ESR1: Ethnographic analysis of the current care pathway from a patient perspective. 
Host: UoD (Acad-Spain), Partners: BEAC (Non Acad-Ireland) [18M] 

There is growing acknowledgement that the patient experience is central to healthcare provision. Methods used to effectively understand this experiential side of the patient-care pathway are nascent. Hosted in UoD, ESR1 will use ethnographic research methods drawn from the discipline of anthropology – the study of human being and knowing to more effectively capture patient insights, ESR1 will spend 10 months (M1-10) in UoD (Acad, Spain), supervised by Dr Zapirain and Mr Solinis, reviewing patient care pathways in cancer treatment literature and receiving local training on ethnographic research methods. Ethnography separates itself from other forms qualitative and quantitative research methods, as the end goal is to create insights that are empathetic and objective. Observation of daily life and semi-structured interviewing are central to this form of data collection. 

Once up-to-speed on both literature and methods, ESR1 will spend 18 months (M11-28) under the supervision of Ms. Daly in the rehabilitation department of BEAC (Non Acad, Ireland) conducting an ethnographic study of the patient care pathway for both genders. By observing and interacting with cancer patients, researchers can comprehend the lived-experience of particular care pathways. In turn, insights gained can be leveraged to assist patient-centred design processes. This will result in the development of appropriately informed, needs-based mobile applications to assist rehabilitation. ESR1 will return to UoD (M29-36), where they will analyse their data and develop a detailed patient pathway that meets the needs of both sexes for all types of cancer. ESR1 will identify elements of that pathway where there are opportunities for technology-enabled post-diagnosis rehabilitation. These outputs will form the basis of ESR1’s PhD thesis which will be awarded by UoD.

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ESR2: Quantification of health habits and needs of people affected by cancer for improve their quality of life (QOL) through physical activity. 
Host: ONCO (Non Acad-Spain), Partners: UCD (Acad-Ireland) [14M] 

The patient’s QOL is an important factor in the treatment of cancer. As an issue of increasing importance in oncology it is necessary to understand what needs to be done to assist patient’s ability to attain a satisfactory QOL. One way through which cancer patients’ QOL is believed to be improved is by engaging in physical exercise. While the most appropriate form of exercise is unknown its value in the improvement QOL cannot be ignored. By engaging in ethnographic research with cancer patients involved in various forms of physical exercise, it will result in the design of a digital intervention to maximise the medical, physical, functional and psychological effects of physical activity programs for men and women with cancer. Hosted in ONCO (Non Acad, Spain) under the supervision of Dr. Mora, ESR2 will study the needs and difficulties facing patients with cancer from both sexes, from medical, physical, functional and psychological perspectives. ESR2 will pay particular attention to the patient’s adherence to physical activity guidelines, before and after their medical treatment. For the first six months (M1-6), ESR2 will conduct a comprehensive literature review under the supervision of Prof Caulfield (UCD, Acad, Ireland) focusing on medical, physical, functional and psychological aspects of cancer treatment for both men and women. Following this literature review, ESR2 will spend three months (M7–10) under the joint supervision of Dr. Mediano-Rambla, Valero-Arzibu M.D. and Valero-Jimenez M.D. in ONCO’s clinical bases in Quirón Sagrado Corazón Hospital and the Clínica Infanta Luisa (Non Acad, Spain). Here, ESR2 will undertake qualitative research with male and female patients to identify factors crucial for the design of a digital intervention. ESR2 will then spend 18 months (M11-28) based out of ONCO head office (Non Acad, Spain) developing guidelines for this population regarding health and lifestyle, paying specific attention to physical activity and how to improve patient QOL during the phases of cancer treatment. These guidelines will be tested onsite at the Center of Sport at University of Seville, where ONCO provides fitness activities for patients with cancer. ESR2 will design a digital intervention to assist patient’s adherence to physical exercise regimes. They will spend M29-36 with Prof Caulfield writing their PhD thesis to be awarded by UCD. 

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ESR3: Strategies for increasing mental wellbeing in patients with cancer. 
Host: UCD (Acad-Ireland), Partners: SALU (Non Acad-Spain) [12M], ONCO (Non Acad-Spain) [6M] 

Cancer decrease QOL and mental due to the disease itself and its treatment. Without effective support, mental health difficulties can escalate, complicating treatment and recovery, and becoming severe problems in themselves. eHealth technologies are already used in mental health but ethnographic research with cancer patients, will allow design of a mobile application to cater specifically for the mental wellbeing of this group. 

