Salutogenesis: a new paradigm for pervasive computing in healthcare environments?

Salutogenesis is now accepted as a part of the contemporary model of disease: an individual is not only affected by pathogenic factors in the environment, but those that promote well-being or salutogenesis. Given that "environment" extends to include the built environment, promotion of salutogenesis has become part of the architectural brief for contemporary healthcare facilities, drawing on an increasing evidence-base. Salutogenesis is inextricably linked with the notion of person-environment "fit". MyRoom is a proposal for an integrated architectural and pervasive computing model, which enhances psychosocial congruence by using real-time data indicative of the individual's physical status to enable the environment of his/her room (colour, light, temperature) to adapt on an on-going basis in response to bio-signals. This work is part of the PRTLI-IV funded programme NEMBES, investigating the use of embedded technologies in the built environment. Different care contexts require variations in the model, and iterative prototyping investigating use in different contexts will progressively lead to the development of a fully-integrated adaptive salutogenic single-room prototype.

The impact of user charges on patient choice of healthcare services in Ireland

This research assesses the impact of user charges in the context of consumer choice to ascertain how user charges in healthcare impact on patient behaviour in Ireland. Quantitative data is collected from a subset of the population in walk-in Urgent Care Clinics and General Practitioner surgeries to assess their responses to user charges and whether user charges are a viable source of part-funding healthcare in Ireland. Examining the economic theories of Becker (1965) and Grossman (1972), the research has assessed the impact of user charges on patient choice in terms of affordability and accessibility in healthcare. The research examined a number of private, public and part-publicly funded healthcare services in Ireland for which varying levels of user charges exist depending on patients’ healthcare cover. Firstly, the study identifies the factors affecting patient choice of privately funded walk-in Urgent Care Clinics in Ireland given user charges. Secondly, the study assesses patient response to user charges for a mainly public or part-publicly provided service; prescription drugs. Finally, the study examines patients’ attitudes towards the potential application of user charges for both public and private healthcare services when patient choice is part of a time-money trade-off, convenience choice or preference choice. These services are valued in the context of user charges becoming more prevalent in healthcare systems over time. The results indicate that the impact of user charges on healthcare services vary according to socio-economic status. The study shows that user charges can disproportionately affect lower income groups and consequently lead to affordability and accessibility issues. However, when valuing the potential application of user charges for three healthcare services (MRI scans, blood tests and a branded over a generic prescription drug), this research indicates that lower income individuals are willing to pay for healthcare services, albeit at a lower user charge than higher income earners. Consequently, this study suggests that user charges may be a feasible source of part-financing Irish healthcare, once the user charge is determined from the patients’ perspective, taking into account their ability to pay.

The knowledge, attitudes and beliefs of patients and their healthcare professionals around oral dosage form modification: a systematic review of the qualitative literature

Objectives: The objective of this systematic review was to synthesize the available qualitative evidence on the knowledge, attitudes and beliefs of adult patients, healthcare professionals and carers about oral dosage form modification. Design: A systematic review and synthesis of qualitative studies was undertaken, utilising the thematic synthesis approach. Data sources: The following databases were searched from inception to September 2015: PubMed, Medline (EBSCO), EMBASE, CINAHL, PsycINFO, Web of Science, ProQuest Databases, Scopus, Turning Research Into Practice (TRIP), Cochrane Central Register of Controlled Trials (CENTRAL) and the Cochrane Database of Systematic Reviews (CDSR). Citation tracking and searching the references lists of included studies was also undertaken. Grey literature was searched using the OpenGrey database, internet searching and personal knowledge. An updated search was undertaken in June 2016. Review methods: Studies meeting the following criteria were eligible for inclusion; (i) used qualitative data collection and analysis methods; (ii) full-text was available in English; (iii) included adult patients who require oral dosage forms to be modified to meet their needs or; (iv) carers or healthcare professionals of patients who require oral dosage forms to be modified. Two reviewers independently appraised the quality of the included studies using the Critical Appraisal Skills Programme Checklist. A thematic synthesis was conducted and analytical themes were generated. Results: Of 5455 records screened, seven studies were eligible for inclusion; three involved healthcare professionals and the remaining four studies involved patients. Four analytical themes emerged from the thematic synthesis: (i) patient-centred individuality and variability; (ii) communication; (iii) knowledge and uncertainty and; (iv) complexity. The variability of individual patient’s requirements, poor communication practices and lack of knowledge about oral dosage form modification, when combined with the complex and multi-faceted healthcare environment complicate decision making regarding oral dosage form modification and administration. Conclusions: This systematic review has highlighted the key factors influencing the knowledge, attitudes and beliefs of patients and healthcare professionals about oral dosage form modifications. The findings suggest that in order to optimise oral medicine modification practices the needs of individual patients should be routinely and systematically assessed and decision-making should be supported by evidence based recommendations with multidisciplinary input. Further research is needed to optimise oral dosage form modification practices and the factors identified in this review should be considered in the development of future interventions.

