Secure and privacy-preserving solutions for mobile health system : design and application

黃嬋穎 Graduate School of Information Managemet and Secur 2015 국내박사

Mobile healthcare (m-health) is a burgeoning electronic healthcare segment, and is designed to improve the safety and quality of healthcare. The objective of m-health is to provide ubiquitous and high-quality healthcare services, such as remote monitoring, mobile telemedicine, remote disease diagnosis and treatment, and emergency care. Recent advances in mobile devices and communication technologies offer unprecedented opportunities and challenges to develop pervasive mobile healthcare. In mobile health system, the target data are generally sensitive health-related data that directly related to individuals' privacy. For this reason, privacy preserving is of great importance for mobile healthcare. The motivation of this thesis is to develop secure and privacy-preserving solutions for typical mobile healthcare services. Specifically, three privacy solutions are provided: A privacy-preserving solution for remote condition monitoring. Compared to previous works, we propose a monitoring solution that provides enhanced privacy protection for patients, such as unlinkability, anonymous authentication and authorized data access. A secure and practical solution for emergency situation response. Our emergency response solution is efficient and suitable for not only general emergency situation, but also emergency occurred in vehicular/automobile environment. A privacy-preserving solution for personal health record (PHR) data sharing. To meet both patients' full control of their PHR and sufficient privacy preservation, a biometric-based health data collection scheme and an attribute-based PHR accessing scheme are proposed in this solution. Furthermore, comprehensive security analysis are conducted to show the proposed solutions meet fundamental security and strengthened privacy requirements. Simulated experiments are also performed to evaluate and validate the effciency.

Just-in-Time Adaptive Interventions: Experiment, Inference and Online Learning

Liao, Peng ProQuest Dissertations & Theses University of Mich 2019 해외박사(DDOD)

The use and development of mobile interventions are experiencing rapid growth. Ideally, mobile devices can be used to provide treatment/support whenever needed and to adapt treatment to the context of the user. Just-In-time Adaptive Interventions (JITAIs) are composed of decision rules that map a user’s context (e.g., user's behaviors, location, current time, social activity, stress and urges to smoke) to a treatment that is delivered to the user via the mobile device in near real-time. Advancements in mobile health engineering and technology (e.g., passive stress sensing) continue to bring us closer to being able to provide interventions in this way. However, a number of important gaps in data science must be addressed before mobile devices can be used to deliver on the promise of JITAIs. First, there is a need for experimental designs to collect data that can be used to assess the effectiveness of the sequence of treatments delivered by a mobile device on health outcomes in order to support the development of JITAIs. Second, there is a need for data-driven methods to inform the construction of efficacious JITAIs. In the vast majority of currently deployed JITAIs, the decision rules underpinning JITAIs are formulated using domain expertise and clinical experience, with very limited use of data evidence. In this dissertation, we make several contributions by tackling the above- mentioned data science barriers to effective JITAI development in mobile health. First, we propose a micro-randomized trial (MRT) design and develop the primary analysis for assessing the proximal causal effect of treatments. In addition, we develop stratified micro-randomized trials for the setting where there is a time-varying, discrete variable, and the primary analysis focuses on how the effectiveness of interventions changes with this variable. We also develop a novel algorithm to design the randomization scheme for this setting when there is an average constraint on the number of times interventions that should be sent in a certain time interval. Second, we develop a semi-parametric model to estimate the long-term average of health outcomes that would accrue should a given JITAI be followed. We derive the rate of convergence and the asymptotic normality of the proposed estimator. Third, we develop an online learning algorithm that continuously learns and improves the JITAI as the data is collected from the user. The proposed algorithm introduces a proxy of future outcomes based on a dosage variable to capture the delayed effect of sending the interventions due to the treatment burden.

Health Communication via Wearable Devices : Effects of Information Tailoring and Regulatory Framing on a Smart Watch

윤홍석 성균관대학교 일반대학원 2016 국내석사

Wearable devices, including smart watches, smart glasses, and fitness trackers, are becoming increasingly popular, and greater emphasis is being placed on their health-related functions. In light of this new development, this study explores the role of smart watches as mobile health communication tools and proposes information tailoring (personalization vs. customization) and regulatory framing (promotion vs. prevention-framed) as potential strategies for promoting the tendency for self-preservation. Results from a between-subjects experiment (N = 100) revealed that a customized as opposed to personalized health message was more effective in promoting self-preservation and inducing positive attitudes toward and representativeness of the message. However, regulatory framing was found to have no effects on the outcome. Theoretical and design implications of the key findings are discussed.

