Self-management di malattie croniche in sistemi di mobile Health: sviluppo di un modello agent-based per casi di diabete

L'obiettivo della tesi è proporre e motivare l'adozione di un modello computazionale Agent-Based nell'ambito del Self-Management di malattie croniche in un sistema di mobile Health. Viene quindi affrontata in maniera approfondita la tematica del mobile Health, settore in grande espansione che vede l'introduzione massiccia dei dispositivi mobili (smartphone, tablet, PDA) in ambito sanitario, e quella del Self-Managment di malattie croniche, un processo di cura caratterizzato dalla partecipazione autonoma del paziente stesso, fornendo una panoramica dei vari approcci computazionali sviluppati. Successivamente vengono presentate le peculiarità dei modelli computazionali risultati dalle ricerche in letteratura strumenti innovati nell'ambito. Nel caso di studio viene adottata la tecnica di modellazione Agent-Based per sviluppare un modello a supporto di malati cronici affetti da diabete mellito di tipo 1. Con la successiva implementazione sulla piattaforma di simulazione MASON, vengono eseguiti diversi esperimenti per dimostrare la fattibilità dell’approccio adottato nell'ambito del Self-Management di malattie croniche.

The self-management approach of health education in the treatment of chronic illnesses

Health education is essential to the successful treatment of individuals with chronic illnesses. Self-management is a philosophical model of health education that has been shown to be effective in teaching individuals with chronic arthritis to manage their illness as part of their daily lives. Despite the proven results of arthritis self-management programs, some limitations of this form of health education were apparent in the literature. The present study attempted to address the problems of the self-management approach of health education such as reasons for lack of participation in programs and poor course outcomes. In addition, the study served to investigate the relationship between course outcomes and participation in programs with the theory upon which arthritis self-management programs are based, known as self-efficacy theory. Through a combination of qualitative and quantitative methodologies, data collection, and analysis, a deeper understanding of the self-management phenomenon in the treatment of chronic arthritic conditions was established. Findings of the study confirm findings of previous studies that suggest that arthritis self-management programs result in enhanced levels of self-efficacy and are effective in teaching individuals with arthritis to self-manage their health and health care. Findings of the study suggest that there are many factors that determine the choice of participants to participate in programs and the outcomes for the individuals who do choose to participate in programs. Some of the major determinants of enrollment and outcomes of programs include: the participant's personality, beliefs, attitudes and abilities, and the degree of emotional acceptance of the illness. Other determinants of course enrollment and outcomes included class size and length of time, timing of participation, and ongoing support after the program. The results of the study are consistent with the self-management literature and confirm the relationship between the underlying philosophies of adult education and Freire's model of education and self-management.

Integrating diabetes self-management with the health goals of older adults: A qualitative exploration

Objective. This study investigates the life and health goals of older adults with diabetes, and explores the factors that influence their diabetes self-management. Methods: Qualitative in-depth interviews were conducted with 24 older adults with diabetes and other morbid conditions and/or their caregivers, when appropriate. ^ Results. Participants’ provided a consistent set of responses when describing life and health goals. Participants described goals for longevity, better physical functioning, spending time with family, or maintaining independence. Diabetes discordant conditions, but not diabetes, were seen as barriers to life goals for participants with functional impairments. Functionally independent participants described additional health goals that related to diabetes self-management as diabetes was seen often a barrier to life goals. Caregivers, co-morbid conditions, denial and retirement were among the factors that influenced initiation of diabetes self-management. ^ Conclusion. Participants endorsed health goals and diabetes self-management practices that they believed would help them accomplish their life goals. Functional capabilities and social support were key factors in the relationship between diabetes self-management and their broader goals. ^ Practice implications. When planning diabetes treatments, clinicians, patients and caregivers should discuss the relationship between diabetes self-management and health and life goals as well as the affects of functional limitations and caregiver support.^

Medical advice, diabetes self-management, and health outcomes of a multi-ethnic population from the National Health and Nutrition Examination Survey 2007--2008