The Effects of Advanced Practice Nurses (APNs) as Intensivists in a Surgical Intensive Care Unit (SICU) on Patient Outcomes, Healthcare Charges, and APN Intensivist Services in the SICU

Intensive Care Units (ICUs) account for over 10 percent of all US hospital beds, have over 4.4 million patient admissions yearly, approximately 360,000 deaths, and account for close to 30% of acute care hospital costs. The need for critical care services has increased due to an aging population and medical advances that extend life. The result is efforts to improve patient outcomes, optimize financial performance, and implement models of ICU care that enhance quality of care and reduce health care costs. This retrospective chart review study examined the dose effect of APN Intensivists in a surgical intensive care unit (SICU) on differences in patient outcomes, healthcare charges, SICU length of stay, charges for APN intensivist services, and frequency of APNs special initiatives when the SICU was staffed by differing levels of APN Intensivist staffing over four time periods (T1-T4) between 2009 and 2011. The sample consisted of 816 randomly selected (204 per T1-T4) patient chart data. Study findings indicated reported ventilator associated pneumonia (VAP) rates, ventilator days, catheter days and catheter associated urinary tract infection (CAUTI) rates increased at T4 (when there was the lowest number of APN Intensivists), and there was increased pressure ulcer incidence in first two quarters of T4. There was no statistically significant difference in post-surgical glycemic control (M = 142.84, SD= 40.00), t (223) = 1.40, p = .17, and no statistically significant difference in the SICU length of stay among the time-periods (M= 3.27, SD = 3.32), t (202) = 1.02, p= .31. Charges for APN services increased over the 4 time periods from $11,268 at T1 to $51,727 at T4 when a system to capture APN billing was put into place. The number of new APN initiatives declined in T4 as the number of APN Intensivists declined. Study results suggest a dose effect of APN Intensivists on important patient health outcomes and on the number of APNs initiatives to prevent health complications in the SICU.

Reference list of 265 sources used for the discovery of relationships between data clusters and metadata properties

Visual cluster analysis provides valuable tools that help analysts to understand large data sets in terms of representative clusters and relationships thereof. Often, the found clusters are to be understood in context of belonging categorical, numerical or textual metadata which are given for the data elements. While often not part of the clustering process, such metadata play an important role and need to be considered during the interactive cluster exploration process. Traditionally, linked-views allow to relate (or loosely speaking: correlate) clusters with metadata or other properties of the underlying cluster data. Manually inspecting the distribution of metadata for each cluster in a linked-view approach is tedious, specially for large data sets, where a large search problem arises. Fully interactive search for potentially useful or interesting cluster to metadata relationships may constitute a cumbersome and long process. To remedy this problem, we propose a novel approach for guiding users in discovering interesting relationships between clusters and associated metadata. Its goal is to guide the analyst through the potentially huge search space. We focus in our work on metadata of categorical type, which can be summarized for a cluster in form of a histogram. We start from a given visual cluster representation, and compute certain measures of interestingness defined on the distribution of metadata categories for the clusters. These measures are used to automatically score and rank the clusters for potential interestingness regarding the distribution of categorical metadata. Identified interesting relationships are highlighted in the visual cluster representation for easy inspection by the user. We present a system implementing an encompassing, yet extensible, set of interestingness scores for categorical metadata, which can also be extended to numerical metadata. Appropriate visual representations are provided for showing the visual correlations, as well as the calculated ranking scores. Focusing on clusters of time series data, we test our approach on a large real-world data set of time-oriented scientific research data, demonstrating how specific interesting views are automatically identified, supporting the analyst discovering interesting and visually understandable relationships.