Design and Analysis of Sequential Randomized Trials with Applications to Mental Health and Online Education

NeCamp, Timothy ProQuest Dissertations & Theses University of Mich 2019 해외박사(DDOD)

Dynamic treatment regimes, also called adaptive interventions, guide sequential treatment decision-making in a variety of fields, including healthcare and education. Dynamic treatment regimes accommodate differences between individuals and changes in individuals over time. Sequential randomized trials are a specific type of trial design useful for developing high-quality dynamic treatment regimes. Sequential randomized trials utilize re-randomization of individuals over time in order to discover how to sequence, time, and personalize treatments. Two of the most commonly used sequential randomized trial designs are sequential multiple assignment randomized trials and micro-randomized trials.In this thesis, we contribute to both the design and analysis of sequential randomized trials. We describe design considerations for sequential randomized trials in online education. We present the design and analysis for a sequential randomized trial developed to reduce dropout in a massively open online course. We also develop statistical methodology and sample size formulae for sequential multiple assignment randomized trial designs which include cluster-level randomization. The techniques are inspired by a trial aiming to develop high-quality dynamic treatment regimes for mental health clinics. Lastly, we illustrate the design, describe the analysis, and present results of a large micro-randomized trial aiming to develop mobile health interventions for improving medical interns' mental health.

Remote management of post-stroke patients with application of mobile healthcare system

