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.

Mindfulness-Based Cognitive Therapy for older people in a community setting: a mixed methods feasibility study

Rationale: In line with complex intervention development, this research takes a systematic approach to examining the feasibility and acceptability of delivering Mindfulness-Based Cognitive Therapy (MBCT) to older people who experience symptoms of depression. Methods: A mixed methods approach was adopted in line with recommendations made by the MRC Complex Intervention Development framework. Quantitative and qualitative methods were combined by administering questionnaires as well as conducting post intervention interviews. A number of trial feasibility factors were examined such as recruitment and attrition rates. Qualitative data was analysed using Braun and Clarke’s thematic analysis framework. Results: Nine participants started the MBCT intervention and six completed the 8-week programme. The results suggest that MBCT for older people is feasible and acceptable. Participants reported improved mindfulness skills. Participants responded positively to being asked to take part in research and appeared to particularly value the group delivery format of the intervention. Conclusions: MBCT is both feasible and acceptable for older people experiencing symptoms of depression. Further research is required with larger sample sizes to allow for more robust statistical exploration of outcome measures, including mechanisms of change.

Molecular probes for monitoring mitochondrial movement and function

This thesis explores two distinct parts of mitochondrial physiology: the role of mitochondria in generation of reactive oxygen species (ROS) and mitochondrial morphology and dynamics within cells. The first area of research is covered in Chapters 1-8. Mitochondrial biofunctionality and ROS production are discussed in Chapter 1, followed by the strategy of targeting bioactive compounds to mitochondria by linking them to lipophilic triphenylphosphonium cations (TPP) (Chapter 2). ROS sensors relevant to the research are reviewed in Chapter 3. Chapter 4 presents design and synthesis of novel probes for superoxide detection in mitochondria (MitoNeo-D), cytosol (Neo-D) and extracellular environment (ExCellNeo-D). The results of biological validation of MitoNeo-D and Neo-D performed in the MRC MBU in Cambridge are presented in Chapter 5. A dicationic hydrogen peroxide sensor that utilizes in situ click chemistry is discussed in Chapter 6. Preliminary work on the synthesis of mitochondria-targeted superoxide generators, which led to the development of mitochondria-targeted analogue of paraquat, MitoPQ, is presented in Chapter 7. A set of bifunctional probes (BCN-Mal, BCN-E-BCN and Mito-iTag) for assessing the redox states of protein thiols is discussed in Chapter 8 along with their biological validation. The second part of the thesis is aimed at the study of mitochondrial morphology and dynamics and is presented in Chapters 9-11. Chapter 9 provides background on the classes of fluorophores relevant to the research, the phenomenon of fluorescence quenching and the principle of photoactivation with examples of photoactivatable fluorophores. Next, the background on mitochondrial morphology and heterogeneity is presented in Chapter 10, followed by the ways of imaging and tracking mitochondria within cells by conventional fluorophores and by photoactivatable fluorophores exploiting super-resolution microscopy. Chapter 11 presents the design and synthesis of four photoactivatable fluorophores for mitochondrial tracking, MitoPhotoRhod110, MitoPhotoNIR, Photo-E+, MitoPhoto-E+, along with results of biological validation of MitoPhotoNIR. The results and discussion concludes with Chapter 12, which is a summary and suggestions for future work, followed by the chemistry experimental procedures (Chapter 13), materials and methods for biological experiments (Chapter 14) and references.