Barriers to working with people affected by cancer: Preliminary qualitative data from a mixed methods exploration of practitioner perspectives in nutritional therapy

Introduction: Cancer is a leading cause of death worldwide. Nutrition may affect occurrence, recurrence and survival rates and many cancer patients and survivors seek individualized nutrition advice. Appropriately skilled nutritional therapy (NT) practitioners may be well-placed to safely provide this advice, but little is known of their perspectives on working with people affected by cancer. This mixed-methods study seeks to explore their views on training, barriers to practice, use of evidence, and other resources, to support the development of safe evidence-based practice. Preliminary data on barriers to practice are reported here. Methods: Two cohorts of NT practitioners were recruited from all UK registered NT practitioners, by an on-line anonymous survey. 84 cancer practitioners (CP) and 165 non-cancer practitioners (NCP) were recruited. Mixed quantitative and qualitative data was collected by the survey. Content analysis was used to analyze qualitative data on the use of evidence, barriers to practice and perceived needs for working with clients with cancer, for further exploration using interviews and focus groups. Preliminary results: For the NCP cohort, exploring themes of perceived barriers to working with people affected by cancer suggested that perceived complexity, risk and need for caution in this area of practice were important barriers. Insufficient specialist knowledge and skills also emerged as barriers. Some NCPs perceived opposition from medical practitioners and other mainstream healthcare professions as an obstacle to starting cancer practice. To overcome these barriers, specialist training emerged as most important. For the CP cohort, in exploring the skills they considered enabled them to undertake cancer work, specialist clinical and technical knowledge emerged strongly. Only 10% CP participants did not want more work with people affected by cancer. 10% CPs reported some NHS referrals, whereas most received clients by self-referral or from other practitioners. When considering barriers that impede their cancer practice, the dominant categories for CPs were hostility or opposition by mainstream oncology professionals, and lack of dialogue and engagement with them. To overcome these barriers, CPs desired engagement with oncology professionals and recognized specialist cancer NT training. For both NCPs and CPs, evidence resources, practice guidelines and practitioner support networks also emerged as potential enablers to cancer practice. Conclusions: This is the first detailed exploration of NT practitioners’ perceived barriers to working with people affected by cancer. Acquiring specialist skills and knowledge appears important to enable NCPs to start cancer work, and for CPs with these skills, the perceived barriers appear foremost in the relationship with mainstream cancer professionals. Further exploration of these themes, and other NT practitioner perspectives on working with people affected by cancer, is underway. This work will inform and support the development of professional practice, training and other resources.

Chemotherapy patient perception regarding communication with the healthcare staff

Purpose: To qualitatively explore the communication between healthcare professionals and oncology patients based on the perception of patients undergoing chemotherapy.Method: Qualitative and exploratory design. Participants were 14 adult patients undergoing chemotherapy at different stages of the disease. A socio-demographic and clinical data form was utilized along with semi-structured interviews. The interviews were audio-recorded, transcribed and content analysis was performed. Two independent judges evaluated the interview content in regards to emerging categories and obtained a Kappa index of 0.834.Results: Three categories emerged from the data: 1) Technical communication without emotional support, in which the information provided is composed of strictly technical information regarding the diagnosis, treatment and/or prognosis; 2) Technical communication, in which the information provided is oriented towards the technical aspects of the patient’s physical condition, while also providing psychological support for the patients’ subjective needs; and 3) Insufficient technical communication, win which there are gaps in the information provided causing confusion and suffering to the patient.Conclusions: Communication with emotional support contributes to greater satisfaction of chemotherapy patients. Practical implications: the results provide elements for the training of healthcare professionals regarding the importance of the emotional support that can be offered to cancer patients during their treatment.

The role of learning design and learning analytics in MOOCs

The last couple of years there has been a lot of attention for MOOCs. More and more universities start offering MOOCs. Although the open dimension of MOOC indicates that it is open in every aspect, in most cases it is a course with a structure and a timeline within which learning activities are positioned. There is a contradiction there. The open aspect puts MOOCs more in the non-formal professional learning domain, while the course structure takes it into the formal, traditional education domain. Accordingly, there is no consensus yet on solid pedagogical approaches for MOOCs. Something similar can be said for learning analytics, another upcoming concept that is receiving a lot of attention. Given its nature, learning analytics offers a large potential to support learners in particular in MOOCs. Learning analytics should then be applied to assist the learners and teachers in understanding the learning process and could predict learning, provide opportunities for pro-active feedback, but should also results in interventions aimed at improving progress. This paper illustrates pedagogical and learning analytics approaches based on practices developed in formal online and distance teaching university education that have been fine-tuned for MOOCs and have been piloted in the context of the EU-funded MOOC projects ECO (Elearning, Communication, Open-Data: http://ecolearning.eu) and EMMA (European Multiple MOOC Aggregator: http://platform.europeanmoocs.eu).