Diabetes self-management, an essential component of diabetes care, includes weight control practices and requires guidance from providers. Minorities are likely to have less access to quality health care than White non-Hispanics (WNH) (American College of Physicians-American Society of Internal Medicine, 2000). Medical advice received and understood may differ by race/ethnicity as a consequence of the patient-provider communication process; and, may affect diabetes self-management. ^ This study examined the relationships among participants’ report of: (1) medical advice given; (2) diabetes self-management, and; (3) health outcomes for Mexican-Americans (MA) and Black non-Hispanics (BNH) as compared to WNH (reference group) using data available through the National Health and Nutrition Examination Survey (NHANES) for the years 2007–2008. This study was a secondary, single point analysis. Approximately 30 datasets were merged; and, the quality and integrity was assured by analysis of frequency, range and quartiles. The subjects were extracted based on the following inclusion criteria: belonging to either the MA, BNH or WNH categories; 21 years or older; responded yes to being diagnosed with diabetes. A final sample size of 654 adults [MA (131); BNH (223); WNH (300)] was used for the analyses. The findings revealed significant statistical differences in medical advice reported given. BNH [OR = 1.83 (1.16, 2.88), p = 0.013] were more likely than WNH to report being told to reduce fat or calories. Similarly, BNH [OR = 2.84 (1.45, 5.59), p = 0.005] were more likely than WNH to report that they were told to increase their physical activity. Mexican-Americans were less likely to self-monitor their blood glucose than WNH [OR = 2.70 (1.66, 4.38), p<0.001]. There were differences among ethnicities for reporting receiving recent diabetes education. Black, non-Hispanics were twice as likely to report receiving diabetes education than WNH [OR = 2.29 (1.36, 3.85), p = 0.004]. Medical advice reported given and ethnicity/race, together, predicted several health outcomes. Having recent diabetes education increased the likelihood of performing several diabetes self-management behaviors, independent of race. ^ These findings indicate a need for patient-provider communication and care to be assessed for effectiveness and, the importance of ongoing diabetes education for persons with diabetes.^

Simulazione agent-based di un sistema di m-Health per il self-management del diabete di tipo 1

L'obiettivo della tesi è dimostrare l'utilità e i vantaggi che può fornire il Self-Management del diabete mellito di tipo 1 in un sistema di mobile Health a partire da un modello computazionale Agent-Based. Viene quindi affrontata in maniera approfondita la tematica del mobile Health ed il suo sviluppo nei paesi a basso/medio reddito, illustrando i risultati ottenuti dalla ricerca scientifica fino ad oggi, ed il concetto di Self-Management di malattie croniche, un processo di cura caratterizzato dalla partecipazione autonoma del paziente stesso, fornendo una panoramica degli approcci computazionali sviluppati. Viene quindi studiato il diabete mellito in ogni sua caratteristica, seguito dall'illustrazione di diverse applicazioni per la gestione autonoma della suddetta patologia tutt'ora in commercio. Nel caso di studio vengono effettuate diverse simulazioni, tramite la piattaforma di simulazione MASON, per realizzare varie dinamiche della rete fisiologica di un paziente al fine di stabilire feedback qualitativi per il Self-Management della patologia.

Mobile phone technologies and advanced data analysis towards the enhancement of diabetes self-management

Advances in the area of mobile and wireless communication for healthcare (m-Health) along with the improvements in information science allow the design and development of new patient-centric models for the provision of personalised healthcare services, increase of patient independence and improvement of patient's self-control and self-management capabilities. This paper comprises a brief overview of the m-Health applications towards the self-management of individuals with diabetes mellitus and the enhancement of their quality of life. Furthermore, the design and development of a mobile phone application for Type 1 Diabetes Mellitus (T1DM) self-management is presented. The technical evaluation of the application, which permits the management of blood glucose measurements, blood pressure measurements, insulin dosage, food/drink intake and physical activity, has shown that the use of the mobile phone technologies along with data analysis methods might improve the self-management of T1DM.

