The Role of mHealth in Facilitating Prediabetic and Diabetic Patients’ Involvement in Health Interventions

Health interventions are useful tools for preventing and alleviating diabetes which show low adherence in medical practice for prediabetic and diabetic patients. mHealth technologies have the potential to facilitate health management and improve prediabetic and diabetic patients’ self-management outcomes. Building on Social Cognitive Theory, this research-in- progress paper proposes a research model to account for the role of physician’s recognition in promoting self-management behaviors for prediabetic and diabetic patients through mHealth technologies. To test the research model, authors developed a mobile diabetes management application and cooperated with a large tertiary hospital in China. In this research-in-progress, we propose to recruit 280 subjects who are in the prediabetic or diabetic conditions. This study is expected to contribute to the research on and practice of the health interventions through mHealth technologies

MOTIBOT: IL COACH VIRTUALE PER INTERVENTI DI COPING SANO PER ADULTI CON DIABETE MELLITO

Il diabete mellito (DM) è una malattia metabolica autogestita, in cui se l'individuo non è motivato o non è in grado di gestire regolarmente il proprio DM, i risultati medici e psicosociali saranno scarsi. Il DM è più di una condizione di salute fisica: ha impatti comportamentali, fisiologici, psicologici e sociali, e richiede alti livelli di motivazione per seguire le raccomandazioni cliniche e adottare comportamenti sani. A questo scopo, le linee guida dell'American Association of Diabetes Educators (AADE) hanno introdotto il costrutto di coping sano per identificare le strategie di coping per ridurre i sintomi di depressione, ansia, stress e disagio emotivo legato al diabete, migliorando anche il benessere degli adulti con DM. In questo contesto, i Virtual Coaches (VCs) sono diventati un importante risorsa nel supporto e nella gestione delle barriere comuni nel contesto dell'aderenza ai comportamenti sani tra gli adulti con DM. Tuttavia, pochi sono i VC specificamente sviluppati a fornire supporto psicosociale agli adulti con DM. L'obiettivo principale della presente tesi è stato, infatti, lo sviluppo di un VC per fornire supporto psicosociale agli adulti con DM di tipo 1 (T1DM) o DM di tipo 2 (T2DM). Più specificamente, questo VC mirava a motivare gli adulti con DM a ridurre sintomi di depressione, ansia, stress, il disagio emotivo legato al diabete, e a migliorare il loro benessere, incoraggiandoli ad acquisire e coltivare strategie di coping psicosociale sano. Queste abilità di coping facevano riferimento alle linee guida dell'AADE e quindi alla pratica della meditazione; in questo studio è stata, infatti, applicata la Mindfulness-Based Cognitive Therapy. La presente tesi è articolata secondo tre studi. Lo studio 1 mirava a fornire prove meta-analitiche sull'efficacia degli interventi eHealth nel sostenere il benessere psicosociale e medico degli adulti con T1DM o T2DM. Lo studio 2 mirava a testare il prototipo del VC simulato, cioè Wizard of Oz (WOZ), attraverso la piattaforma di messaggistica WhatsApp per 6 settimane, con due sessioni a settimana. In particolare, questo studio ha indagato l'accettabilità preliminare e la User Experience (UX) del protocollo di intervento, che sarà incorporato nel futuro VC. Infatti, il metodo di progettazione è stato duplice. Da un lato, è stato applicato il metodo WOZ, in cui gli studenti di psicologia credevano di interagire con un VC; invece, stavano comunicando con un essere umano. Dall'altro lato, è stato utilizzato il modello Obesity-Related Behavioural Intervention Trials (ORBIT), in particolare le sue prime fasi, poiché favorisce un approccio iterativo. Lo studio 3, seguendo le fasi successive del modello ORBIT, mirava a valutare l'efficacia preliminare del VC, chiamato Motibot - abbreviazione di Motivational bot - sviluppato attraverso una combinazione di Natural Language Processing (NLU) e regole pre-strutturate. Un totale di 13 adulti italiani con DM (Mage = 30.08, SD = 10.61) hanno interagito con Motibot attraverso l'applicazione di messaggistica Telegram per 12 sessioni, in cui il paziente poteva pianificare l'appuntamento secondo le sue esigenze: ha interagito con Motibot una o due sessioni a settimana. Motibot è stato percepito come motivante, incoraggiante e capace di innescare un'auto-riflessione sulle proprie emozioni: gli utenti e i pazienti hanno