Hosted and supervised by Dr Coyle (UCD-Acad, Ireland) ESR3 will investigate strategies for using digital health to reinforce and improve psycho-oncology interventions (addressing emotional and mental health issues associated with cancer.) ESR3 will focus on behavioural and emotional support - increasing motivation, reducing asthenia and fatigue - devising new strategies to improve patients’ psychological and physical wellbeing. Central to the IRP is that both genders experience different cancer types. As such, it will be necessary to develop an understanding of the most effective motivational strategies for different groups. ESR3 will spend 6 months at UCD on reviewing literature on increasing motivation, supporting positive health behaviour and prior use of technology in mental health support, including a review of psycho-oncology projects that use new technologies. To ground their theoretical understanding, ESR3 will conduct qualitative research for 6 months at UCD (interviews, focus-groups, workshops) with a diverse group of patients and care givers with different cancers from both genders. This will provide a detailed and empathic understanding of cancer patients’ lived experiences. In the process, ESR3 will develop motivational framework that maps behavioural and emotional strategies for diverse cancer patients and survivors. ESR3 will begin a 12-month secondment at SALU (Non Acad, Spain) to access and evaluate existing app prototypes for prostate cancer patients based on the new motivational framework. ESR3 will design a new app that instantiates the framework. Versions of the app will be designed for alternate patient groups (e.g. prostate and breast cancer) and will be implemented by the IT team at SALU. New patient-oriented content will be created in collaboration with ONCO (Non Acad, Spain). For 6 months in ONCO, ESR3 will undertake to test these new apps and motivational framework with relevant patient groups. ESR3 will return to UCD for
6 months to analyse results, refine the motivational framework and complete their PhD, to be awarded by UCD. 

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ESR4: Gamification Strategies for Health Promotion of People Affected by Cancer. 
Host: SALU (Non Acad-Spain), Partners: UCD (Acad- Ireland) [12M], BEAC (Non Acad-Ireland) [6M], ONCO (Non Acad-Spain) [6M] 

The use of game-based techniques in digital health interventions for patients has been researched for over 20 years. One advantage of gamification in digital health interventions is the increased engagement of the users. This reduces attrition and reinforces expected behavioural changes and learning outcomes. While there are examples of the use of game-based interventions in oncology, these interventions have mainly focused on helping patients deal with side effects of pharmacological treatment, especially during the acute phase. In this project, focus will be on motivation aspects related to lifestyle change and improving health behaviour. This is an emerging problem since cancer is a chronic condition requiring long term treatment and lifestyle change. Designing a gamified intervention for these patients is not a trivial task, due to the complexity of oncology treatment, psychological and social factors. ESR4 will design and implement a social mobile app for prostate cancer patients and survivors offering continuous support and motivate patients to have cancer-specific healthier lifestyles. To do this, ESR4 will perform a systematic scoping review of games techniques and previous cancer-specific digital solutions in SALU (Non Acad, Spain) (M01-M06). For the following 6 months in SALU, ESR4 will implement a first version of the app based on their obtained experience (M07-M12). ESR4 will spend
6-months with ONCO (Non Acad, Spain-M12-M18) study consulting with oncology experts regarding the safety, usefulness and accuracy of the game. They will optimize the app in light of this feedback. Additionally, they will define a protocol study to measure the most successful game features for patient engagement. This may be done through A/B testing, where two versions of the product are placed side by side and compared. ESR4 will then compare with real patient engagement in BEAC (Non Acad, Ireland) (M19-M24). Finally, ESR4 will engage in data mining and complete a PhD thesis at UCD (M25-M36). 

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ESR5: Artificial Exercise Support. 
Host: UCD (Acad-Ireland), Partners: BEAC (Non Acad-Ireland) [6M], ONCO (Non Acad-Spain) [12M] 

