Exploring attitudes towards use of technology to support stroke survivors living at home: A quantitative and qualitative content analysis study in Spain.

PURPOSE: The aim of this study was to better understand the attitudes towards the use of technology to support chronic stroke survivors in a home-based setting. METHODS: A quantitative study was used on the data obtained from a face to face survey with the sample group, incorporating quantitative statistical analysis. RESULTS: Participants reported positive attitudes towards using technology for their own independent health management. The purpose of the home-based technology was different: source of information, supporting self-management, pharmacological treatment reminders… and differed according to age, educational level and survivor disability. Installing devices and sharing information remains a challenge. CONCLUSIONS: 100% of stroke survivors living in the community with any type of disability, reported that they would like to use technology as a tool to help improve their health status.

Hospital readmissions of patients with heart failure from real world: timing and associated risk factors.

AIMS: This study aims to investigate hospital readmissions and timing, as well as risk factors in a real world heart failure (HF) population. METHODS AND RESULTS: All patients discharged alive in 2016 from Sahlgrenska University Hospital/Östra, Gothenburg, Sweden, with a primary diagnosis of HF were consecutively included. Patient characteristics, type of HF, treatment, and follow-up were registered. Time to first all-cause or HF readmission, as well as number of 1 year readmissions from discharge were recorded. In total, 448 patients were included: 273 patients (mean age 78 ± 11.8 years) were readmitted for any cause within 1 year (readmission rate of 60.9%), and 175 patients (mean age 76.6 ± 13.7) were never readmitted. Among readmissions, 60.1% occurred during the first quarter after index hospitalization, giving a 3 month all-cause readmission rate of 36.6%. HF-related 1 year readmission rate was 38.4%. Patients who were readmitted had significantly more renal dysfunction (52.4% vs. 36.6%, P = 0.001), pulmonary disease (25.6% vs. 15.4%, P = 0.010), and psychiatric illness (24.9% vs. 12.0%, P = 0.001). Number of co-morbidities and readmissions were significantly associated (P < 0.001 for all cause readmission rate and P = 0.012 for 1 year HF readmission rate). Worsening HF constituted 63% of all-cause readmissions. Psychiatric disease was an independent risk factor for 1 month and 1 year all-cause readmissions. Poor compliance to medication was an independent risk factor for 1 month and 1 year HF readmission. CONCLUSIONS: In our real world cohort of HF patients, frequent hospital readmissions occurred in the early post-discharge period and were mainly driven by worsening HF. Co-morbidity was one of the most important factors for readmission.

Feasibility of ActivABLES to promote home-based exercise and physical activity of community-dwelling stroke survivors with support from caregivers: A mixed methods study.

BACKGROUND: Technical applications can promote home-based exercise and physical activity of community-dwelling stroke survivors. Caregivers are often able and willing to assist with home-based exercise and physical activity but lack the knowledge and resources to do so. ActivABLES was established to promote home-based exercise and physical activity among community-dwelling stroke survivors, with support from their caregivers. The aim of our study is to investigate the feasibility of ActivABLES in terms of acceptability, demand, implementation and practicality. METHODS: A convergent design of mixed methods research in which quantitative results were combined with personal experiences of a four-week use of ActivABLES by community-dwelling stroke survivors with support from their caregivers. Data collection before, during and after the four-week period included the Berg Balance Scale (BBS), Activities-Specific Balance Confidence Scale (ABC), Timed-Up-and-Go (TUG) and Five Times Sit to Stand Test (5xSST) and data from motion detectors. Semi-structured interviews were conducted with stroke survivors and caregivers after the four-week period. Descriptive statistics were used for quantitative data. Qualitative data was analysed with direct content analysis. Themes were identified related to the domains of feasibility: acceptability, demand, implementation and practicality. Data was integrated by examining any (dis)congruence in the quantitative and qualitative findings. RESULTS: Ten stroke survivors aged 55-79 years participated with their informal caregivers. Functional improvements were shown in BBS (+ 2.5), ABC (+ 0.9), TUG (- 4.2) and 5xSST (- 2.7). More physical activity was detected with motion detectors (stand up/sit down + 2, number of steps + 227, standing + 0.3 h, hours sitting/lying - 0.3 h). The qualitative interviews identified themes for each feasibility domain: (i) acceptability: appreciation, functional improvements, self-initiated activities and expressed potential for future stroke survivors; (2) demand: reported use, interest in further use and need for follow-up; (3) implementation: importance of feedback, variety of exercises and progression of exercises and (4) practicality: need for support and technical problems. The quantitative and qualitative findings converged well with each other and supported the feasibility of ActivABLES. CONCLUSIONS: ActivABLES is feasible and can be a good asset for stroke survivors with slight or moderate disability to use in their homes. Further studies are needed with larger samples.