riferito di aver avuto un'esperienza molto positiva con Motibot. Motibot può essere uno strumento utile per fornire supporto psicosociale agli adulti con DM; potrebbe essere prescritto dal diabetologo come misura preventiva per il benessere del paziente e/o quando il paziente presenta sintomi psicosociali lievi e moderati. L'approccio di design centrato sull'utente e il concetto di bidirezionalità tra fattori psicosociali e medici sono punti chiave nello sviluppo di un trattamento digitale personalizzato.Diabetes Mellitus (DM) is a self-managed, metabolic disease, in which if the individual is unwilling, unmotivated, or unable to regularly self-manage their DM, the medical and psychosocial outcomes will be poor. Indeed, DM is more than a physical health condition: it has behavioural, physiological, psychological, and social impacts, and demands high levels of motivation in order to follow the clinical recommendations and adopt healthy behaviours. To this end, the American Association of Diabetes Educators (AADE) guidelines introduced the healthy coping construct to identify healthy coping strategies for reducing symptoms of depression, anxiety, stress, and diabetes-related emotional distress while also improving the well-being of adults with DM. Virtual Coaches (VCs) have recently become more prevalent in the support and management of common barriers in the context of adherence to healthy behaviours among adults with DM, in particular those regarding medical and physical behaviours. However, few VCs were found to be specifically aimed at providing psychosocial support to adults with DM. The main aim of the present thesis was, indeed, the development and implementation of a VC for the provision of psychosocial support to adults with Type 1 (T1DM) or Type 2 DM (T2DM). More specifically, this VC aimed at motivating adults with DM to reduce depression, anxiety, perceived stress symptoms, diabetes-related emotional distress, and improve their well-being, by encouraging them to acquire and cultivate psychosocial healthy coping strategies. These coping skills referred to the AADE guidelines and thus to practicing meditation; in this study, the Mindfulness-Based Cognitive Therapy has been applied. The present thesis is articulated according to three studies. Study 1 aimed at providing meta-analytical evidence on the efficacy of eHealth interventions in supporting the psychosocial and medical well-being of adults with T1DM or T2DM. Study 2 aimed at testing the prototype of the simulated VC, namely Wizard of Oz (WOZ), via the WhatsApp messaging platform for 6-week, with two sessions per week. In particular, this study investigated the preliminary acceptability and the User Experience (UX) of the intervention protocol, which will be incorporated into the future VC. Indeed, the design method was two-fold. On the one hand, the WOZ method was applied, in which psychology students believed that they were interacting with a VC, instead they were communicating with a human being. On the other hand, the Obesity-Related Behavioural Intervention Trials (ORBIT) model was used, particularly its early phases, since it favours an iterative approach. Study 3, following the next phases of the ORBIT model, aimed at assessing the preliminary efficacy of the VC, called Motibot—the abbreviation for Motivational bot—developed through a combination of Natural Language Processing (NLU) and hand-crafted rules. A total of 13 Italian adults with DM (Mage = 30.08, SD = 10.61) interacted with Motibot through the Telegram messaging application for 12 sessions, in which the patient planned the appointment according to his/her needs: he/she interacted with Motibot one or two sessions per week. Therefore, Motibot was perceived as motivating, encouraging and able to trigger self-reflection on one’s own emotions: users and patients reported having a very positive experience with Motibot. Motibot, thus, can be a useful tool to provide psychosocial support to adults with DM; as such, it might be prescribed by the diabetologist as a preventive measure for the patient’s well-being and/or when the patient presents mild and moderate psychosocial symptoms. The user-centred design approach and the concept of bidirectionality between psychosocial and medical factors are key points in the development of a personalised treatment within the digital intervention

Determinants for the acceptance and use of mobile health applications: Diabetic patients in the Western Cape, South Africa