A significant proportion of cancer survivors suffer cachexia, resulting in reduced functional capacity following treatment. Participation in standard voluntary exercise programs becomes extremely difficult. Neuromuscular electrical stimulation (NMES) may serve as an early stage training modality for these patients, acting as an artificial exercise support. Standard NMES approaches, based on tetanic muscle strengthening protocols, can improve functional exercise capacity and muscle strength in patients with severe pulmonary disease or heart failure. A pilot study in cancer patients suggests that NMES intervention is well tolerated by cancer patients but researchers have failed to demonstrate clinical or functional benefits from NMES intervention in cancer patients using traditional muscle strengthening protocols. Previous efforts have simply applied NMES protocols, routinely used to strengthen muscles in management of other patients (e.g. post orthopaedic surgery, neurological rehabilitation). Recent developments in NMES have resulted in its successful used in hybrid aerobic training and muscle strengthening in healthy adult, spinal cord injury, and diabetic populations across both genders. In previous work, Prof Caulfield’s team (UCD) were the first to use NMES in aerobic exercise training. The associated technology platform has been successfully applied in a range of groups including healthy young adults, sedentary adults, and healthy elderly, as well as patients with heart failure, spinal cord injury, and obesity. It is likely that this approach can be modified to meet the needs of cancer patients; NMES could be a ‘bridge’ to traditional exercise. 

ESR5 will design, develop, implement and evaluate an NMES training program for male and female cancer patients. Phase 1 will be carried out in ONCO (Non Acad, Spain) (M1-M6) to understand the exercise rehabilitation needs of patients with breast or prostate cancer. In phase 2, (M7-18) ESR5 will be located in UCD. Here, they will develop an NMES-mediated hybrid training protocol that meets the specific needs of the two significant cancer survivor cohorts - prostate cancer and breast cancer. This will consist of evaluation of the acute physiological and subjective effects of application of different variations of a hybrid NMES protocol in a cohort of the target population. This will help optimise the protocol. Phase 3 (M19-M24) in BEAC (Non Acad, Ireland) will consist of a pilot trial with a group of prostate and breast cancer survivors too deconditioned to meaningfully benefit from standard physical exercise. The trial will require patients to undergo self-directed home-based NMES training for a period of 8-16 weeks. Approximately 40 participants (equally gender balanced) will be recruited for the prospective trial. The program will be evaluated through clinical and functional outcomes, and user experience. Phase 4 in ONCO (Non Acad, Spain) (M25-30) will help understand the potential application of the outputs in the context of care pathways for cancer patients, particularly how this technology can be integrated with drug therapy for cachexia. They will spend the final six months (M31–36) in UCD writing their PhD thesis. 

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ESR6: Targeted rehabilitation exercise biofeedback system for cancer care. 
Host: BEAC (Non Acad-Ireland), Partners: SALU (Non Acad-Spain) [12M], UCD (Acad-Ireland) [6M] 

While aerobic forms of exercise are important in cancer patients’ cardiovascular training, patients need to carry out more ‘targeted’ rehabilitation exercises designed to re-educate and strengthen specific muscle groups and improve flexibility. In some cases, these targeted exercise requirements are unique to the specific circumstances of the condition (e.g. the need to regain adequate shoulder flexibility post breast surgery). Rehabilitation exercise professionals routinely prescribe targeted exercises for cancer patients at various stages of treatment. The patient is expected to complete these exercises at home. However, up to 70% of patients cannot comply as a result of a lack of motivation and inability to remember the technique of the exercises. Recent years have witnessed the emergence of a range of interactive biofeedback ‘exergaming’ applications to address this problem. The reason these applications have failed to gain widespread traction with clinicians and patients could be due to lack of clinical accuracy in monitoring and evaluating exercise performance. Recent developments include clinically relevant, machine-learning based, automated exercise performance classification systems for lower extremity orthopaedic rehabilitation exercise. This has lead to significant improvements in clinical acceptability. There is a need to develop this technology platform and accommodate rehabilitation exercises commonly prescribed for cancer patients, accompanied by cancer care educational and communication tools for patients and clinicians. Working with clinicians and cancer patients the project will design, implement and evaluate a ‘virtual personal therapist’ mobile app. 

