Kettlewell, Jade
(2019)
Evaluating Brain-in-Hand for adults with an acquired brain injury.
PhD thesis, University of Nottingham.
Abstract
Over one million people live with the long-term consequences of acquired brain injury (ABI). Individuals with ABI may find it difficult to self-manage the effects of injury and it is important to provide them with the skills to live independently. Many smart technologies exist to aid rehabilitation, but there is limited technology available to support self-management. Brain-in-Hand (BiH) is a smartphone application that was specifically engineered to support the management of persistent emotional and behavioural problems, which are commonly seen following ABI. However, it has not been systematically evaluated in this population. The aim of this thesis was to understand the perspectives and experiences of people with ABI and healthcare professionals after using BiH.
A systematic review was conducted to highlight the level of evidence available for smart technologies in the ABI population, and determine the effectiveness of technologies compared to usual care/other technologies on independence and functional outcomes. The review included six randomised controlled trials that utilised a range of technology interventions (e.g., smartphone, iPad, Neuropage). All included a measure of goal attainment/function, however none measured independence or fatigue. Only one measured quality of life and participation. The review highlighted a lack of studies focusing on some of the hidden consequences of ABI such as lack of independence, fatigue, anxiety and poor participation.
An engagement study was conducted with stakeholders (n=50) (including people with ABI, carers and professionals), to explore their views and opinions of BiH, and identify some of the barriers and facilitators to its use. A mixed methods approach was used (focus groups, questionnaires, and presentations) to obtain feedback. Stakeholders identified areas that BiH could potentially target such a memory and managing routine. They also highlighted some of the barriers to use such as smartphone competency, lack of interest in technology, and not seeing a personal use for BiH. These findings informed the design of the subsequent case studies.
An n-of-1 mixed method case study design was used. All ABI participants were provided with BiH for 12 months. Data were collected using questionnaires (at baseline, 6 and 12 months post-intervention) and semi-structured interviews (at six months post-intervention) with ABI participants and healthcare professionals. Questionnaire data were used to determine whether BiH had any effect on functional outcomes, mood, fatigue, participation, quality of life and cognition of ABI participants. The interviews aimed to explore the barriers and facilitators associated with the use of BiH. These were thematically analysed using a framework informed by the Behaviour Change Wheel (BCW) and International Classification of Functioning, Disability and Health (ICF). A feasibility health economics evaluation was also conducted.
The quantitative findings showed that BiH had no effect on mood, functional independence, participation, quality of life, fatigue, or quality of life. However, there was a significant increase in goal attainment over the first six months. There was also a slight improvement in cognitive function. An overarching theme of context (personal/environmental factors) was identified as a key factor influencing the use and effectiveness of BiH. The four subthemes were: 1) insight and self-awareness following injury and its impact on BiH use; 2) patient and therapist support/training to use BiH; 3) motivation to use BiH and achieve goals; 4) technology specific barriers/facilitators. Having a sufficient level of insight, appropriate support (set up, training, monitoring etc.), and motivation appeared to facilitate BiH use. The health economics evaluation identified potential cost drivers as therapist appointments and the cost of BiH. It was feasible to collect this data from the ABI population.
Contextual factors need to be considered when implementing BiH, or similar technology interventions in the ABI population. Personal and environmental factors play a key role in the use and effectiveness of BiH. It is important to identify important barriers and facilitators early in the implementation process, to guide the development of BiH for ABI, and its wider applicability to other long-term neurological conditions. Additional research is required to determine its effectiveness in the ABI population. BiH has the potential to be a valuable tool in community rehabilitation by facilitating independent living for people with ABI and providing a way to self-monitor and manage their fatigue/anxiety.
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