Philosophiae Doctor - PhDThe increased pervasiveness of information communication and technology and increasing internet access creates anticipation for how contemporary technologies can address critical developmental problems. Non-communicable diseases are the leading cause of death globally, even though more than 40% of the deaths are premature and avoidable. Diabetes is such a disease that causes 80% of non-communicable disease deaths in low and middle-income countries. Diabetes is also the leading cause of death in the Western Cape province of South Africa. Diabetes thus constitutes a challenge to achieve Sustainable Development Goal 3 that focuses on health and well-being for all people, at all ages. The potential of technology, such as the use of m-health applications, is recognised as a means to advance the Sustainable Development Goals through supporting health systems in all countries

Effective behavior change techniques in digital health interventions targeting non-communicable diseases: an umbrella review

Background: Despite an abundance of digital health interventions (DHIs) targeting the prevention and management of common non-communicable diseases (NCDs), it is unclear what specific components make an intervention effective in changing human behavior.Purpose: The aim of this umbrella review was to identify the most effective behavior change techniques (BCTs) in DHIs that address the most common NCDs. Methods: Five electronic databases were searched for articles published in English between 1st January 2007 and 24th January 2021. Studies were included if they were systematic reviews or meta-analyses of e- or mHealth interventions targeting the modification of one or more NCD-related risk factors in adults. Study quality was assessed using AMSTAR 2. Sixty-one articles, spanning 10 health domains and comprising over half a million individual participants, were included in the review. Results: DHIs are favorably associated with improved health outcomes for patients with cardiovascular disease, cancer, type 2 diabetes, and asthma, and health-related behaviors including physical activity, sedentary behavior, diet, weight management, medication adherence, and abstinence from substance use. There was strong evidence to suggest education, communication with a professional, tailored reminders, goals and planning, feedback and monitoring, and personalization components increase the effectiveness of DHIs targeting NCDs and lifestyle behaviors. Conclusions: Common BCTs across health domains, such as ‘goals and planning’, increase DHI effectiveness and should be prioritized for inclusion within future interventions. These findings are critical for the future development and upscaling of DHIs and should inform best practice guidelines

The use of mobile text messaging as a behavioural intervention to increase physical activity in adults with T2DM in Saudi Arabia

This feasibility study has informed the suitability of the protocol design for a future full-size RCT. Our findings have demonstrated that the research processes for our feasibility design have been feasible and acceptable. Our collected data demonstrated a small but statistically significant increase in exercise self-efficacy, physical activity levels and barriers to physical activity, although these findings need to be confirmed by randomised experimental trials in the future

Synergising youth empowerment and co-design to transform Pasifika youth into agents of social change : a novel approach to advance healthy lifestyles in Pasifika communities : a thesis presented in partial fulfilment of the requirements of Doctor of Philosophy in Public Health at Massey University, Wellington campus, New Zealand

Current population health statistics demonstrate the need for innovative approaches to improve health outcomes and prevent non-communicable disease (NCD) for Pasifika peoples. This research builds off pilot studies on the effects of youth empowerment programmes to address obesity-related issues amongst Pasifika communities. It developed and tested an original model of co-design embedded within the youth empowerment framework of the Pasifika Prediabetes Youth Empowerment Programme. The programme was co-delivered with two community health service providers (one rural and one urban), employing Community-Based Participatory Research (CBPR) methodology. N=29 youth (aged 15-24 years) participated in eleven educational and capacity-building modules that comprised the empowerment and co-design components during weekly sessions from MayOctober 2018. At the end of the programme, the model of co-design generated two individualised community intervention action plans to reduce prediabetes in their communities. This research employed a qualitative research design with four data collection techniques and thematic analysis to evaluate the effects of the tested programme. It used an original framework of social change to determine the impacts on the youth’s values, knowledge, and behaviours as well as the community organisations, and the socio-cultural norms of each community. It also explicated the contextual considerations of programme uptake in each location. Overall, this research illustrated that co-design is an effective addition to empowerment frameworks. It demonstrated how to operationalise co-design in a community-based setting with youth, and the tested model provided a practical framework to translate empowerment ii outcomes into the community. The programme analyses also led to a more nuanced understanding of social change. This research developed a concept of the process of social change that can be used to inform future programme development and evaluation. This research suggests future translations of the programme to maximise uptake and postulates different community contexts and settings for delivery, beyond Pasifika prediabetes prevention