Supervised by Prof Caulfield (UCD) and working closely with ESR1, ESR6 will spend 6 months (M1-M6) conducting a literature review on cancer-specific, targeted rehabilitation exercise programmes, focusing on the information gap between the patient, consultant and physiotherapist and the patient’s ability to access information about their own care. They will then spend six months in BEAC (Non Acad, Ireland; M7-M12) gathering data from cancer patients performing exercises in a clinical setting to inform the exercise classification model. They will analyse cancer patients’ information needs through ethnographic research, under the supervision of Ms Daly. This research will focus on younger and metastatic patients. The data collected will be used over the following 12 months in SALU (Non Acad, Spain) supervised by Dr Fernandez-Luque (M13-M24). Here, ESR6 will develop exercise classification algorithms and a prototype app tailored specifically to each patient’s needs by their clinician. This would allow the patient to attain credible information on their progress with rehabilitation, regardless of their geographical location. ESR6 will then spend the final 12 months of their fellowship evaluating the prototype. They will spend 6 months at BEAC evaluating it in clinical deployment (M25-M30) and 6 months in UCD evaluating and reworking it from a ‘technology and care’ model perspective (M31-M36). This period will be co-supervised by Dr Maria Quinlan and Mr David Singleton (UCD). ESR6 will write their PhD thesis under Prof Caulfield’s supervision (UCD) and will be awarded their PhD (UCD). 

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ESR7: Supporting commercialization of technology-enabled cancer solutions through design thinking. 
Host: SDU (Acad-Denmark), Partners: SALU (Non Acad-Spain) [18M] 

Sustainable eHealth innovation requires integration of different disciplines and ideas, and information sharing by industry, users and public partners. Firms must often rearrange their organisation and values to integrate these external and internal elements in a commercialisation process. Based in SDU, jointly supervised by Evald (Public-private innovation and intrapreneurship) and Munksgaard (Relationship management and design), ESR7 will combine the emerging field of PPI with design thinking and methods to mediate between heterogeneous innovators and between external and internal surroundings, facilitating new understanding and insight in an open yet structured way. User-centred innovation and co-creation, incorporating innovation problem solving and business development by hands-on experimenting, will allow users and businesses to explore and uncover multiple relevant user needs that are also commercially viable. ESR7 will spend 6 months in SDU (Acad, Denmark, M1-M6) systematically reviewing PPI, commercialization and design literatures complemented by interviews with up to 20 users (cancer patients, researchers, clinicians) leveraging Evald and Munksgaard’s extensive experience with PPI-projects on how firms turn developed health solutions into commercial successes. 

ESR7 will have a 6 month (M7-12) secondment in SALU (Non Acad, Spain) to understand the context in which solutions are developed. Returning to SDU M13-18), ESR7 will develop preliminary guidelines for how private firms can use design thinking (methods) to secure the handling of collaboration, innovation, diffusion and commercialization challenges and qualify the process of developing technology-enabled cancer care solutions. ESR7 will spend 12 months (M19-30) with SALU conducting three workshops to gather knowledge from external and internal partners and users before conducting a pilot evaluation of the processes that characterise the development of technology-enabled cancer care solutions, to assess whether design has strengthened the firms’ awareness of different external and internal challenges and how to handle them. 6 months (M31-36) will be spent writing the PhD thesis, to be awarded by SDU. 

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ESR8: Qualifying private organisations’ commercialization efforts through stakeholder interactions. 
Host: SDU (Acad-Denmark), Partners: BEAC (Non Acad-Ireland) [10M], SALU (Non Acad-Spain) [8M] 

Recent literature adds other stakeholders to customers and R&D collaborators in terms of enhancing commercialization activities. They can articulate customer needs and market structure issues, assist to re-define the market, and thereby turn the invention into a commercially successful innovation. Early engagement and interaction with network stakeholders (suppliers, distributors and customers) is crucial to innovation success. 

Hosted in SDU (Acad, Denmark), jointly supervised by Højbjerg Clarke (Innovation and User/ Stakeholder involvement) and Evald (Public-private innovation and intrapreneurship), ESR8 will examine how stakeholder interactions influence the development and realization of commercialization plans. ESR8 will spend 6 months in SDU (M1-6) systematically reviewing PPI, commercialization and stakeholder literatures, and leveraging Højbjerg Clarke and Evald’s experience of projects turning health solutions into commercial successes. ESR8 will then spend 10 months (M7-16) at BEAC (Non Acad, Ireland) understanding the context in which cancer care solutions are developed and forming preliminary guidelines for how private firms can use stakeholder interactions to qualify commercialization efforts. The first 16 months will include interviews with up to 30 private and public actors engaged in PPI. Returning to SDU, ESR8 will spend 6 months (M17-22) refining the guidelines, followed by 8 months (M23-30) with SALU (Non Acad, Spain). Here, they will conduct a pilot evaluation of the processes the PPI-projects have undergone and assess whether stakeholder interactions have strengthened private firms’ awareness of different challenges and how to handle them. 6 months will be spent in SDU writing their PhD thesis (M31-36). 

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