김도연 서울대학교 대학원 2020 국내석사

Advances in mobile health (mHealth) has enabled systematic and continuous management for patients with chronic diseases. We have developed an mHealth system, Smart After-Care, for health-behavior management and risk factor control in stroke patients. This study includes the development of a mHealth management system, which offers multifaceted care including exercise, nutrition, medication, and stress management and 12-week practical application to eligible post-stroke patients. The system was constituted with 1) regular blood pressure, blood glucose, physical activity measurements, 2) stroke self-education program, 3) exercise program, 4) nutrition program, 5) medication program, 6) feedback with reviewing of patients’ records by clinicians. Clinical assessments consisted of patient’s satisfaction and patient’s adherence to the system. During the 12-week follow-up period, tendencies of stroke awareness score (SAS), Beck Depression Inventory (BDI), EuroQol-5 Dimensions (EQ-5D) for quality of life, and blood pressure (BP) at visit 1 (baseline), visit 2 (4 weeks), and visit 3 (12 weeks) were assessed. System satisfaction was assessed using 5-level Likert scale. Individual utilization of the programs was defined by the average number of program access during the follow-up. Temporal differences of above-mentioned parameters were investigated with repeated-measures analyses of variance. Among 110 patients who were enrolled for the study from September to December 2016, 99 participants were included in our analyses. Overall satisfaction scale were 3.74/5 on average. Participants‘ average program access numbers for medication intake program were 100.9, BP measurement were 90.6, exercise program were 24.0, and stroke education contents were 29.1 during 12-week follow-up. Furthermore, SAS (visit 1: 59.6±18.1, visit 2: 67.6±16.0, visit 3: 74.7±14.0, p<0.001) and BDI (visit 1: 12.7±10.1, visit 2: 11.2±10.2, visit 3: 10.7±10.2, p<0.001) showed gradual improvement; however, no significant difference was found in EQ-5D score. Twenty six patients who had uncontrolled BP at baseline had a 13.92 and 6.19mmHg decrement on average in systolic and diastolic BP. We evaluated feasibility of the system, and patient satisfaction after using the system. During the follow-up period, SAS improved, and BDI and BP were lowered with Smart After-Care system integrated in clinical care. 배경: 모바일 헬스케어가 발전하면서 만성질환에 대해서 체계적이고 지속적인 관리가 가능해졌다. 우리는 뇌졸중 환자에 대한 건강-행동 관리와 위험인자 관리를 위하여 모바일 헬스케어 시스템인 스마트 애프터케어를 개발하였다. 방법: 본 연구는 운동, 영양, 복약, 스트레스 관리를 위한 모바일 헬스케어 시스템의 개발과 이를 이용하여 뇌졸중 후 환자에 대한 12주의 간의 실재적인 적용으로 구성되어 있다. 중재는 1) 주기적인 혈압, 혈당, 활동량 측정, 2) 뇌졸중 자가 교육 프로그램, 3) 운동 프로그램, 4) 영양 프로그램, 5) 복약 프로그램, 6) 의료진의 환자 기록 확인으로 이루어져 있었다. 임상적 평가는 환자의 만족도와 환자의 시스템에 대한 순응도로 이루어졌다. 12주간의 추적기간 동안 뇌졸중 인지도, 벡 우울 척도, 삶의 질 측정을 위한 유로퀄 5차원 척도, 그리고 매 방문시 (첫 방문, 4주 후, 12주 후) 마다 측정한 혈압의 경향성을 확인하였다. 시스템 만족도는 5단계의 리커트 척도를 이용하여 평가되었다. 개인의 프로그램 사용도는 사용 기간 동안 평균 프로그램 접속으로 정의하였다. 위 척도들의 12주간의 시간에 따른 변화를 반복측정 분산분석을 통해 확인하였다. 결과: 2016년 9월부터 12월까지의 연구 참가자 110명 중 99명이 분석되었다. 전반적인 만족도는 평균 3.74/5점이었다. 12주간 참가자의 평균 약물 복용 프로그램 활용 빈도는 100.9, 혈압은 90.6, 운동프로그램은 24.0 그리고 뇌졸중 교육 컨텐츠 확인은 평균 29.1회 였다. 뇌졸중 인지도 (첫 방문: 59.6±18.1, 두 번째 방문: 67.6±16.0, 세 번째 방문: 74.7±14.0, p<0.001)와 벡 우울 척도 (첫 번째 방문: 12.7±10.1, 두 번째 방문: 11.2±10.2, 세 번째 방문: 10.7±10.2, p<0.001) 는 점차적인 발전이 있었으나 유로퀄 5차원 척도와 환자 주관 평가에는 유의한 변화가 없었다. 첫 방문에서 혈압이 조절되지 않았던 26명은 12주 후 방문 시에 혈압약 변경 없이도 수축기 혈압과 이완기 혈압이 각각 13.92와 6.19mmHg가 감소되었다. 결론: 본 연구에서 시스템의 접근성과 환자의 만족도를 평가하였다. 추적기간 동안 뇌졸중 인지도와 우울감 그리고 혈압 수치는 스마트 애프터케어와 치료를 병행하였을 때에 호전되는 양상을 보였다.

The effectiveness of mobile health intervention to develop digital therapeutics for treatments of postpartum depression : : a systematic review and meta-analysis

성시수 성균관대학교 일반대학원 2023 국내석사

본 연구는 산후 우울증 치료 디지털치료기기 개발 관련 모바일 헬스에 대한 효과크기를 확인 및 분석을 통해 모바일 헬스를 통한 디지털치료기기 개발의 가능성과 필요성에 대해서 살펴보고자 하였다. 연구를 위해 2013년부터 2022년까지 국내외에서 발표된 학술지 논문 총 113편 중 체계적 문헌고찰을 통해 5편을 선정하여 메타분석을 수행하였다. 그 결과는 다음과 같았다. 산후 우울증 감소를 위한 모바일 헬스 처치의 전체 효과크기는 Hedges’ g 효과크기의 기준에 의하면 랜덤모형의 효과크기는 -2.4084으로 큰 효과크기로 나타났다. 모바일 헬스 처치를 진행한 후, Edinburgh Postnatal Depression Scale (EPDS)의 감소를 확인하였다. 하지만 본 연구의 사례 수와 대상자 수가 충분하지 않은 관계로 신뢰구간 0을 포함하여 통계적으로 유의하지 않은 것으로 나타났다. 이러한 연구결과는 산후 우울증의 감소를 위한 모바일 헬스 활용 치료가 효과적인 치료방법임을 시사한다. 본 연구는 산후 우울증의 감소를 위한 모바일 헬스 치료에 대해서 발전 방향을 제시하여 향후 디지털치료기기 개발을 진행을 계획하고 실행할 때 활용될 수 있는 유용한 정보를 제공할 수 있을 것이다. This study aimed to examine the possibility and necessity of developing digital therapeutics through mobile health intervention by confirming and analyzing the effect size for postpartum depression treatment. For this study, a meta-analysis was performed by selecting 5 of 113 articles published in domestic and international journals from 2013 to 2022 through a systematic literature review. The results were as follows. The overall effect size of mobile health intervention to reduce postpartum depression was found to have a large effect size according to the effect size criteria by Hedges’ g. After mobile health treatment was performed, a decrease in the Edinburgh Postnatal Depression Scale (EPDS) was confirmed. However, the insufficient number of cases and subjects in this study, it was found to be statistically insignificant due to including the confidence interval of 0. The finding suggests that mobile health treatment for the reduction of postpartum depression is an effective treatment method. This study provides useful information that can be used when planning and implementing the development of digital therapeutics in the future by suggesting the improvement direction of mobile health treatment for the reduction of postpartum depression.