Development of risk profiling matrix for chronic diseases and preventive smartphone application

Cardiovascular diseases and type 2 diabetes mellitus are highly prevalent chronic diseases. They have similar risk factors and are preventable with lifestyle changes. Mobile applications (apps) can provide behaviour change interventions widely at a relatively low cost. This thesis aimed to identify risk assessment tools suitable for laypeople to determine their cardiovascular and diabetes risk, develop an app for risk awareness and prevention of the two diseases, and test the feasibility of the mobile health intervention. Chapter 2 contains a rapid review of cardiovascular and diabetes risk models. In Chapters 3 and 4, two models based on lifestyle-related risk factors were externally validated in a large Australian cohort. In Chapter 5, the literature was systematically reviewed to evaluate the effectiveness of preventive mobile interventions for the two diseases. Chapter 6 comprises a cross-sectional analysis of mobile health use in older Australians. Chapter 7 describes the development process of a smartphone app according to a framework and iterative testing of the app's usability in a small sample. In Chapter 8, the feasibility of the intervention was assessed over three months with app data and a survey. The rapid review in Chapter 2 included the risk models routinely used in Australian clinical practice and two lifestyle-based risk models without Australian validation. In Chapters 3 and 4, the lifestyle-based diabetes risk model performed satisfactorily, but the cardiovascular model predicted a 5-year risk poorly. The systematic review in Chapter 5 found some indications for the effectiveness of mobile interventions in preventing cardiovascular disease and diabetes. The cross-sectional analysis in Chapter 6 showed low mobile health use in older Australians. The app developed in Chapter 7 encompassed four modules: risk assessment, goal setting, self-monitoring, and health information. Usability testing participants found the app easy to use. In the feasibility study in Chapter 8, 20 out of 46 participants never used the app, 15 dropped out, and 8 used the app weekly. The overall app quality rating was satisfactory. Although the intervention was easy to use, the levels of adoption and sustained use were low. Further research is needed to adapt the app to make it more appealing and provide greater benefits. The potential utility of digital health interventions is vast, but they still need to live up to their expectations

An Investigation into the Association Between Skin Microcirculation and Small Fibre Function in the Foot: Potential Implications in Assessing the Cutaneous Neurovascular Response in Diabetic Foot Disease

Diabetes is a global public health problem as it is associated with various complications. One of the major complications of diabetes is diabetic foot syndrome, which leads to catastrophic events such as ulceration and amputation. The triggers of ulcerations are multifactorial, including cutaneous microcirculatory changes in the foot of people with diabetes. The cutaneous microcirculation of the foot is strongly influenced by the small fibres that mediate the sensation of heat and pain, in addition to sympathetic activities such as thermoregulation and vasodilation. However, there is a lack of knowledge on the subject of microcirculation, small fibre nerves, their relationship, evaluation and possible role in ulceration in the context of diabetic foot. This research aimed to investigate the relationship between cutaneous microvascular and small fibre nerve functions in the foot. The review of the existing literature, which was undertaken as a part of this thesis, revealed that there is a relationship between microcirculation and the functions of the small nerve fibres. The first study of this thesis highlighted that the skin microcirculation in the foot can be systematically and reliably assessed with the Post-Occlusive Reactive Hyperaemia (PORH) test with an occlusion time of 30 seconds, which makes the test potentially viable in a clinical setting for diabetic foot assessment. The minimal time occlusion can be safe for people with underlying complications and be easily measured alongside ABI or TBI. This study also confirmed that small fibre nerves play an important role in regulating skin temperature, which affects cutaneous perfusion. It was concluded that there is a strong relationship between cutaneous microcirculation and foot skin temperature. In addition, it was found that the skin temperature is an independent predictor of microcirculation, meaning it can be a surrogate method of assessing microcirculation. In summary, this research has contributed to a thorough understanding of the relationship between microcirculatory and both sensory and autonomic functions of the small fibre nerves and their interdependence. Risk assessment of diabetic foot requires comprehensive assessment as one parameter alone cannot help to understand the foot microclimate and identify a foot at risk. The results of the current thesis contribute to the understanding of soft tissue biomechanics and to help develop strategies for a comprehensive assessment of the diabetic foot using time-efficient methods such as PORH and foot temperature measurement. The findings have clinical implications as simple, non-invasive techniques can be instrumental in determining a foot at risk of ulceration, as temperature changes have been associated with foot complications. Such simple assessment techniques can be used in both high and low resource settings for mass screening or even self-screening of the foot. This, in turn, can aid in the prevention and early detection of ulcers, thereby reducing amputations

