examined for interventions performed with SMI and cancer for ultimate results to be finalized as a written report. Significance: The results of this research can optimize healthcare and prognosis for the population of mental health patients with cancer and also reduce costs to the healthcare system. Conclusion: The 10 studies reviewed indicated that collaborative psychiatric-oncology care with specific Registered Nurse (RN)-led interventions, such as medication management programs and behavioral counseling, was associated with increased rates of cancer treatment adherence and lower rates of healthcare utilization. Conclusions were based on data collected in cohort studies, randomized control trials, pre- and post-intervention assessments, and clinic data from quality improvement projects. More research is needed to explore the implementation of collaborative care practices.

Aim: The purpose of this study is to investigate how some high school students experience their school's health work as well as their view on/understanding of health. Since the study is conducted in collaboration with the Swedish Institute FMS particular attention will be paid to a special intervention, named FMS. The research questions read: How is health presented in the students’ stories about the school’s health work? Where does the school's health work take place according to the students' stories? How do the students experience the subject Sport and Health? How do the students experience FMS:s health intervention? Method: A qualitative method has been used where nine students have been interviewed individually with the ambition to understand the phenomenon from the interviewees own perspective. A total of 18 interviews have been conducted since all participating students were interviewed on two different occasions. Results: Health for the students is primarily about feeling good and having the energy to perform. The pathogenic perspective appears the most when talking about physical health, while the salutogenic perspective becomes clearer when they argue about mental health and even more clear in social health. When the students talk about the opportunities and difficulties they experience about their own health, it mainly involves physical activity and diet. Here is a picture of how students seem to be about improving their health by being physically active and eating "good". Occasions when it is not possible to be physically active or to eat "good" therefore means that the students experience a difficulty for their own health. The school’s health work seems to, according to the student’s stories, mainly take place in the subject of Sport and Health, which is a subject the majority experiences provides good information and is fun. All students experience that the health intervention FMS has given them a deeper insight into what they can and can not do and what they need to improve with themselves. Overall, the interviewees describe how they think the FMS has been very good and fun. Conclusions: Regardless of whether a health work has a pathogenic or salutogenic perspective is it important for the school to think about how health is expressed in education and other health initiatives as it can ultimately affect students' approach to their health. / Syfte: Syftet med denna studie är att undersöka hur några gymnasieelever upplever sin skolas hälsoarbete samt deras syn på/förståelse av hälsa. Då studien genomförs i samverkan med Svenska Institutet FMS kommer särskild uppmärksamhet att ägnas åt en speciell hälsoinsats, kallad FMS. Frågeställningarna lyder: Hur framställs hälsa i elevernas berättelser om skolans hälsoinsatser? Var sker skolans hälsoarbete enligt elevernas berättelser? Hur upplever eleverna ämnet Idrott och hälsa? Hur upplever eleverna FMS:s hälsoinsats? Metod: En kvalitativ metod har använts där nio elever har intervjuats individuellt med ambitionen att förstå fenomenet ur de intervjuades egna perspektiv. Totalt har 18 intervjuer genomförts då samtliga deltagande elever intervjuades vid två olika tillfällen. Resultat: Hälsa för eleverna handlar främst om att må bra och att ha ork till att prestera. Det patogena perspektivet framträder starkast när de talar om fysisk hälsa, medan det salutogena perspektivet blir tydligare när de resonerar om psykisk hälsa och än tydligare vid social hälsa. När eleverna talar om vilka möjligheter och svårigheter de upplever kring den egna hälsan rör det främst fysisk aktivitet och kost. Här framträds en bild av hur det för eleverna verkar handla om att man ska främja sin hälsa genom att vara fysiskt aktiv och att äta ”bra”. Tillfällen då det inte är möjligt att vara fysiskt aktiv eller att äta ”bra” ter sig därför för eleverna till att upplevas som en svårighet för den egna hälsan.   Skolans hälsoarbete verkar enligt elevernas berättelser främst ske i ämnet Idrott och hälsa, vilket är ett ämne som majoriteten upplever ger bra information och är roligt. Hälsoinsatsen FMS upplevs av samtliga elever ha givit dem endjupare insikt i vad de kan och inte kan göra samt vad de behöver förbättra med sig själva. Det beskrivs överlag i intervjuerna hur de tycker att FMS har varit väldigt bra och roligt. Slutsats: Oavsett om ett hälsoarbete har en patogen eller salutogen utgångspunkt är det viktigt för skolan att fundera över hur hälsa kommer till uttryck i såväl undervisning som övriga hälsoinsatser då det i slutändan kan påverka elevers förhållningssätt till sin hälsa.