Developing ActivABLES for community-dwelling stroke survivors using the Medical Research Council framework for complex interventions.

BACKGROUND: Novel technical solutions are called for to promote home-based exercise among community-dwelling stroke survivors supported by their caregivers. Lack of resources and knowledge about how to accomplish it, has been demonstrated. The objective of this study is to describe in detail the development of ActivABLES, a technical intervention to promote home-based exercise and physical activity engagement of community-dwelling stroke survivors with support from their caregivers. METHODS: The technical development process of ActivABLES was guided by the Medical Research Council (MRC) framework for development and evaluation of complex interventions as well as by principles of human-centred design and co-design. The main steps included: (1) Synthesis of evidence supporting the inclusion of balance exercises, mobility and walking exercises and exercises for the upper arm; (2) Implementation of initial user studies with qualitative data collection from individual interviews with stroke survivors, and focus group interviews with caregivers and health professionals; (3) Preliminary testing of eight prototypes with seven stroke survivors and their caregivers. RESULTS: After the preliminary testing of eight prototypes, four prototypes were not further developed whereas four prototypes were modified further. In addition, two new prototypes were developed, leaving six prototypes for further modification: 1) ActivFOAM for balance exercises, 2) WalkingSTARR to facilitate walking, 3) ActivBALL for hand exercises, 4) ActivSTICKS for upper arm exercises, and 5) ActivLAMP and 6) ActivTREE which both give visual feedback on progress of daily exercise and physical activities. ActivFOAM, ActivBALL and ActivSTICKS are all connected to a tablet where exercise instructions are given. All the exercise prototypes can be connected to ActivLAMP and ActivTREE to give feedback on how much exercise the user has done. Settings can be individualised and recommended daily time and/or repetition can easily be changed as the user progresses to higher activity levels. CONCLUSIONS: The development process of ActivABLES was guided by the principles of human-centred design, with iterative testing of future users, and by the MRC framework of complex intervention, with a repeated process of development and testing. This process resulted in six prototypes which are available for feasibility testing among a small group of community-dwelling stroke survivors.

Universal Balance?

In the ActivAbles and STARR projects we are developing interactive training tools for stroke survivors. As our initial user studies pointed to balance being a key ability, one of the developed tools is an interactive balance mat. While balance equipment is common, interactive balancing equipment for persons with poor balance is less common. Equipment exists for persons with good balance (eg. Wii), but most games and exercises are less suited for many stroke survivors. The development process has been done in close collaboration with stroke survivors. We have used both creative workshops and individual iterative testing in the development, and have currently a prototype that is being tested in the home of 12 stroke survivors. This prototype is based on a foam mat which incorporates pressure sensing, and which allows you to see the pressure distribution as you exercise, but also allows you to play music or play different games. The feedback is designed to be inclusive - designs are multimodal (visual and auditory), and the setup is flexible and can easily be adapted. Initial test results show that the overall design is promising and works well (is robust, motivating and used). Problems identified are connected to the fact that we use main stream tablets for feedback, which adds complexity for the user both with interaction and charging. We are currently working on solving these problems, and expect to end up with a balance mat well suited for a wide range of users - not only stroke survivors.

Stroke and Universal Design.

Universal Design (UD) is usually stated to be "for all ages and abilities". Given that stroke is a major source of disability, it is important that UD recommendations take stroke-specific problems into account. Within the framework of EU project STARR, we have investigated user requirements of stroke survivors. In this project we have used a mix of interviews, focus groups, design workshops and technology tests to come up with a set of design recommendations, which we present as a first step towards universal design recommendations which are inclusive for stroke survivors. Our general recommendations are: make it fun, do not make people fail, empower and encourage. The technology needs to be highly adaptable to different sets of abilities. Safety, but also aesthetics and simplicity is important, but it is pointed out that designs should not be "childish" - this can be felt to be degrading. It is important to be able to see and follow your progress and win small victories often. Consider social applications and activities - being able to connect to others in the same situation can enable discussions and provide peer support. More stroke consequence specific recommendations are to design to allow one-sided use (hemiplegia), avoid sensory and activity overload (fatigue), complement speech with images (aphasia), limit demand on memory, support learning and avoid errors (memory problems), and include multiple modalities in your design (reduced vision or hearing).

Conjuring up New Technology - Using Magic Objects in Co-Ideation with Stroke Survivors.

Ideation means to generate ideas, and when involving non-designers in these activities they need to be informed about the scope of the possibilities without limiting their imagination. This is a general challenge, which becomes particularly important when it comes to advanced technology ideation together with participants that may not have in-depth knowledge of technological designs and solutions. In this study, we supported the ideation process by presenting a kit of magic objects (consisting of cards and physical props) to stroke survivors participating in a co-design workshop carried out within the STARR EU project. The kit was seen to generally work well, but improvements are suggested for the introduction, the design of the cards and the number of objects used.