Introduction: The number of stroke survivors living with post-stroke deficits is increasing worldwide. Although stroke rehabilitation can improve these deficits and promote the recovery of function when initiated early post-stroke, many survivors are not able to access rehabilitation because of a lack of resources. Early mobile tablet-based stroke rehabilitation may be a feasible means of improving access to recovery promoting therapies. Objective: To summarize and advance the knowledge of early mobile tablet-based therapies (MTBTs) for stroke survivors with regards to feasibility and barriers to care. Methods: This thesis is comprised of two major studies. (1) A scoping review summarizing the literature for MTBTs following stroke. (2) A cohort study testing the feasibility of a MTBT for post-stroke communication, cognitive, and fine-motor deficits. Results: (1) Twenty-three studies of MTBTs following stroke were identified. Most of these therapies targeted communication or fine-motor deficits, and involved patients in the chronic stages of stroke. Barriers to care were summarized. (2) A 48% recruitment rate was achieved and therapy was administered a median of four days post-stroke. However, therapy adherence was very low because of frequently encountered barriers to care. Conclusions: Stroke survivors are interested in using tablet technology to assist with their post-stroke recovery. However, early MTBT post-stroke may be challenging for some survivors because of encountered barriers to care. Regular patient-therapist communication using a convenient method of interaction appears necessary to minimize barriers and to help patients overcome barriers when they occur.

Indiana University-Purdue University Indianapolis (IUPUI) / Motivation deficits remain an unmet treatment need in schizophrenia. Recent preclinical research has identified novel mechanisms underlying motivation deficits, namely impaired effort-cost computations and reduced future reward-value representation maintenance, that may serve as more effective treatment targets to improve motivation. The main aim of this study was to test the feasibility and preliminary effectiveness of a translational mechanism-based intervention, MEMS (Mobile Enhancement of Motivation in Schizophrenia), which leverages mobile technology to target these mechanisms with text-messages. Fifty-six participants with a schizophrenia-spectrum disorder were randomized to MEMS (n = 27) or a control condition (n = 29). All participants set recovery goals to complete over eight-weeks. The MEMS group also received personalized, interactive text-messages each weekday to support motivation. Retention and engagement in MEMS was high: 92.6% completed 8 weeks of MEMS, with an 86.1% text-message response rate, and 100% reported that they were satisfied with the text-messages. Compared to the control condition, the MEMS group had significantly greater improvements in interviewer-rated motivation and anticipatory pleasure and obtained significantly more recovery-oriented goals at the end of the 8-week period. There were no significant group differences in performance-based effort-cost computations and future reward-value representations, self-reported motivation, quality of life, functioning, or additional secondary outcomes of positive symptoms, mood symptoms, or neurocognition. Results suggest that MEMS is feasible as a relatively brief, low-intensity mobile intervention that could effectively improve interviewer-rated motivation, anticipatory pleasure, and recovery goal attainment in those with schizophrenia-spectrum disorders.

Background and objectives: Information and communication technologies (ICTs) have been in use in the health setting since the time of the first telephones. However, the advent of computers, personal-computers (PCs) and, more recently, mobile information and communication technologies (mICTs) such as mobile phones, smartphones, tablet-pcs and laptops, has seen technology become increasingly integrated into how care is delivered and received. No research has yet explored how people with mood disorders use mICTs in their everyday lives and, more specifically, how they might use mICTs to look after themselves. This oversight has led to technology redundancy and high attrition rates in the use of this type of technology. Further research was therefore required to understand the meaning that this type of technology holds for people with mood disorders. This qualitative study aimed to explore the views and experiences of people with mood disorders, and their mental health and social care professionals, in using mICTs. Design and methods: A meta-synthesis was completed, guided by the work of Sandelowski and Barroso, using thematic synthesis an approach, as designed by Thomas and Harden. An exploratory qualitative approach, using in-depth, semi-structured interviews with 26 patients with mood disorders in secondary and specialist mental health services, and ten mental health and social care professionals, was subsequently employed. Participants’ datasets were analysed using Constructivist Grounded Theory (CGT). Grounded theory (GT) involves the gradual identification and integration of categories of meaning from the data, and the identification of relationships between them. Results: The rigorous and systematic nature of the meta-synthesis identified shortcomings in current research and clearly identified a gap in the research literature regarding mICTs and mood disorders. The in-depth primary study created a theory explaining how mobile technology was used in daily life, and also, more specifically, how it was used to manage recovery from mood disorders. The core category and participants’ main concern that emerged from the data, forming theory, was ‘Centrality; through praxis of interconnectivity’. Patients with mood disorders used their mICTs to stay central within their on-and-offline worlds and held them central in their importance of attachment. Health and social care professionals worked around their provision of basic mICTs and lack of informational support when using them with their patients. Centrality was achieved through the ‘Praxis of interconnectivity’; the act of managing their connectedness using mICTs. This interconnectivity was not fixed; instead, it offered fluidity for participants to manage their continuums of use through their ‘Outsourcing of needs’, ‘Management of needs’, and ‘Disconnection of needs’. Conclusions and future implications: This study refocused the attention of ICT research onto arguably the most important person, the end-user, and, in this instance, the people recovering from mood disorders, and their health and social care professionals. The CGT provided, for the first time, a theory that explained how people made use of their mICTs. Additional research is warranted to further understand the transferability of the theory to other client groups, and, in so doing, whether it can be transformed into a formal theory. Also, further research is recommended to translate the theory into practical tools for clinicians; for example, the creation of an mICT self-management questionnaire or a digital hygiene support package. Both patients recovering from mood disorders, and health and social care professionals, can utilise the findings of this study to help make sense of their mICT use. The study findings can also help inform and encourage the further incorporation of mICTs into the health and social care settings; spanning the therapeutic to systemic levels so that the full potential of these ubiquitous technologies can be harnessed to improve care and care delivery.