Sistemi di Mobile-Health per il monitoraggio e l'assistenza alla gravidanza

Con il termine "Mobile-Health" si intende l’uso di tecnologie mobili in ambito medico-sanitario. Questa tesi si propone di fornire un quadro generale di come i sistemi di Mobile-Health possano aiutare nell'assistenza e nel monitoraggio della gravidanza. Attraverso l'analisi delle ricerche effettuate in questo campo, e lo studio dei sistemi attualmente utilizzati in ambito ospedaliero, si cerca di valutare se effettivamente questo tipo di tecnologie può fornire un contributo significativo nell'assistere le donne incinte. Viene trattato il tema del Self-Management che riguarda appunto l'auto-gestione della propria condizione di salute attraverso l’uso di tecnologie mobili. Vengono introdotti problemi e complicazioni della gravidanza e i corrispettivi trattamenti. Si analizzano studi e ricerche che riguardano dispositivi e software per le donne incinte, compreso il tema delle “app mediche”. Infine, grazie al contributo delle dottoresse Iliana Colonna e Marina Carfagna (coordinatrici ostetriche negli ospedali di Rimini e Cesena), si presenta una panoramica sull’attuale uso di tecnologie nei reparti ospedalieri di ostetricia.

Reaching those most in need: a review of diabetes self-management interventions in disadvantaged populations

There has been increased recognition of the importance of developing diabetes self-management education (DSME) interventions that are effective with under-served and minority populations. Despite several recent studies in this area, there is to our knowledge no systematic review or synthesis of what has been learned from this research. An electronic literature search identified five formative evaluations and ten controlled DSME intervention trials focused on under-served (low-income, minority or aged) populations. The RE-AIM (Reach, Efficacy, Adoption, Implementation, Maintenance) evaluation framework was used to evaluate the controlled studies on the dimensions of reach, efficacy, adoption, implementation, and maintenance. Fifty percent of the studies identified reported on the percentage of patients who participated, and the percentages were highly variable. The methodological quality of the articles was generally good and the short-term results were encouraging, especially on behavioral outcomes. Data on adoption (representativeness of settings and clinicians who participate) and implementation were almost never reported. Studies of modalities in addition to group meetings are needed to increase the reach of DSME with under-served populations. The promising formative evaluation work that has been conducted needs to be extended for more systematic study of the process of intervention implementation and adaptation with special populations. Studies that explicitly address the community context and that address multiple issues related to public health impact of DSME interventions are recommended to enhance long-term results. Copyright (C) 2002 John Wiley Sons, Ltd.

Communication in Smoking Cessation and Self-management : a study at Nurse-led COPD-clinics in Primary Health Care

ABSTRACTThe general aim of this thesis was to investigate behavioral change communication at nurse-led chronic obstructive pulmonary disease (COPD) clinics in primary health care, focusing on communication in self-management and smoking cessation for patients with COPD.Designs: Observational, prospective observational and experimental designs were used.Methods: To explore and describe the structure and content of self-management education and smoking cessation communication, consultations between patients (n=30) and nurses (n=7) were videotaped and analyzed with three instruments: Consulting Map (CM), the Motivational Interviewing Treatment Integrity (MITI) scale and the Client Language Assessment in Motivational Interviewing (CLAMI). To examine the effects of structured self-management education, patients with COPD (n=52) were randomized in an intervention and a control group. Patients’ quality of life (QoL), knowledge about COPD and smoking cessation were examined with a questionnaire on knowledge about COPD and smoking habits and with St. George’s Respiratory Questionnaire, addressing QoL. Results: The findings from the videotaped consultations showed that communication about the reasons for consultation mainly concerned medical and physical problems and (to a certain extent) patients´ perceptions. Two consultations ended with shared understanding, but none of the patients received an individual treatment-plan. In the smoking cessation communication the nurses did only to a small extent evoke patients’ reasons for change, fostered collaboration and supported patients’ autonomy. The nurses provided a lot of information (42%), asked closed (21%) rather than open questions (3%), made simpler (14%) rather than complex (2%) reflections and used MI non-adherent (16%) rather than MI-adherent (5%) behavior. Most of the patients’ utterances in the communication were neutral either toward or away from smoking cessation (59%), utterances about reason (desire, ability and need) were 40%, taking steps 1% and commitment to stop smoking 0%. The number of patients who stopped smoking, and patients’ knowledge about the disease and their QoL, was increased by structured self-management education and smoking cessation in collaboration between the patient, nurse and physician and, when necessary, a physiotherapist, a dietician, an occupational therapist and/or a medical social worker.Conclusion The communication at nurse-led COPD clinics rarely involved the patients in shared understanding and responsibility and concerned patients’ fears, worries and problems only to a limited extent. The results also showed that nurses had difficulties in attaining proficiency in behavioral change communication. Structured self-management education showed positive effects on patients’ perceived QoL, on the number of patients who quit smoking and on patients’ knowledge about COPD.