Applying standards to systematize learning analytics in serious games

Learning Analytics is an emerging field focused on analyzing learners’ interactions with educational content. One of the key open issues in learning analytics is the standardization of the data collected. This is a particularly challenging issue in serious games, which generate a diverse range of data. This paper reviews the current state of learning analytics, data standards and serious games, studying how serious games are tracking the interactions from their players and the metrics that can be distilled from them. Based on this review, we propose an interaction model that establishes a basis for applying Learning Analytics into serious games. This paper then analyzes the current standards and specifications used in the field. Finally, it presents an implementation of the model with one of the most promising specifications: Experience API (xAPI). The Experience API relies on Communities of Practice developing profiles that cover different use cases in specific domains. This paper presents the Serious Games xAPI Profile: a profile developed to align with the most common use cases in the serious games domain. The profile is applied to a case study (a demo game), which explores the technical practicalities of standardizing data acquisition in serious games. In summary, the paper presents a new interaction model to track serious games and their implementation with the xAPI specification.

Game Learning Analytics: Learning Analytics for Serious Games

Video games have become one of the largest entertainment industries, and their power to capture the attention of players worldwide soon prompted the idea of using games to improve education. However, these educational games, commonly referred to as serious games, face different challenges when brought into the classroom, ranging from pragmatic issues (e.g. a high development cost) to deeper educational issues, including a lack of understanding of how the students interact with the games and how the learning process actually occurs. This chapter explores the potential of data-driven approaches to improve the practical applicability of serious games. Existing work done by the entertainment and learning industries helps to build a conceptual model of the tasks required to analyze player interactions in serious games (gaming learning analytics or GLA). The chapter also describes the main ongoing initiatives to create reference GLA infrastructures and their connection to new emerging specifications from the educational technology field. Finally, it explores how this data-driven GLA will help in the development of a new generation of more effective educational games and new business models that will support their expansion. This results in additional ethical implications, which are discussed at the end of the chapter.

A realist synthesis of educational interventions to improve nutrition care competencies and delivery by doctors and other healthcare professionals

Objective: To determine what, how, for whom, why, and in what circumstances educational interventions to improve the delivery of nutrition care by doctors and other healthcare professionals work?

Design: Realist synthesis following a published protocol and reported following Realist and Meta-narrative Evidence Synthesis: Evolving Standards (RAMESES) guidelines. A multidisciplinary team searched Medline, CINAHL, ERIC, EMBASE, PsyINFO, Sociological Abstracts, Web of Science, Google Scholar, and Science Direct for published and unpublished (grey) literature. The team identified studies with varied designs; appraised their ability to answer the review question; identified relationships between contexts, mechanisms, and outcomes (CMOs); and entered them into a spreadsheet configured for the purpose. The final synthesis identified commonalities across CMO configurations.

Results: Over half of the 46 studies from which we extracted data originated from the US. Interventions that improved the delivery of nutrition care improved skills and attitudes rather than just knowledge; provided opportunities for superiors to model nutrition care; removed barriers to nutrition care in health systems; provided participants with local, practically relevant tools and messages; and incorporated non-traditional, innovative teaching strategies. Operating in contexts where student and qualified healthcare professionals provided nutrition care in both developed and developing countries, these interventions yielded health outcomes by triggering a range of mechanisms, which included: feeling competent; feeling confident and comfortable; having greater self-efficacy; being less inhibited by barriers in healthcare systems; and feeling that nutrition care was accepted and recognised.

Conclusion: These findings show how important it is to move education for nutrition care beyond the simple acquisition of knowledge. They show how educational interventions embedded within systems of healthcare can improve patients’ health by helping health students and professionals to appreciate the importance of delivering nutrition care and feel competent to deliver it.

The epidemiology, healthcare and societal burden and costs of asthma in the UK and its member nations: analyses of standalone and linked national databases

Background: There are a lack of reliable data on the epidemiology and associated burden and costs of asthma. We sought to provide the first UK-wide estimates of the epidemiology, healthcare utilisation and costs of asthma. 

Methods: We obtained and analysed asthma-relevant data from 27 datasets: these comprised national health surveys for 2010-11, and routine administrative, health and social care datasets for 2011-12; 2011-12 costs were estimated in pounds sterling using economic modelling. 

Results: The prevalence of asthma depended on the definition and data source used. The UK lifetime prevalence of patient-reported symptoms suggestive of asthma was 29.5 % (95 % CI, 27.7-31.3; n = 18.5 million (m) people) and 15.6 % (14.3-16.9, n = 9.8 m) for patient-reported clinician-diagnosed asthma. The annual prevalence of patient-reported clinician-diagnosed-and-treated asthma was 9.6 % (8.9-10.3, n = 6.0 m) and of clinician-reported, diagnosed-and-treated asthma 5.7 % (5.7-5.7; n = 3.6 m). Asthma resulted in at least 6.3 m primary care consultations, 93,000 hospital in-patient episodes, 1800 intensive-care unit episodes and 36,800 disability living allowance claims. The costs of asthma were estimated at least £1.1 billion: 74 % of these costs were for provision of primary care services (60 % prescribing, 14 % consultations), 13 % for disability claims, and 12 % for hospital care. There were 1160 asthma deaths. 