BACKGROUND: Seven out of every 10 adults in the United States can benefit from weight loss. Overweight and obesity have emerged at the forefront of public health concerns and are associated with significant morbidity and mortality. Primary care providers have the opportunity to identify overweight/obese patients and initiate weight loss efforts with an efficacious treatment plan that addresses individual challenges and barriers. Modest weight loss of 5-10% can be achieved with referral to a high-intensity, on-site, comprehensive lifestyle intervention program. However, most overweight/obese patients do not enroll in these programs; thus, there is a significant demand for alternative weight loss strategies. Providers can help patients individualize and apply the 3 evidence-based components of lifestyle intervention (reduced calorie diet, increased physical activity, and behavior modification) to create a plan that defines weight loss goals, dietary and physical activity targets, and behavior change strategies. LITERATURE REVIEW: mHealth applications show promise for augmenting weight loss efforts, likely by facilitating behavior change strategies such as self-monitoring. High-quality data is lacking to define the precise role of mHealth apps in weight loss, but a limited number of studies report significant app features and average frequency of use associated with weight loss. PROPOSED PROJECT: Preliminary evidence-based recommendations advise patients to use an mHealth app to log dinner and 1 other meal every day, log all minutes of moderate-to-vigorous physical activity, and log body weight 2-3 times per week. Wearable sensors can be used to enhance user experience, but should not substitute for manually logging physical activity. Patients should monitor their caloric intake, minutes of physical activity, and body weight frequently with reference to their goals and prescribed recommendations. CONCLUSION & SIGNIFICANCE: Overweight/obesity is a disease that demands attention from the medical profession due to the high prevalence and associated morbidity and mortality. Primary care providers can begin to address the obesity epidemic by propagating patient weight loss efforts. Clinically significant weight loss can be accomplished with lifestyle modification, so providers should be encouraged to prescribe evidence-based lifestyle recommendations for reduced caloric intake, increased physical activity, and behavior change strategies. Patients can actively engage with these recommendations by using an mHealth app with guidance from their providers. Employing pragmatic lifestyle interventions that incorporate evidence-based strategies and encourage longevity may decrease the prevalence of overweight/obesity and its’ associated chronic conditions.