Relationships among epilepsy self-management, health outcomes, and socioeconomic status

The purpose of this study was to investigate the association between epilepsy self-management and disease control and socio-economic status. Study participants were adult patients at two epilepsy specialty clinics in Houston, Texas that serve demographically and socioeconomically diverse populations. Self-management behaviors- medication, information, safety, seizure, and lifestyle management were tested against emergency room visits, hospitalizations, and seizure occurrence. Overall self-management score was associated with a greater likelihood of hospitalizations over a prior twelve month time frame, but not for three months, and was not associated with seizure occurrence or emergency room visits, at all. Scores on specific self-management behaviors varied in their relationships to the different disease control indicators, over time. Contrary to expectations based on the findings of previous research, higher information management scores were associated with greater likelihood of emergency room visits and hospitalizations, over the study's twelve months. Higher lifestyle management scores were associated with lower likelihood of any emergency room visits, over the preceding twelve months and emergency room visits for the last three months. The positive associations between overall self-management scores and information management behaviors and disease control are contrary to published research. These findings may indicate that those with worse disease control in a prior period employ stronger self-management efforts to better control their epilepsy. Further research is needed to investigate this hypothesis.^

Health changes in Hispanic older adults in a Spanish arthritis self -management education program

Arthritis is the most common chronic condition affecting older people and is a major cause of limited activity. Arthritis education programs in English have demonstrated a positive impact on health but these programs have not reached the Hispanic communities where arthritis is the leading cause of disability. Minorities, such as Hispanics, have traditionally been reluctant to pursue self-help programs, and have been identified as an under-served population in terms of medical care. This study examined the effectiveness of one community health adult education program targeting Hispanic older adults with arthritis, the Spanish Arthritis Self Management Education Program (SASMEP), by evaluating changes in the participants' general health, pain, disability, self-efficacy, health perceptions, frequency of physician visits, and exercise. A pre and post control group experimental design and analyses of covariance were used to determine the pre and post differences in health status and health behaviors for a group participating in the SASMEP and a group who did not using gender and age as covariates. A repeated measures design was also used, and repeated measures analyses of variance and post hoc tests were done on health status and health behavior data collected pre, post and one-year post education to determine long-term differences. ^ Results indicated the participants' health status significantly improved in general health, significantly decreased in pain, and significantly decreased in arthritic disability immediately following the education. Self-efficacy and health perceptions increased for both groups but not significantly. The participants' health behaviors showed significantly fewer physician visits and significantly increased time spent performing stretching and strengthening exercise and time spent performing aerobic exercise. No group differences were found in the frequency of arthritis physician visits. ^ The improvements seen immediately after the SASMEP participation were not reflected in the post one-year scores. No significant differences were found for the participants' health status or health behaviors one year following the education. Health status and health behaviors did not return below baseline scores after one year suggesting the participants' health, although not improved, did not deteriorate. Therefore, the SASMEP education provided short-term health benefits for older Hispanic adults with arthritis, but not long-term health benefits. ^

Diabetes Self Management: Are Cuban Americans Receiving Quality Health Care?

Objectives: We investigated the relationship among factors predicting inadequate glucose control among 182 Cuban-American adults (Females=110, Males=72) with type 2 diabetes mellitus (CAA). Study Design: Cross-sectional study of CAA from a randomized mailing list in two counties of South Florida Methods: Fasted blood parameters and anthropometric measures were collected during the study. BMI was calculated (kg/ m2). Characteristics and diabetes care of CAA were self-reported Participants were screened by trained interviewers for heritage and diabetes status (inclusion criteria: self-reported having type 2 diabetes; age  35 years, male and female; not pregnant or lactating; no thyroid disorders; no major psychiatric disorders). Participants signed informed consent form. Statistical analyses used SPSS and included descriptive statistic, multiple logistic and ordinal logistic regression models, where all CI 95%. Results: Eighty-eight percent of CAA had BMI of ≥ 25 kg/ m2. Only 54% reported having a diet prescribed/told to schedule meals. We found CAA told to schedule meals were 3.62 more likely to plan meals (1.81, 7.26), p<0.001) and given a prescribed diet, controlling for age, corresponded with following a meal plan OR 4.43 (2.52, 7.79, p<0.001). The overall relationship for HbA1c < 8.5 to following a meal plan was OR 9.34 (2.84, 30.7. p<0.001). Conclusions: The advantage of having a medical professional prescribe a diet seems to be an important environmental support factor in this sample’s diabetes care, since obesity rates are well above the national average. Nearly half CAA are not given dietary guidance, yet our results indicate CAA may improve glycemic control by receiving dietary instructions.