As the research field about persuasive technologies is growing there is a need to consider how we design motivating tools that empower users. This paper aims to raise this discussion by analysing the Motivational Technologies framework. With a Research through Design approach, a case about designing a preventive health application for individuals with rheumatoid arthritis is used as an example to drive the discussion. Through interviews, workshops and prototyping, three design concepts were developed: All in One, Healthie and Three Coaches. Findings from the design process support that for building self-determination, the three key aspects customization, navigability and interactivity from the framework could be important. However, the findings also highlight that other aspects, such as transparency, handling of relapses and encouragement are important to consider and that a critical view of social interaction is needed. Thus, the analysis provides new perspectives to the on-going discourse and shows that the framework needs nuancing. / I takt med att det blir allt vanligare med teknik för att främja beteendeförändringar är det viktigt att diskutera hur sådan teknik kan designas på ett sätt som stärker och motiverar användare. Syftet med denna artikel är att genom en analys av ramverket Motivational Technologies lyfta denna diskussion. Som utgångspunkt för diskussionen används en designutmaning som innefattar design av en livstilsförändrande applikation för att förebygga ledgångsreumatism. Genom intervjuer, idéseminarier och skapandet av prototyper togs tre designkoncept fram: All in One, Healthie och Three Coaches. Resultatet av designutmaningen stödjer att ramverkets huvudaspekter customization, navigability och interactivity är viktiga. Däremot visar resultatet även att andra aspekter, så som transparens, hantering av återfall och uppmuntran är viktiga att ta hänsyn till och att ett kritiskt perspektiv på social interaktion behövs. Därmed bidrar analysen med nya infallsvinklar till den pågående diskursen och visar att det studerade ramverket bör nyanseras.

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Essay #1 - Parental Social Influence in Childhood Obesity Interventions: a Systematic Review The objective of this study is to understand the pathways through which social influence at the family level moderates childhood obesity interventions. We conducted a systematic review of obesity interventions in which parents' behaviors are targeted to change children's obesity outcomes, due to the potential social and environmental influence of parents on the nutrition and physical activity behaviors of children. Results for existing mechanisms that moderate parents' influence on children's behavior are discussed and a causal pathway diagram is developed to map out social influence mechanisms that affect childhood obesity. We provide health professionals and researchers with recommendations to leverage family-based social influence mechanisms for increasing the efficacy of the obesity intervention programs. Essay #2 - Dynamics of Obesity Interventions inside Organizations: a Case Study of Food Carry-Outs in Baltimore A large number of obesity prevention interventions, from upstream (policy and environmental) to downstream (individual level), have been put forward to curb the obesity trend; however, not all those interventions have been successful. Overall effectiveness of obesity prevention interventions relies not only on the average efficacy of a generic intervention, but also on the successful Reach, Effectiveness, Adoption, Implementation, and Maintenance (RE-AIM) of that intervention. In this study, we aim to understand how effectiveness of organizational level obesity prevention interventions depends on dynamics of AIM. We focus on an obesity prevention intervention, implemented in food carry-outs in low-income urban areas of Baltimore city, which aims to improve dietary behavior for adults through better food access to healthier foods and point-of-purchase prompts. Building on data from interviews and the literature we develop a dynamic model of the key processes of AIM. We first develop a contextualized map of causal relationships integral to the dynamics of AIM, and then quantify those mechanisms using a system dynamics simulation model. With simulation analysis, we show how as a result of several reinforcing loops that span stakeholder motivation, communications, and implementation quality and costs, small changes in the process of AIM can make a big difference in impact. We present how the dynamics surrounding communication, motivation, and depreciation of interventions can create tipping dynamics in AIM. Specifically, small changes in allocation of resources to an intervention could have a disproportionate long-term impact if those additional resources can turn stakeholders into allies of the intervention, reducing the depreciation rates and enhancing sustainability. We provide researchers with a set of recommendations to increase the sustainability of the interventions. Essay #3 - Dynamics of Implementation and Maintenance of Organizational Health Interventions: Case Studies of Obesity Interventions In this study, we present case studies to explore the dynamics of implementation and maintenance of obesity interventions. We analyze how specific obesity prevention interventions are built and eroded, how the building and erosion mechanisms are interconnected, and why we can see significantly different erosion rates across otherwise similar organizations. We use multiple comparative case studies to provide empirical information on the mechanisms of interest, and use qualitative systems modeling to integrate our evolving understanding into an internally consistent and transparent theory of the phenomenon. Our preliminary results identify reinforcing feedback mechanisms, including design of organizational processes, motivation of stakeholders, and communication among stakeholders, which influence implementation and maintenance of intervention components. Over time, these feedback mechanisms may drive a wedge between otherwise similar organizations, leading to distinct configurations of implementation and maintenance processes. / Ph. D.