The Benefits of Mobile Health Applications for Individuals with Type 2 Diabetes

Shikapwashya, Lorraine ProQuest Dissertations & Theses University of Brid 2022 해외박사(DDOD)

Background: Diabetes mellitus is considered an expanding worldwide epidemic with most cases being Type 2 Diabetes Mellitus (T2DM). Various approaches have been employed including patient health literacy to mitigate the global burden of Type 2 Diabetes Mellitus. Developments in technology have advanced the use of mHealth applications as a source of patient health literacy. Purpose: This literature review sought to explore the benefits of mHealth literacy applications for individuals with Type 2 Diabetes Mellitus. Methods: A total of 31 clinical studies published from September to November 2021 were used to cumulate evidence for the literature review emphasizing several topics, including: (a) mobile health applications used in Type 2 Diabetes health literacy, (b) Type 2 Diabetes Mellitus health literacy guides, and (c) self-management for Type 2 Diabetes Mellitus patients and mobile health applications. Results: The results of the chosen studies underscored numerous benefits of continued diabetes health literacy using mHealth literacy applications. Patient tailored mHealth literacy applications have been shown to increase diabetes knowledge in Type 2 Diabetes Mellitus patients and improve self-management measures such as nutrition, medication adherence, testing and attendance of regularly scheduled clinic visits. Conclusion: mHealth applications have shown to be multi-functional in use and effective when deployed in diabetes health literacy interventions. The ubiquity of mobile phones and available technology creates an ideal medium to use mHealth literacy application interventions to support Type 2 Diabetes Mellitus patients to improve self-management that in turn reduces morbidity, complications, and mortality.

Evaluating the Usability of Mobile JKN, the Indonesian App for Universal Healthcare Coverage, Using the Technology Acceptance Model (TAM)