Problem formulation. The European Commission considers that health care providers and potential payers may need further evidence of mobile health (mHealth) clinical and economic benefits and despite there are hundreds of mHealth initiatives, most of them did not move beyond the pilot phase.   Purpose. This thesis aims at analyzing how can mHealth companies contribute towards solving existing health care challenges while becoming successful businesses in such an immature market. The expected results are a set of empirical evidences for companies and investors interested in this relatively new industry for the development of successful businesses, products and services.   Literature. The authors have explored classic theories and models on market entry, business and strategy development in combination with recent studies on health care, Internet and mHealth economy and ecosystem.   Methods. A qualitative multiple case study has been conducted. An analytical framework with propositions derived from the literature analysis guide the empirical study of two organizations that have successfully developed mHealth solutions in two countries with different socio-economic situations: China and Spain. Organization A is a health care and lifestyle company from Beijing responsible for a successful app with 80 million users that has brought 45 million USD investment. Organization B is the first intrapreneurial public organization born within a hospital in Madrid and committed to make knowledge available to patients and health care professionals through ICT. After a set of interviews with executive representatives and project managers, a pattern-matching analysis has been used to extract inferences and to identify correlations and deviations from literature research.   Key findings. The main conclusion of this thesis work is that mHealth is clearly a profitable blue ocean industry nowadays with lots of business opportunities to explore, room for competition and complex challenges to solve. On one side, mHealth is presented as a disruptive industry expected to cause a big impact in health care by contributing to solve costs and quality problems although there is little evidence on such benefits. On the other side, privacy, security, regulations, governments’ decisions and reluctant health care professionals become the main barriers for adoption. The outlook for the future of mHealth proves that it will be fundamental to count with multidisciplinary teams of professionals, geographically distributed health centers and technological platforms with secure and standardized communications. All these will not be possible without a general mindset change from government, administrators, regulators and health care professionals to incentivize and foster new mobile health technologies treating them as an ally rather than a threat.

The purpose of this study is to investigate how processes of subjectification constitute the empowered citizen/patient in the discourses on smart cities. Descriptions of smartphone apps which use environmental sensor data are analysed through discourse analytic approach to governmentality. More specifically the thesis investigates the empowered citizen in relation to responsibilisation and relations to knowledge and power. The study finds that the citizen-subject is responsibilised and the relations knowledge are reformulated and redistribute responsibility. Data and the derived knowledge is represented as a form of empowerment. The citizen-subject is constituted as a manager of their own health, and a catalysts for changing the environment. Emphasising the importance of data and putting the user at the heart of data collecting further contributes to the responsibilisation. However, as the information from the data streams is transferable it also redistributes responsibility in the network of individuals who have access to it. The way of knowing the self and the environment is augmented to include a codified interface, which conditions the relationship. A distributed network of sensors allows the citizen-subject is able to simultaneously read the environment in multiple locations. Relations in knowledge production are also found to be altered.

Shown is the design of the Smartphone Oral Cancer Detection System (SOCeeDS). The SOCeeDS attaches to a smartphone and utilizes its embedded imaging optics and sensors to capture images of the oral cavity to detect oral cancer. Violet illumination sources excite the oral tissues to induce fluorescence. Images are captured with the smartphone’s onboard camera. Areas where the tissues of the oral cavity are darkened signify an absence of fluorescence signal, indicating breakdown in tissue structure brought by precancerous or cancerous conditions. With this data the patient can seek further testing and diagnosis as needed. Proliferation of this device will allow communities with limited access to healthcare professionals a tool to detect cancer in its early stages, increasing the likelihood of cancer reversal.

Background - Mobile health (mHealth) interventions to promote medication adherence have shown promise; among patients primarily diagnosed with Coronary Heart Disease (CHD), however, there is a lack of evidence for nurse-led mHealth interventions, in this particular group in Iran. Aim - To refine and evaluate a pre-developed nurse-led mHealth intervention to promote cardiovascular medication adherence in Iranian adult, male and female Cardiac Rehabilitation (CR) outpatients. Methods - A quantitative-dominant mixed methods study was conducted drawing upon the Medical Research Council’s (MRC) Framework on the development and evaluation of complex interventions. Phase 1 comprised of a self-completion CHD patients’ survey (n=123) and three focus groups with cardiac nurses (n=23) within three public university-affiliated hospitals in Tehran, which in turn informed Phase 2 (the exploratory trial phase). The automated Short Message Service (SMS) medication reminder was designed based on the dimensions of adherence suggested by the World Health Organisation (WHO) and Bandura’ Self-efficacy Theory. The intervention was refined according to the findings from Phase 1 and then piloted in an Iranian CR setting. Seventy eight CHD patients who were 18 years or older, and had mobile phone access were recruited and randomised to receive either daily SMS reminders (n=39) or usual care (n=39) for 12 weeks. The primary outcome was the effect on cardiovascular medication adherence as measured by the self-reported Morisky Medication Adherence Scale; secondary outcomes explored the feasibility of the mHealth intervention, intervention effect on medication adherence selfefficacy, cardiac ejection fraction, cardiac functional capacity, hospital readmission/ death rate and health-related quality of life. Patient acceptability was assessed through completion of a post-intervention survey. Results - Feasibility was evidenced by high ownership of mobile phones in CHD patients, high application of SMS messaging, positive patients’ perception about the intervention, suboptimal cardiovascular medication adherence and patients’ high interest in receiving SMS reminders for their medications. Participants in the intervention group showed higher self-reporting of medication adherence compared to the usual care group χ2 (2) = 23.447; P < 0.001. The Relative Risk (RR) was indicated that it was 2.19 times more likely for the control group to be less adherent to their medications than the intervention group (RR = 2.19; 95% Confidence Interval (CI) 1.5 - 3.19). All secondary outcomes improved in the intervention group at the end of the study. Acceptability was evidenced by participants who received the intervention reporting that they perceived the SMS reminders useful. Conclusion - The SMS medication reminder intervention was well accepted and feasible with significantly higher reporting of medication adherence in Iranian CHD patients. Effect sizes were established for use in future follow-up evaluations of the mHealth intervention.