High infant mortality (IM) rates in the U.S. have been a major public health concern for decades. Many studies have focused on understanding causes, risk factors, and interventions that can reduce IM. However, death of an infant is the result of the interplay between many risk factors, which in some cases can be traced to the infancy of their parents. Consequently, these complex interactions challenge the effectiveness of many interventions. The long-term goal of this study is to advance the common understanding of effective interventions for improving health outcomes and, in particular, infant mortality. To achieve this goal, I implemented systems and data science methods in three essays to contribute to the understanding of IM causes and risk factors. In the first study, the goal was to identify patterns in the leading causes of infant mortality across states that successfully reduced their IM rates. I explore the trends at the state-level between 2000 and 2015 to identify patterns in the leading causes of IM. This study shows that the main drivers of IM rate reduction is the preterm-related mortality rate. The second study builds on these findings and investigates the risk factors of preterm birth (PTB) in the largest obstetric population that has ever been studied in this field. By applying the latest statistical and machine learning techniques, I study the PTB risk factors that are both generalizable and identifiable during the early stages of pregnancy. A major finding of this study is that socioeconomic factors such as parent education are more important than generally known factors such as race in the prediction of PTB. This finding is significant evidence for theories like Lifecourse, which postulate that the main determinants of a health trajectory are the social scaffolding that addresses the upstream roots of health. These results point to the need for more comprehensive approaches that change the focus from medical interventions during pregnancy to the time where mothers become vulnerable to the risk factors of PTB. Therefore, in the third study, I take an aggregate approach to study the dynamics of population health that results in undesirable outcomes in major indicators like infant mortality. Based on these new explanations, I offer a systematic approach that can help in addressing adverse birth outcomes—including high infant mortality and preterm birth rates—which is the central contribution of this dissertation. In conclusion, this dissertation contributes to a better understanding of the complexities in infant mortality and health-related policies. This work contributes to the body of literature both in terms of the application of statistical and machine learning techniques, as well as in advancing health-related theories. / Doctor of Philosophy / The U.S. infant mortality rate (IMR) is 71% higher than the average rate for comparable countries in the Organization for Economic Co-operation and Development (OECD). High infant mortality and preterm birth rates (PBR) are major public health concerns in the U.S. A wide range of studies have focused on understanding the causes and risk factors of infant mortality and interventions that can reduce it. However, infant mortality is a complex phenomenon that challenges the effectiveness of the interventions, and the IMR and PBR in the U.S. are still higher than any other advanced OECD nation. I believe that systems and data science methods can help in enhancing our understanding of infant mortality causes, risk factors, and effective interventions. There are more than 130 diagnoses—causes—for infant mortality. Therefore, for 50 states tracking the causes of infant mortality trends over a long time period is very challenging. In the first essay, I focus on the medical aspects of infant mortality to find the causes that helped the reduction of the infant mortality rates in certain states from 2000 to 2015. In addition, I investigate the relationship between different risk factors with infant mortality in a regression model to investigate and find significant correlations. This study provides critical recommendations to policymakers in states with high infant mortality rates and guides them on leveraging appropriate interventions. Preterm birth (PTB) is the most significant contributor to the IMR. The first study showed that a reduction in infant mortality happened in states that reduced their preterm birth. There exists a considerable body of literature on identifying the PTB risk factors in order to find possible explanations for consistently high rates of PTB and IMR in the U.S. However, they have fallen short in two key areas: generalizability and being able to detect PTB in early pregnancy. In the second essay, I investigate a wide range of risk factors in the largest obstetric population that has ever been studied in PTB research. The predictors in this study consist of a wide range of variables from environmental (e.g., air pollution) to medical (e.g., history of hypertension) factors. Our objective is to increase the understanding of factors that are both generalizable and identifiable during the early stage of pregnancy. I implemented state-of-the-art statistical and machine learning techniques and improved the performance measures compared to the previous studies. The results of this study reveal the importance of socioeconomic factors such as, parent education, which can be as important as biomedical indicators like the mother's body mass index in predicting preterm delivery. The second study showed an important relationship between socioeconomic factors such as, education and major health outcomes such as preterm birth. Short-term interventions that focus on improving the socioeconomic status of a mother during pregnancy have limited to no effect on birth outcomes. Therefore, we need to implement more comprehensive approaches and change the focus from medical interventions during pregnancy to the time where mothers become vulnerable to the risk factors of PTB. Hence, we use a systematic approach in the third study to explore the dynamics of health over time. This is a novel study, which enhances our understanding of the complex interactions between health and socioeconomic factors over time. I explore why some communities experience the downward spiral of health deterioration, how resources are generated and allocated, how the generation and allocation mechanisms are interconnected, and why we can see significantly different health outcomes across otherwise similar states. I use Ohio as the case study, because it suffers from poor health outcomes despite having one of the best healthcare systems in the nation. The results identify the trap of health expenditure and how an external financial shock can exacerbate health and socioeconomic factors in such a community. I demonstrate how overspending or underspending in healthcare can affect health outcomes in a society in the long-term. Overall, this dissertation contributes to a better understanding of the complexities associated with major health issues of the U.S. I provide health professionals with theoretical and empirical foundations of risk assessment for reducing infant mortality and preterm birth. In addition, this study provides a systematic perspective on the issue of health deterioration that many communities in the US are experiencing, and hope that this perspective improves policymakers' decision-making.