Characteristics and quality of physical activity apps which provide feedback on user affect. A systematic review and evaluation of public and academic apps

Despite its benefits to both physical and mental health, physical activity levels worldwide remain low and new solutions for behaviour change must be sought. Smartphone apps are extremely popular and prevalent across the population, however their quality is still questionable. Physical activity produces an acute ‘feel good’ effect and intervention designers should consider the role that affect (mood) plays in uptake and maintenance of behaviours. It is timely to examine the use of affect as a motivator for physical activity, using new tools that allow real-time capture of both affect and physical activity (smartphones). The existence, characteristics and quality of physical activity apps that provide feedback on affect were explored in this thesis A mixed methods approach, comprising a systematic review (study 1) and a systematic evaluation (study 2) was taken. Data collection methods included both quantitative and qualitative assessments, using pre-existing and fit-for purpose tools. Twenty-two physical activity apps that provided feedback on affect were identified. Apps often failed to target groups most at risk of poor physical activity levels. Feedback on affect was performed in a variety of ways. Quality of apps, based on 13 criteria, was mixed. Recommendations are made for researchers, app developers and funders, including the need for development of high quality physical activity apps incorporating and emphasising affective benefits, consideration of archiving processes for developed apps once development ceases, and collaboration between researchers, developers and users when designing apps

WHAT DO COMMUNITY HEALTH WORKERS NEED TO PROVIDE COMPREHENSIVE CARE THAT INCORPORATES NON-COMMUNICABLE DISEASES?