Andriani, Firma 서울대학교 대학원 2019 국내석사

초록 본 논문의 목족은 정보기술수용모형 설문지를 통해 인도네시아 사람들이 이용한 Mobile JKN 사용현황을 분석한다. 특히, 본 연구는 다음의 목표를 달성하기 위해 노력한다: (1) 보편적 의료 보험을 제공하는 국가 보험 프로게렘인 JKN을 지원하기 위해, Mobile JKN (정부 보건 관리 기관에서 발급한 모바일엡)을 이용하는 인도네시아 사용자의 사용현황을 확인하는 것; (2) Mobile JKN 엡에 대한 사용자의 인식 파악하는 것; (3) 사용현황에 영향을 미치는 인구통계학적 요인을 파악하는 것이다. 본 연구의 방법론은 기술, 탐구 및 단면 분석이었다. 본 논문의 설문자에 대한 선택 기준은 정부 보건 관리 기관으로 연결된 JKN 모바일을 다운 받아 사용하는 인도네시아 보편적의료보럼의 회원이다. 설문자는 페스북, WhatsApp, 라인, 카카오톡과 같은 소설 미디어 플랫폼을 통해 배포되었다. 본 연구의 참여한 JKN모바일엡 사용자는 총 128명이었다. 지각된 유연성(PU)와 지각된 사용 요이성(PEOU) 사이에 관련이 있는지 테스트하기 위해 피어슨 상관계수를 적용했고, JKN모바일엡의 지각된 유연성(PU)와 지각된 사용 요이성(PEOU)에 대한 인구통계확적 요인의 영향을 분석하기 위해 표준중다회귀분석을 했다. 본 논문의 연구 결과는 설문자들은 JKN모바일엡을 받아들었다. 데이터 분석 결과에 따르면, PU의 평균점수는 3.8점과 PEOU의 평균점수는 3.7점으로 대다수의 사용자들이 모바일엡은 유용한 것으로 인식한다. 또한, PU변수와 PEOU변수가 P-value <0.05와 유의하게 상관관계가 있음을 보여주었다. 모바일앱 사용시간은 PEOU 점수의 유일한 영향력 있는 예측 변수가 되었고, PEOU의 변화율 4%만 설명하였는데, 그러나 PU 변수에 큰 영향을 미치지 않았고, PEOU 변수만 PU에 영향을 미치며, 30%의 차이를 설명하였다. 본 연구는 보건 정보학 분야, 특히 모바일헬스 엡 분야의 기술 수용과 관련된 지식을 강화한다. 키워드: 모바일헬스(mHealth), 정보기술수용모형, JKN 모바일, 모바일엡, 사용현황, 인도네시아인. 학생 번호: 2016-29060 Abstract The main purpose of this research was to analyze Mobile JKN acceptance by the Indonesian community using the Technology Acceptance Model (TAM) questionnaire. Specifically, the study seeks to achieve the following aims: (a) Identify Indonesian users’ acceptance of Mobile JKN—an app issued by BPJS Kesehatan, the government’s health management agency, in support of JKN, the national insurance program that delivers universal healthcare coverage; (b) Identify users’ perception of the Mobile JKN app; (c) Identify the demographic factors influencing the acceptance. The research methodology applied in this study was descriptive, exploratory, and cross-sectional analysis. The criterion for participants in this research was a member of Universal Healthcare Coverage of Indonesia who had already downloaded and used the Mobile JKN app as the tools to connect to BPJS Kesehatan Institution. The questionnaires were distributed through social media platforms such as Facebook, WhatsApp, LINE, and KakaoTalk. There were 128 Mobile JKN app users participated in this study. The Pearson correlation coefficient was applied to test if a relationship existed between the variables of perceived usefulness (PU) and perceived ease-of-use (PEOU) and standard multiple regression was calculated to analyze the influence of demographic factors regarding the PU and PEOU of the Mobile JKN app. The finding showed that the participants accepted the Mobile JKN app. Analysis of the data explained that the majority of the users perceived the app as useful, with the mean score of PU being 3.8, and that it was easy to use, with the mean score of PEOU being 3.7. It also showed that the PU variable and PEOU variables significantly correlated, with P-value <0.05. The duration of app usage time became the only influential predictor of PEOU score and it explained only 4% of variance of PEOU; however, it did not significantly affect the PU variable. Only the PEOU variable has an influence on PU and it explained 30% of the variance. This research enriches the knowledge related to technology acceptance in the field of health informatics, specifically on mobile health apps. Keywords: Mobile Health (mHealth), Technology Acceptance Model, Mobile JKN, Mobile app, Acceptance, Indonesian. Student ID: 2016-29060

(The) Effects of Energy Intake Self-monitoring Using a Mobile Application on Anthropometric and Metabolite Profile Changes : A Randomized Trial