Abstract Information technologies have opened new opportunities to develop persuasive systems that support people to adopt and sustain healthy behaviors. Both web-based and ubiquitous information systems have shown promising results in supporting people to adopt healthy routines. Persuasive systems have therefore received increasing attention from researchers over the past decade. Behavior Change Support Systems are an object of persuasive technology. These systems are designed to facilitate behavior change process over an extended period of time. This dissertation comprises of six studies, including two investigative, two experimental, and two field studies. An effort has been made to consecutively build these studies to formulate a central research question: To what extent virtual rehearsal augmented with reminders influence overall efficacy of health Behavior Change Support Systems? The primary theoretical underpinning is the Persuasive Systems Design model, which highlights seven postulates and twenty-eight software features for developing Behavior Change Support Systems. However, in the presented work, reminders and virtual rehearsal are explicitly studied. The interplay between these software features is examined through using a mixed-method research approach, using qualitative methodology as a core research approach. The results indicate that carefully selected and integrated persuasive software features have significant impact on the overall efficacy of Behavior Change Support Systems. Presented work addresses health behavioral change as a critical aspect of healthcare, and also extends contemporary research on critical issues in healthcare including task adherence, attrition and compliance. / Tiivistelmä Uudet informaatioteknologiat ovat mahdollistaneet sellaisten vakuuttavien järjestelmien kehittämisen, jotka voivat tukea terveellisten käyttäytymismallien omaksumisessa ja niiden ylläpitämisessä. Sekä web-pohjaisilla että jokapaikan tietojärjestelmillä on saatu lupaavia tuloksia terveellisten rutiinien omaksumisessa. Vakuuttavat järjestelmät ovat näin viimeisen vuosikymmenen aikana saaneet kasvavaa huomiota tutkijoilta. Yksi vakuuttavan teknologian tutkimuskohteista on käyttäytymisen muutoksen tukijärjestelmät. Nämä järjestelmät on suunniteltu helpottamaan käyttäytymisen muutoksessa pitkähkön aikajakson kuluessa. Tämä väitöskirja koostuu kuudesta tutkimuksesta, sisältäen kaksi eksploratiivista, kaksi kokeellista ja kaksi kenttätutkimusta. Kyseiset tutkimukset on suunnitelut siten, että on voitu muodostaa yksi keskeinen tutkimuskysymys: Missä määrin virtuaalinen harjoittelu yhdessä muistutusten kanssa voi vaikuttaa käyttäytymisen muutoksen tukijärjestelmien tehokkuuteen? Pääasiallisena teoreettisena pohjana toimii vakuuttavien järjestelmien PSD-suunnittelumenetelmä (Persuasive Systems Design Model), joka korostaa seitsemää perusoletusta ja 28 ohjelmisto-ominaisuutta tällaisten käyttäytymisen muutoksen tukijärjestelmien kehittämisessä. Tässä väitöskirjassa on keskitytty tutkimaan erityisesti virtuaalisia muistutuksia ja virtuaalista harjoittelua. Kyseisiä ohjelmisto-ominaisuuksia on tarkasteltu käyttämällä mixed-method -tutkimustapaa erityisesti laadullisella tutkimusotteella. Tässä tutkimuksessa saadut tulokset osoittavat, että järjestelmien huolella valituilla ja toteutetuilla vakuuttavilla ominaisuuksilla on merkittävä vaikutus käyttäytymisen muutoksen tukijärjestelmien tehokkuuteen. Väitös osoittaa terveyskäyttäytymisen muutoksen olevan kriittinen osa terveydenhoitoa. Väitöstyö myös lisää terveydenhoidon tietämystä sen kriittisissä ongelmissa, erityisesti harjoituksiin sitoutumisessa tai vastaavasti harjoitusten tekemättä jättämisessä ylipäätään ja ohjeiden noudattamisessa.