Diabetes Self-management Behaviors, Medical Care, Glycemic Control, and Self-rated Health in US Men by Race/Ethnicity

Men, particularly minorities, have higher rates of diabetes as compared with their counterparts. Ongoing diabetes self-management education and support by specialists are essential components to prevent the risk of complications such as kidney disease, cardiovascular diseases, and neurological impairments. Diabetes self-management behaviors, in particular, as diet and physical activity, have been associated with glycemic control in the literature. Recommended medical care for diabetes may differ by race/ethnicity. This study examined data from the National Health and Nutrition Examination Surveys, 2007 to 2010 for men with diabetes (N = 646) from four racial/ethnic groups: Mexican Americans, other Hispanics, non-Hispanic Blacks, and non-Hispanic Whites. Men with adequate dietary fiber intake had higher odds of glycemic control (odds ratio = 4.31, confidence interval [1.82, 10.20]), independent of race/ethnicity. There were racial/ethnic differences in reporting seeing a diabetes specialist. Non-Hispanic Blacks had the highest odds of reporting ever seeing a diabetes specialist (84.9%) followed by White non-Hispanics (74.7%), whereas Hispanics reported the lowest proportions (55.2% Mexican Americans and 62.1% other Hispanics). Men seeing a diabetes specialist had the lowest odds of glycemic control (odds ratio = 0.54, confidence interval [0.30, 0.96]). The results of this study suggest that diabetes education counseling may be selectively given to patients who are not in glycemic control. These findings indicate the need for examining referral systems and quality of diabetes care. Future studies should assess the effectiveness of patient-centered medical care provided by a diabetes specialist with consideration of sociodemographics, in particular, race/ethnicity and gender.

Programas de self-management em pacientes com DPOC: uma revisão sistemática

Introdução: Programas de self-management têm como objectivo habilitar os pacientes com estratégias necessárias para levar a cabo procedimentos específicos para a patologia. A última revisão sistemática sobre selfmanagament em DPOC foi realizada em 2007, concluindo-se que ainda não era possível fornecer dados claros e suficientes acerca de recomendações sobre a estrutura e conteúdo de programas de self-managament na DPOC. A presente revisão tem o intuito de complementar a análise da revisão anterior, numa tentativa de inferir a influência do ensino do self-management na DPOC. Objectivos: verificar a influência dos programas de self-management na DPOC, em diversos indicadores relacionados com o estado de saúde do paciente e na sua utilização dos serviços de saúde. Estratégia de busca: pesquisa efectuada nas bases de dados PubMed e Cochrane Collaboration (01/01/2007 – 31/08/2010). Palavras-chave: selfmanagement education, self-management program, COPD e pulmonary rehabilitation. Critérios de Selecção: estudos randomizados sobre programas de selfmanagement na DPOC. Extracção e Análise dos Dados: 2 investigadores realizaram, independentemente, a avaliação e extracção de dados de cada artigo. Resultados: foram considerados 4 estudos randomizados em selfmanagement na DPOC nos quais se verificaram benefícios destes programas em diversas variáveis: qualidade de vida a curto e médio prazo, utilização dos diferentes recursos de saúde, adesões a medicação de rotina, controle das exacerbações e diminuição da sintomatologia. Parece não ocorrer alteração na função pulmonar e no uso de medicação de emergência, sendo inconclusivo o seu efeito na capacidade de realização de exercício. Conclusões: programas de self-management aparentam ter impacto positivo na qualidade de vida, recurso a serviços de saúde, adesão à medicação, planos de acção e níveis de conhecimento da DPOC. Discrepâncias nos critérios de selecção das amostras utilizadas, períodos de seguimento desiguais, consistência das variáveis mensuradas, condicionam a informação disponibilizada sobre este assunto.