김태월 서울대학교 대학원 2020 국내석사

Mobile health (mHealth) applications are useful tools for dietary modification and obesity management. Self-monitoring of energy intake through mobile applications may lead to weight loss. The objective of this study was to identify energy intake self-monitoring effects using a mobile application on anthropometric and metabolite profile changes compared to a paper-based diary. A two-arm randomized parallel trial was conducted among 57 participants (30 men and 27 women) aged 18-37 years. Participants with body mass index (BMI) >25.0 kg/m2 were randomly assigned to either the mobile application group (App group) (n=30; 16 men and 14 women) or the paper-based diary group (Paper group) (n=27; 14 men and 13 women). Participants were instructed to record their foods and supplements consumed using the “Noom Coach” application or a paper-based diary and advised to reduce by 500 kcal/day from the estimated energy requirements (EER) during the 12-week intervention period. Relative changes in anthropometric and clinical parameters from pre- to post-intervention were compared between the two groups in men and women. Clustering of untargeted metabolomics were determined to discriminate between the pre- and post-intervention metabolite profiles within the two groups by combining and separating men and women. Moreover, energy and macronutrient intake at the 1st week and the 12th week were compared among participants in the App group. All the analyses except for metabolite profiling were performed according to the intent-to-treat principle. Out of the 57 participants, 54 (94.7%) participants completed the trial. The frequency of recording was significantly higher in the App group than the Paper group (p for group difference=0.001). Change in BMI was not significantly different between the two groups (p for group difference=0.11), and no difference persisted for either man or women. However, we observed increases in body fat mass and LDL-cholesterol levels in the App group and decreases in these measures in the Paper group (p for group difference: 0.03 and 0.02, respectively). Although this difference was mainly derived by men, there were no differences in the changes in body fat mass and LDL-cholesterol levels between the two groups when data were analyzed in men and women separately. Change in triglyceride level was significantly different between the two groups among women (p for group difference=0.03), which increased in the App group and decreased in the Paper group. Acetylcholine (m/z: 146.12 [M+H]+) level decreased to a greater extent from pre- to post-intervention in the App group than the Paper group (p for group difference=0.05). Difference in acetylcholine intensity was inversely associated with changes in total cholesterol, HDL-cholesterol and hsCRP levels in the App group. In addition, 1-acyl-sn-glycero-3-phosphocholine (m/z: 570.35 [M+Na]+) and alpha-linolenic acid (m/z: 317.19 [M+K]+) levels significantly decreased in the App group, whereas methylglyoxal (m/z: 601.27 [M+H-H2O]+), (S)-malate (m/z: 152.06 [M+NH4]+) and phosphatidylcholine (m/z: 800.51 [M+Na]+) levels significantly decreased in the Paper group. When we separated men and women, differences in metabolite intensity from pre- to