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.

Connected Hopf algebras of finite Gelfand-Kirillov dimension

Following the seminal work of Zhuang, connected Hopf algebras of finite GK-dimension over algebraically closed fields of characteristic zero have been the subject of several recent papers. This thesis is concerned with continuing this line of research and promoting connected Hopf algebras as a natural, intricate and interesting class of algebras. We begin by discussing the theory of connected Hopf algebras which are either commutative or cocommutative, and then proceed to review the modern theory of arbitrary connected Hopf algebras of finite GK-dimension initiated by Zhuang. We next focus on the (left) coideal subalgebras of connected Hopf algebras of finite GK-dimension. They are shown to be deformations of commutative polynomial algebras. A number of homological properties follow immediately from this fact. Further properties are described, examples are considered and invariants are constructed. A connected Hopf algebra is said to be "primitively thick" if the difference between its GK-dimension and the vector-space dimension of its primitive space is precisely one . Building on the results of Wang, Zhang and Zhuang,, we describe a method of constructing such a Hopf algebra, and as a result obtain a host of new examples of such objects. Moreover, we prove that such a Hopf algebra can never be isomorphic to the enveloping algebra of a semisimple Lie algebra, nor can a semisimple Lie algebra appear as its primitive space. It has been asked in the literature whether connected Hopf algebras of finite GK-dimension are always isomorphic as algebras to enveloping algebras of Lie algebras. We provide a negative answer to this question by constructing a counterexample of GK-dimension 5. Substantial progress was made in determining the order of the antipode of a finite dimensional pointed Hopf algebra by Taft and Wilson in the 1970s. Our final main result is to show that the proof of their result can be generalised to give an analogous result for arbitrary pointed Hopf algebras.