Non-Communicable Diseases (NCDs) such as heart disease, stroke, cancer, chronic respiratory diseases and diabetes are the leading cause of premature death and disability worldwide, accounting for 60% of all deaths globally and 80% of NCD related mortality occurring in low and middle-income countries (LMICs). Health systems in LMICs have been oriented toward maternal and child health, and infectious illnesses as these were the main causes of morbidity and mortality until recently. Over the last decade, health systems in LMICs have recognized the need to address NCDs, and have restructured health services to include relevant prevention and control strategies. Health workforce is one of the key building blocks of health systems; however, most LMICs have a shortage of physicians. In addition, the available health care providers are unevenly distributed within countries with the majority concentrated in urban regions compared to rural regions where large proportions of the population reside. This poor distribution and shortage of physicians has led some countries to rely on task shifting, where tasks normally performed by qualified health professionals are transferred to other health providers with a lower level of education and professional training. In 1978, the Declaration of Alma-Ata included trained community health workers (CHWs) and traditional medical practitioners as part of the health team as a fundamental step towards comprehensive primary care. Since then, CHWs have been a cornerstone of health systems in several countries with over 26 different CHW programs identified in the literature across more than 24 LMICs. Traditionally, CHWs do not hold formal professional certification but receive job-related pre-service training. However, there is a lot of variation across countries where some countries require CHW certification before they can start performing their roles. CHWs reside in the community where they work, and are usually volunteers and sometimes receive financial compensation for receiving training and performance-based incentives for health related activities. CHWs can enable essential health care services to be provided in a cost-effective manner. They have been instrumental in reducing maternal and neonatal mortality rates through their presence for home births and making referrals for emergency obstetric care, and by promoting vaccination uptake, breastfeeding, and education about infectious disease. More recently, CHWs have been useful in HIV/AIDS prevention and control, educating communities and performing tasks such as screening, counselling and supplying antiretroviral drugs. With the increasing prevalence of NCDs and to meet changing community health needs, CHWs are sought to provide a similarly appropriate care for NCD risk factors control. While CHWs may not replace qualified health providers, they can play a considerable role in improving health outcomes by educating, screening, referring and following-up individuals at high risk of NCDs. CHWs have been trained in some settings to screen, educate and follow-up patients with NCDs or people at increased risk of NCDs. However, there is a need to better understand how to support CHW programs to be more effective and sustainable. There is knowledge gap in terms of the CHWs current capacity, working conditions, training provided for NCD prevention and control, remuneration, supervision and other upstream challenges facing CHWs and the health systems. The literature suggests that the there is a range of context-specific factors which can have an impact on the performance of CHWs and the quality of the care they provide. Some of these factors include the remuneration schemes employed, the workload, task complexity, lack of clarity in job description, and other essential factors such as interpersonal relationships between CHWs and other members of the primary health care team. CHW programs operate differently across and within countries. Evidence-based policy interventions are required to inform policy decision to ensure effective CHW program implementation. This thesis applies a mixed-methods approach to explore the capacity of the CHWs and the system support necessary to facilitate the CHW’s role in providing comprehensive, community-oriented, continuous primary health care which includes prevention and control strategies for NCDs. Part One provides an insight into the historical background of CHWs and how their role has evolved due to global health needs. With the expanding role of CHWs to incorporate NCDs, part two throws light on training of CHWs for NCDs in LMICs. Chapter two presents results of a systematic review about the effectiveness of training CHWs for cardiovascular disease prevention and management in LMICs. The chapter findings demonstrate the importance of having interactive and culturally adapted training sessions to make the training easier to follow and understand by the CHWs. The findings also highlight the need for evaluating the knowledge and skill-set of the CHWs to capture the training impact; and the necessity of scheduling refresher training at regular intervals to ensure knowledge retention. Chapter three demonstrates the importance of using an evaluation framework such as Kirkpatrick’s evaluation model to evaluate the effectiveness of training among CHWs. Using an evaluation framework, not only assesses the knowledge change but rather employs multiple measures to assess knowledge, skills and behaviour change of the CHWs. This allows for a more comprehensive interpretation of the training outcomes. The qualitative data involved in Chapter three provided insight on the low morale and discontent of the CHWs with their working conditions. In part three, I use a discrete choice experiment (DCE) to provide evidence of effective interventions that can keep the CHWs motivated and retain them in the workforce. Chapter Four explains the process of designing a DCE for Accredited Social Health Activists (ASHAs), who are CHWs in India. It also provides evidence of the feasibility of using Android computer tablets to display the DCE for the CHWs. In chapter five, I examine the relative importance of stated preferences of ASHAs to remain in service using a DCE survey. Career progression was found to be the main influencing factor for ASHAs in addition to fixed salary and other non-financial factors such as priority free family health-check and reduced workload. The findings demonstrated that the ASHAs sociodemographic characteristics such as their education level plays a key role in shaping their preference profile. These findings can inform future policy decisions of evidence-based recruitment and retention strategies that are applicable to the local context. CHWs have proven to be effective in providing a wide range of services including NCDs care. However to optimize the performance of CHW programs, we need to understand the system level support needed and the strategies necessary to be considered in the design and operation of CHWs’ programs. Part four, investigates the policy and implementation elements and system level support needed to enable the CHWs in rural India to provide comprehensive primary health care that incorporates NCDs. Chapter six uses policy review and qualitative research to understand the policy and implementation gaps, current capacity, working conditions and challenges faced by ASHAs in providing NCDs care to their community. It provides an overview of the perspectives of the key stakeholders of the ASHA program including ASHAs, ANMs, primary care doctors, community members, and district medical officers. Findings revealed that ASHAs are unrecognised as formal members of the NCDs delivery team, however they are overburdened with extensive NCDs tasks without receiving training or remuneration for these tasks. ASHAs remain to be volunteers that receive performance based remuneration and are not covered by any of the workers’ rights or laws. However, ASHAs remain enthusiastic about helping their communities and aspire to be recognised as formal employees of the health system with a potential career progression pathway. The concluding chapter summarises the key findings, discusses the main themes emerging from the thesis and outlines the future research directions and policy recommendations