post-intervention were not significant between the App group and the Paper group among either men or women, but there were metabolite profile changes from pre- to post-intervention in men and women. ʟ-tyrosine (m/z: 200.04 [M+K]+) and riboflavin (m/z: 394.17 [M+NH4]+) levels decreased at post-intervention compared with pre-intervention in the App group and the Paper group among men, respectively. In the App group, phosphatidylethanolamine (PE) (16:1(9Z)/22:4(7Z,10Z,13Z,16Z)) (m/z: 783.57 [M+NH4]+), lysophosphatidylcholine (lysoPC) (15:0/0:0) (m/z: 482.32 [M+H]+), phosphatidic acid (PA) (16:0/16:0) (m/z: 687.44 [M+K]+), and phosphatidylcholine (20:5(5Z,8Z,11Z,14Z,17Z)/22:4(7Z,10Z,13Z,16Z)) (m/z: 856.58 [M+H]+) levels increased from pre- to post-intervention among women, whereas acetylcholine (m/z: 146.12 [M+H]+) level decreased. In the Paper group, phenylethylamine (m/z: 122.10 [M+H]+), phenylacetaldehyde (m/z: 138.09 [M+NH4]+), and phenylpyruvic acid (m/z: 165.05 [M+H]+) levels decreased from pre- to post-intervention among women. Energy and macronutrient intake did not change significantly from the 1st week to the 12th week among participants in the App group. In the App group, carbohydrate intake significantly decreased at 12th week among women (p for group difference=0.04), but not among men. Our study suggested that energy intake self-monitoring may confer favorable changes in metabolite profiles to a greater extent with the use of a paper-based diary than a mobile application, although neither showed significant differences in anthropometric parameters. 세계적으로 증가하고 있는 비만 유병률에 맞서 더욱 효과적으로 비만 및 건강 관리를 할 수 있는 모바일 헬스 (mobile health)가 대두되고 있다. 이는 핸드폰, 노트북, 스마트 워치 등 모바일 장치를 이용하여 건강 데이터를 수집하고 건강관리 서비스를 제공하는 것을 뜻한다. 선행된 연구에서는 모바일 헬스가 체중 감량의 도구로서 효과가 있다고 보고한 바 있으나 (Fakih El Khoury, 2019), 이를 이용한 에너지 섭취 자가 모니터링이 체중 감량 및 혈액 대사체 개선에 대한 효과는 아직 밝혀지지 않았다. 이에, 본 연구에서는 체질량지수 (BMI) ≥25kg/m2인 건강한 비만 성인을 대상으로 모바일 애플리케이션을 이용한 에너지 섭취 자가 모니터링이 신체계측, 임상지표 및 혈청 대사체 변화에 미치는 영향을 식사기록노트와 비교하고자 하였다. 만 18−50세의 체질량지수가 25kg/m2 이상의 성인 57명 (남자 30명, 여자 27명)이 모집되었고 참여자들은 성별 층화 무작위법을 통해 애플리케이션군 (30명)과 식사기록노트군 (27명)에 배정되었다. 애플리케이션군으로 배정된 참여자는 중재 기간 12주 동안 애플리케이션 “눔 코치”를 사용하여 식사 및 보충제 섭취를 기록하게 하였고 식사기록노트군으로 배정된 참여자는 식사기록노트를 사용하도록 하였다. 참여자는 Estimated Energy Requirement (EER) 계산식을 통해 산출한 1일 에너지 필요 추정량을 기반으로 500 kcal/day를 감소하여 식사하도록 하였다. 중재 전과 후 2차례 참여자들의 신체계측 측정과 및 임상지표 분석을 수행하였다. 액체 크로마토그래피-질량분석기를 이용하여 두 군 각각의 중재 전, 후 혈청 대사체 분석을 수행하였고 성별에 따라서도 분석하였다. 대응표본 t-검정 (paired t-test) 혹은 윌콕슨 부호순위 검정 (Wilcoxon signed-rank test)을 이용하여 중재 전, 후 유의하게 변화한 대사체를 확인하였다. 또한, 이러한 대사체의 변화가 두 군 간에서 차이가 있는지를 독립표본 t-검정 (independent t-test) 혹은 윌콕슨 순위합 검정 (Wilcoxon rank sum test)을 이용하여 확인하였다. 혈청 대사체 분석은 중재를 모두 완료한 참여자들만 포함하여 계획서 의도군 분석 (per-protocol analysis)을 수행하였고 이외의 모든 분석은 치료 의도군 분석 (intent-to-treat analysis)을 이용하여 수행되었다. 독립표본 t-검정 혹은 윌콕슨 순위합 검정을 이용하여 중재 전, 후 신체계측 및 임상지표의 퍼센트 변화가 애플리케이션군과 식사기록노트군에서 차이가 있는지를 확인하였다. 각 군 내에서 신체계측 및 임상지표의 중재 전, 후 차이는 대응표본 t-검정 혹은 윌콕슨 부호순위 검정을 이용하여 분석되었다. 또한 애플리케이션군에서 중재 1주차와 12주차의 평균 에너지 및 다량영양소 섭취량을 산출하여 차이를 비교하였다. 또한, 신체계측, 임상지표 및 에너지 및 다량영양소 섭취량의 변화가 성별에 따라서 차이가 있는지를 확인하였다. 애플리케이션군과 식사기록노트군으로 배정된 참여자들의 중재 전 특성은 차이가 없었다. 모집된 57명의 참여자 중 총 54명 (94.7%)이 12주의 중재를 완료하였다. 중재 기간 동안 애플리케이션군의 식사 기록일수는 식사기록노트군보다 유의하게 많았다 (p-value=0.001). 