Conclusions: Asthma is very common and is responsible for considerable morbidity, healthcare utilisation and financial costs to the UK public sector. Greater policy focus on primary care provision is needed to reduce the risk of asthma exacerbations, hospitalisations and deaths, and reduce costs.

Outlier effects on robust joint modelling of longitudinal and survival data

Robust joint modelling is an emerging field of research. Through the advancements in electronic patient healthcare records, the popularly of joint modelling approaches has grown rapidly in recent years providing simultaneous analysis of longitudinal and survival data. This research advances previous work through the development of a novel robust joint modelling methodology for one of the most common types of standard joint models, that which links a linear mixed model with a Cox proportional hazards model. Through t-distributional assumptions, longitudinal outliers are accommodated with their detrimental impact being down weighed and thus providing more efficient and reliable estimates. The robust joint modelling technique and its major benefits are showcased through the analysis of Northern Irish end stage renal disease patients. With an ageing population and growing prevalence of chronic kidney disease within the United Kingdom, there is a pressing demand to investigate the detrimental relationship between the changing haemoglobin levels of haemodialysis patients and their survival. As outliers within the NI renal data were found to have significantly worse survival, identification of outlying individuals through robust joint modelling may aid nephrologists to improve patient's survival. A simulation study was also undertaken to explore the difference between robust and standard joint models in the presence of increasing proportions and extremity of longitudinal outliers. More efficient and reliable estimates were obtained by robust joint models with increasing contrast between the robust and standard joint models when a greater proportion of more extreme outliers are present. Through illustration of the gains in efficiency and reliability of parameters when outliers exist, the potential of robust joint modelling is evident. The research presented in this thesis highlights the benefits and stresses the need to utilise a more robust approach to joint modelling in the presence of longitudinal outliers.

Gestengestützte Schema- und Datenexploration

Der Zugang zu Datenbanken über die universelle Abfragesprache SQL stellt für Nicht-Spezialisten eine große Herausforderung dar. Als eine benutzerfreundliche Alternative wurden daher seit den 1970er-Jahren unterschiedliche visuelle Abfragesprachen (Visual Query Languages, kurz VQLs) für klassische PCs erforscht. Ziel der vorliegenden Arbeit ist es, eine generische VQL zu entwickeln und zu erproben, die eine gestenbasierte Exploration von Datenbanken auf Schema- und Instanzdatenebene für mobile Endgeräte, insbesondere Tablets, ermöglicht. Dafür werden verschiedene Darstellungsformen, Abfragestrategien und visuelle Hints für Fremdschlüsselbeziehungen untersucht, die den Benutzer bei der Navigation durch die Daten unterstützen. Im Rahmen einer Anforderungsanalyse erwies sich die Visualisierung der Daten und Beziehungen mittels einer platzsparenden geschachtelten NF2-Darstellung als besonders vorteilhaft. Zur Steuerung der Datenbankexploration wird eine geeignete Gestensprache, bestehend aus Stroke-, Multitouch- und Mid-Air-Gesten, vorgestellt. Das Gesamtkonzept aus Darstellung und Gestensteuerung wurde anhand des im Rahmen dieser Arbeit entwickelten GBXT-Prototyps auf seine reale Umsetzbarkeit hin, als plattformunabhängige Single-Page-Application für verschiedene mobile Endgeräte mittels JavaScript und HTML5/CSS3 untersucht.

The Big Crunch : A Mapping of the Swedish Party System from 1991 to 2010

Previous research claims that there has been a narrowing of distance between the Swedish political parties. Typically, such research into political distance has primarily focused on studying voters rather than the political parties themselves. In this article, the author conducts a longitudinal analysis of Comparative Manifesto Project data to determine if, and to what extent, the political parties have converged ideologically on a Left-Right continuum in the period 1991-2010. After first unraveling the concept of political distance, the author moves on to explain why the ideological dispersion of political parties is an important and consequential characteristic within party systems. Furthermore, the author argues that the Left-Right ideological scale continues to be a highly useful model with which to conceptualize and study this characteristic. The author then discusses the methodological approach and explains why quantitative manifesto data, often overlooked in favor of voter interview data, is deemed a valid and reliable material for measuring the ideological positions of political parties. The findings are that there indeed have been over all tendencies of ideological convergence between the blocs and that, in terms of how political parties are dispersed on a Left- Right ideological continuum, by 2010, the Swedish party system (the Sweden Democrats excluded) had become much less polarized than it had been in 1991.