Supporting self-management: development and evaluation of a digital resource for adults with asthma

The problem: Around 300 million people worldwide have asthma and prevalence is increasing. Support for optimal self-management can be effective in improving a range of outcomes and is cost effective, but is underutilised as a treatment strategy. Supporting optimum self-management using digital technology shows promise, but how best to do this is not clear. Aim: The purpose of this project was to explore the potential role of a digital intervention in promoting optimum self-management in adults with asthma. Methods: Following the MRC Guidance on the Development and Evaluation of Complex Interventions which advocates using theory, evidence, user testing and appropriate modelling and piloting, this project had 3 phases. Phase 1: Examination of the literature to inform phases 2 and 3, using systematic review methods and focussed literature searching. Phase 2: Developing the Living Well with Asthma website. A prototype (paper-based) version of the website was developed iteratively with input from a multidisciplinary expert panel, empirical evidence from the literature (from phase 1), and potential end users via focus groups (adults with asthma and practice nurses). Implementation and behaviour change theories informed this process. The paper-based designs were converted to the website through an iterative user centred process (think aloud studies with adults with asthma). Participants considered contents, layout, and navigation. Development was agile using feedback from the think aloud sessions immediately to inform design and subsequent think aloud sessions. Phase 3: A pilot randomised controlled trial over 12 weeks to evaluate the feasibility of a Phase 3 trial of Living Well with Asthma to support self-management. Primary outcomes were 1) recruitment & retention; 2) website use; 3) Asthma Control Questionnaire (ACQ) score change from baseline; 4) Mini Asthma Quality of Life (AQLQ) score change from baseline. Secondary outcomes were patient activation, adherence, lung function, fractional exhaled nitric oxide (FeNO), generic quality of life measure (EQ-5D), medication use, prescribing and health services contacts. Results: Phase1: Demonstrated that while digital interventions show promise, with some evidence of effectiveness in certain outcomes, participants were poorly characterised, telling us little about the reach of these interventions. The interventions themselves were poorly described making drawing definitive conclusions about what worked and what did not impossible. Phase 2: The literature indicated that important aspects to cover in any self-management intervention (digital or not) included: asthma action plans, regular health professional review, trigger avoidance, psychological functioning, self-monitoring, inhaler technique, and goal setting. The website asked users to aim to be symptom free. Key behaviours targeted to achieve this include: optimising medication use (including inhaler technique); attending primary care asthma reviews; using asthma action plans; increasing physical activity levels; and stopping smoking. The website had 11 sections, plus email reminders, which promoted these behaviours. Feedback during think aloud studies was mainly positive with most changes focussing on clarification of language, order of pages and usability issues mainly relating to navigation difficulties. Phase 3: To achieve our recruitment target 5383 potential participants were invited, leading to 51 participants randomised (25 to intervention group). Age range 16-78 years; 75% female; 28% from most deprived quintile. Nineteen (76%) of the intervention group used the website for an average of 23 minutes. Non-significant improvements in favour of the intervention group observed in the ACQ score (-0.36; 95% confidence interval: -0.96, 0.23; p=0.225), and mini-AQLQ scores (0.38; -0.13, 0.89; p=0.136). A significant improvement was observed in the activity limitation domain of the mini-AQLQ (0.60; 0.05 to 1.15; p = 0.034). Secondary outcomes showed increased patient activation and reduced reliance on reliever medication. There was no significant difference in the remaining secondary outcomes. There were no adverse events. Conclusion: Living Well with Asthma has been shown to be acceptable to potential end users, and has potential for effectiveness. This intervention merits further development, and subsequent evaluation in a Phase III full scale RCT.

Deindustrialisation and industrial communities: the Lanarkshire coalfields c.1947-1983

This thesis examines deindustrialisation, the declining contribution of industrial activities to economic output and employment, in Lanarkshire, Scotland’s largest coalfield between the early nineteenth and mid-twentieth century. It focuses on contraction between the National Coal Board’s (NCB) vesting in 1947 and the closure of Lanarkshire’s last colliery, Cardowan, in 1983. Deindustrialisation was not the natural outcome of either market forces or geological exhaustion. Colliery closures and falling coal employment were the result of policy-makers’ decisions. The thesis consists of four thematic chapters: political economy, moral economy, class and community, and generation and gender. The analysis is based on archival sources including Scottish Office reports and correspondence relating to regional policy, and NCB records. These are supported by National Union of Mineworkers Scottish Area and STUC meeting minutes, and oral history testimonies from over 30 men and women with Lanarkshire coalfield backgrounds, as well as two focus groups. The first two chapters analyse the process of deindustrialisation, with the first offering a top-down perspective and the second a bottom-up viewpoint. In chapter one deindustrialisation is analysed through changes in political economy. Shifts in labour market structure are examined through the development of regional policy and its administration by the Scottish Office. The analysis centres upon a policy network of Scottish business elites and civil servants who shaped a vision of modernisation via industrial diversification through attracting inward investment. In chapter two the perspective shifts to community and workforce. It analyses responses to coalfield contraction through a moral economy of customary rights to colliery employment. A detailed investigation of Lanarkshire colliery closures between the 1940s and 1980s emphasises the protracted nature of deindustrialisation. Chapters three and four consider the social and cultural structures which shaped the moral economy but were heavily altered by deindustrialisation. Chapter three focuses on the dense networks that linked occupation, community, and class consciousness. Increasing coalfield centralisation and remote control of pits from NCB headquarters in London, and mounting hostility to coal closures, contributed to an accentuated sense of Scottish-ness. Chapter four illuminates gender and generational dimensions. The differing experiences of cohorts of men who faced either early retirement, redundancy or transfer to alternative sectors, or those who never attained anticipated industrial employment due to final closures, are analysed in terms of constructions of masculinity and the endurance of cultural as well as material losses. This is counterpoised to women who gained industrial work in assembly plants and the perceived gradual attainment of an improved economic and social position whilst continuing to navigate structures of patriarchy.