Mobile applications (“apps”) are increasingly used in medical education and practice. However, many medical apps are of variable quality, lack supporting evidence and fall outside the remit of regulators. In this thesis, I explore how the quality and credibility of apps for healthcare practitioners could be improved. I argue that interdisciplinary collaboration throughout the app life-cycle is critical and discuss how this can be facilitated. My argument rests on prior work in eHealth and neighbouring disciplines, and on original research in transfusion medicine. Blood transfusion can be a life-saving medical treatment. However, it also carries risks. Failures to provide irradiated and cytomegalovirus-negative blood components according to guidelines are frequently reported in the UK. Such incidents put patients at risk of serious complications. Haemovigilance data indicates that enhancing practitioner knowledge may reduce mistakes. Thus, I worked with medical experts to develop and evaluate the Special Blood Components (SBC) mobile learning app. To facilitate this work, I created two tools: the Web App Editor (WAE) and the Web App Trial (WAT). The former is a collaborative editor for building apps in a web browser and the latter is a system for conducting online randomised controlled app trials. The results are reported in five studies. Studies 1 and 2, based on interviews with seven practitioners, revealed shortcomings in an existing transfusion app and the SBC prototype. Study 3 demonstrated how students using theWAE were able to collaborate on apps, including an app in stroke medicine. Study 4, an evaluation of the revised SBC app with 54 medical students, established the ease of use as acceptable. In study 5, a WAT pilot study with 61 practitioners, the SBC app doubled scores on a knowledge test and was rated more favourably than existing hospital guidelines. In conclusion, creating high quality medical apps that are supported by evidence is a considerable undertaking and depends on a mix of knowledges and skills. It requires that healthcare practitioners, software developers and otherswork together effectively. Hence, the WAE and WAT are key research outcomes. They enabled participants to contribute improvements and assess the usability and efficacy of the SBC app. The results suggest that the SBC app is easy to use and can improve practitioner knowledge. Further work remains to pilot and evaluate the SBC app in a hospital setting.

abstract: In the last decade, the number of people who own a mobile phone or portable electronic communication device has grown exponentially. Recent advances in smartphone technology have enabled mobile devices to provide applications (“mHealth apps”) to support delivering interventions, tracking health treatments, or involving a healthcare team into the treatment process and symptom monitoring. Although the popularity of mHealth apps is increasing, few lessons have been shared regarding user experience design and evaluation for such innovations as they relate to clinical outcomes. Studies assessing usability for mobile apps primarily rely on survey instruments. Though surveys are effective in determining user perception of usability and positive attitudes towards an app, they do not directly assess app feature usage, and whether feature usage and related aspects of app design are indicative of whether intended tasks are completed by users. This is significant in the area of mHealth apps, as proper utilization of the app determines compliance to a clinical study protocol. Therefore it is important to understand how design directly impacts compliance, specifically what design factors are prevalent in non-compliant users. This research studies the impact of usability features on clinical protocol compliance by applying a mixed methods approach to usability assessment, combining traditional surveys, log analysis, and clickstream analysis to determine the connection of design to outcomes. This research is novel in its construction of the mixed methods approach and in its attempt to tie usability results to impacts on clinical protocol compliance. The validation is a case study approach, applying the methods to an mHealth app developed for early prevention of anxiety in middle school students. The results of three empirical studies are shared that support the construction of the mixed methods approach. / Dissertation/Thesis / Masters Thesis Computer Science 2016