두 군 간 체질량지수의 퍼센트 변화는 유의한 차이가 없었다 (p-value=0.11). 그러나 체지방량과 LDL 콜레스테롤의 퍼센트 변화는 두 군 간에서 유의한 차이가 있었다 (체지방량 p-value=0.03; LDL 콜레스테롤 p-value=0.02). 체지방량과 LDL 콜레스테롤의 차이는 애플리케이션군의 남자에서 유의하게 증가한 것으로 확인되었지만 성별에 따른 두 군 간 차이는 유의하지 않았다. 여자에서 중성지방의 변화가 두 군 간 유의한 차이를 보였고 (p-value=0.03), 이는 애플리케이션군에서 증가하고 식사기록노트군에서 감소하는 경향을 보였으나, 남자에서는 유의한 차이가 없었다. 애플리케이션군 내에서 아세틸콜린 (acetylcholine, m/z: 146.12 [M+H]+)이 감소한 정도는 식사기록노트군보다 더 많았고 (p-value=0.05), 이는 애플리케이션군 내 총 콜레스테롤, HDL 콜레스테롤 및 고감도 C반응단백의 변화와 역의 상관관계를 보였다. 또한, 애플리케이션군 내에서 중재 후 1-acyl-sn-glycero-3-phosphocholine (m/z: 570.35 [M+Na]+) 과 알파-리놀렌산 (alpha-linolenic acid, m/z: 317.19 [M+K]+)이 중재 전보다 유의하게 증가하였고, 식사기록노트군에서는 메틸글리옥살 (methylglyoxal, m/z: 601.27 [M+H-H2O]+), (S)-말산 (malate, m/z: 152.06 [M+NH4]+), 포스파티딜콜린 (phosphatidylcholine, m/z: 800.51 [M+Na]+)이 중재 전보다 유의하게 감소하였음을 확인하였다. 성별에 따른 중재 전, 후 대사체의 변화를 보았을 때, 남, 여 각각에서 유의한 군 간 차이는 없었다. 남자에서 중재 후 ʟ-타이로신 (tyrosine, m/z: 200.04 [M+K]+)과 리보플라빈 (riboflavin, m/z: 394.17 [M+NH4]+)이 각각 애플리케이션군 및 식사기록노트군에서 감소한 것으로 나타났다. 여자에서 애플리케이션군의 경우, 중재 전보다 중재 후 포스파티딜에탄올아민 (phosphatidylethanolamine, PE (16:1(9Z)/22:4(7Z,10Z,13Z, 16Z)), m/z: 783.57 [M+NH4]+), 리소포스파티딜콜린 (lysophosphatidylcholine, lysoPC (15:0/0:0), m/z: 482.32 [M+H]+), 포스파티드산 (phosphatidic acid, PA (16:0/16:0), m/z: 687.44 [M+K]+) 및 포스파티딜콜린(20:5(5Z,8Z,11Z,14Z,17Z) /22:4(7Z,10Z,13Z,16Z)), m/z: 856.58 [M+H]+)이 증가였고, 아세틸콜린이 감소하였다. 식사기록노트군의 경우, 펜에틸아민 (phenylethylamine, m/z: 122.10 [M+H]+), 페닐아세트알데히드 (phenylacetaldehyde, m/z: 138.09 [M+NH4]+) 및 페닐피루브산 (phenylpyruvic acid, m/z: 165.05 [M+H]+)이 중재 전보다 중재 후에서 감소하였음을 확인되었다. 애플리케이션군 내에서 중재 1주차와 12주차의 에너지 및 다량영양소 섭취량은 유의한 차이가 없었다. 그러나 성별에 따른 차이를 확인하였을 때, 여자에서 탄수화물 섭취량이 감소하였다 (p-value=0.04). 본 연구 결과에 의하면, 두 가지 도구를 이용한 에너지 섭취 자가 모니터링은 유의한 신체계측 변화를 일으키지 않았지만, 식사기록노트는 애플리케이션에 비해 혈청 대사체 프로파일에 더욱 유리한 변화를 가져올 수 있는 것으로 확인되었다.

Perceptions of Tanzanian Health Care Workers Towards the Use of Mobile Phone Clinical Applications

Haman, Gregory Harvard University ProQuest Dissertations & Theses 2015 해외박사(DDOD)

The use of mobile phones in health care offers the promise of improved quality of care in developing countries. D-Tree International has developed mobile phone applications utilizing clinical protocols that are currently being used by health workers in Tanzania. There is limited literature showing medical professionals’ perceptions of barriers to mobile phone based technology in a Tanzanian context. After obtaining appropriate Institutional Review Board approval, from July- August, 2012 I consented and interviewed a total of 42 health care workers (nurses, community health workers, and their supervisors) selected via purposive sampling. These interviews took place in the Dar es Salaam, Pwani, and Zanzibar Regions of Tanzania and resulted in over 26 hours of recorded data. These interviews explored strategies to address how this technology can be sustainably implemented in health care settings. Having conducted and reviewed these interviews, I have documented my impressions of health care worker perceptions. I used these perceptions to comment broadly on D-tree’s operations and, where applicable, suggest future directions for D-Tree International. After completion of interviews, I submitted my impressions to D-Tree International staff who discussed the findings.