'Expanding Horizons': investigating the Glasgow 2014 legacy for young people in the East End of Glasgow

The recent staging of Glasgow 2014 drew universal praise as the ‘Best Games Ever’. Yet the substantial undertaking of hosting the Commonwealth Games (CWG) was sold to the nation as more than just eleven days of sporting spectacle and cultural entertainment. Indeed, the primary strategic justification offered by policymakers and city leaders was the delivery of a bundle of positive and enduring benefits, so-called ‘legacy’. This ubiquitous and amorphous concept has evolved over time to become the central focus of contemporary hosting bids, reflecting a general public policy shift towards using major sporting mega events as a catalyst to generate benefits across economic, environmental and social dimensions, on a scale intended to be truly transformative. At the same time, the academy has drawn attention to the absence of evidence in support of the prevailing legacy rhetoric and raised a number of sociological concerns, not least the socially unequitable distribution of purported benefits. This study investigated how young people living in the core hosting zone related to, and were impacted upon, by the CWG and its associated developments and activities with reference to their socio-spatial horizons, the primary outcome of interest. An ‘ideal world’ Logic Model hypothesised that four mechanisms, identified from official legacy documents and social theories, would alter young people’s subjective readings of the world by virtue of broadening their social networks, extending their spatial boundaries and altering their mind sets. A qualitative methodology facilitated the gathering of situated and contextualised accounts of young people’s attitudes, perceptions, beliefs and behaviours relating to Glasgow 2014. In-depth interviews and focus groups were conducted before and after the Games with 26 young people, aged 14-16 years, at two schools in the East End. This approach was instrumental in privileging the interests of people ‘on the ground’ over those of city-wide and national stakeholders. The findings showed that young people perceived the dominant legacy benefit to be an improved reputation and image for Glasgow and the East End. Primary beneficiaries were identified by them as those with vested business interests e.g. retailers, restaurateurs, and hoteliers, as well as national and local government, with low expectations of personal dividends or ‘trickle down’ benefits. Support for Glasgow 2014 did not necessarily translate into individual engagement with the various cultural and sporting activities leading up to the CWG, including the event itself. The study found that young people who engaged most were those who had the ability to ‘read’ the opportunities available to them and who had the social, cultural and economic capital necessary to grasp them, with the corollary that those who might have gained most were the least likely to have engaged with the CWG. Doubts articulated by research participants about the social sustainability of Glasgow 2014 underscored inherent tensions between the short-lived thrill of the spectacle and the anticipated longevity of its impacts. The headline message is that hosting sporting mega events might not be an effective means of delivering social change. Aspirant host cities should consider more socially equitable alternatives to sporting mega events prior to bidding; and future host cities should endeavour to engage more purposefully with more young people over longer time frames.

Investigating assistive technology to support memory for people with cognitive impairments

Technologies such as automobiles or mobile phones allow us to perform beyond our physical capabilities and travel faster or communicate over long distances. Technologies such as computers and calculators can also help us perform beyond our mental capabilities by storing and manipulating information that we would be unable to process or remember. In recent years there has been a growing interest in assistive technology for cognition (ATC) which can help people compensate for cognitive impairments. The aim of this thesis was to investigate ATC for memory to help people with memory difficulties which impacts independent functioning during everyday life. Chapter one argues that using both neuropsychological and human computing interaction theory and approaches is crucial when developing and researching ATC. Chapter two describes a systematic review and meta-analysis of studies which tested technology to aid memory for groups with ABI, stroke or degenerative disease. Good evidence was found supporting the efficacy of prompting devices which remind the user about a future intention at a set time. Chapter three looks at the prevalence of technologies and memory aids in current use by people with ABI and dementia and the factors that predicted this use. Pre-morbid use of technology, current use of non-tech aids and strategies and age (ABI group only) were the best predictors of this use. Based on the results, chapter four focuses on mobile phone based reminders for people with ABI. Focus groups were held with people with memory impairments after ABI and ABI caregivers (N=12) which discussed the barriers to uptake of mobile phone based reminding. Thematic analysis revealed six key themes that impact uptake of reminder apps; Perceived Need, Social Acceptability, Experience/Expectation, Desired Content and Functions, Cognitive Accessibility and Sensory/Motor Accessibility. The Perceived need theme described the difficulties with insight, motivation and memory which can prevent people from initially setting reminders on a smartphone. Chapter five investigates the efficacy and acceptability of unsolicited prompts (UPs) from a smartphone app (ForgetMeNot) to encourage people with ABI to set reminders. A single-case experimental design study evaluated use of the app over four weeks by three people with severe ABI living in a post-acute rehabilitation hospital. When six UPs were presented through the day from ForgetMeNot, daily reminder-setting and daily memory task completion increased compared to when using the app without the UPs. Chapter six investigates another barrier from chapter 4 – cognitive and sensory accessibility. A study is reported which shows that an app with ‘decision tree’ interface design (ApplTree) leads to more accurate reminder setting performance with no compromise of speed or independence (amount of guidance required) for people with ABI (n=14) compared to a calendar based interface. Chapter seven investigates the efficacy of a wearable reminding device (smartwatch) as a tool for delivering reminders set on a smartphone. Four community dwelling participants with memory difficulties following ABI were included in an ABA single case experimental design study. Three of the participants successfully used the smartwatch throughout the intervention weeks and these participants gave positive usability ratings. Two participants showed improved memory performance when using the smartwatch and all participants had marked decline in memory performance when the technology was removed. Chapter eight is a discussion which highlights the implications of these results for clinicians, researchers and designers.