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.

"Am I Korean American?": beliefs and practices of parents and children living in two languages and two cultures

The purpose of this study is to explore attitudes and practices regarding their heritage language and the dominant English language among Korean American immigrant families. Using the framework of Language Ideology (Silverstein, 1979), I had three research questions: a) why do parents send their children to a Korean language school, b) what attitudes do immigrant parents and their children show toward Korean and English, and c) how are the parents and children involved in the practices of these two languages? I conducted a survey of parents whose children attended a Korean language school in Urbana-Champaign, Illinois, where the number of Korean sojourners (temporary residents) exceeds that of Korean immigrants. Forty participant parents provided demographic information. They described their children's language-use patterns depending on interlocutors as well as their language proficiency in both Korean and English. The reasons for sending their children to the Korean language school were significantly different depending on the respondents' residential status. In comparison to the sojourners, immigrants tended to give more priority to their children's oral language development and Korean identity construction. I also conducted case studies of three Korean immigrant families with 3- to 5-year-old children, using interviews, observations, and photographs of children's work. The collected data were analyzed according to themes such as daily life, parental beliefs about two languages, practices in two languages, children's attitudes toward two languages, and challenges and needs. Despite individual families' different immigration histories, the three families faced some common challenges. Because of their busy daily routines and different lifestyles, the immigrant families had limited interactions with other Koreans. The parents wanted their children to benefit from two communities and build a combined ethnic identity as Korean Americans. I argue that a Korean language school should expand its role as a comfort zone for all Koreans and Korean Americans. This study explores the heterogeneity among Korean sojourner and immigrant families and their language use and identity construction.

Cost-effectiveness analysis of apixaban compared to low-molecular-weight heparins and vitamin k antagonists for treatment and secondary prevention of venous thromboembolism

Objective: Cost-effectiveness analysis of a 6-month treatment of apixaban (10 mg/12h, first 7 days; 5 mg/12h afterwards) for the treatment of the first event of venous thromboembolism (VTE) and prevention of recurrences, versus low-molecular-weight heparins/vitamin K antagonists treatment (LMWH/VKA). Material and methods: A lifetime Markov model with 13 health states was used for describing the course of the disease. Efficacy and safety data were obtained from AMPLIFY and AMPLIFY-EXT clinical trials; health outcomes were measured as life years gained (LYG) and quality-adjusted life years (QALY). The chosen perspective of this analysis has been the Spanish National Health System (NHS). Drugs, management of VTE and complications costs were obtained from several Spanish data sources (€, 2014). A 3% discount rate was applied to health outcomes and costs. Univariate and probabilistic sensitivity analyses (SA) were performed in order to assess the robustness of the results. Results: Apixaban was the most effective therapy with 7.182 LYG and 5.865 QALY, versus 7.160 LYG and 5.838 QALYs with LMWH/VKA. Furthermore, apixaban had a lower total cost (€13,374.70 vs €13,738.30). Probabilistic SA confirmed dominance of apixaban (led to better health outcomes with less associated costs) in 89% of the simulations. Conclusions: Apixaban 5 mg/12h versus LMWH/VKA was an efficient therapeutic strategy for the treatment and prevention of recurrences of VTE from the NHS perspective.

Search for Higgs Boson Production Beyond the Standard Model Using the Razor Kinematic Variables in pp Collisions at √s=8 TeV and Optimization of Higgs Boson Identification Using a Quantum Annealer

In the first part of this thesis we search for beyond the Standard Model physics through the search for anomalous production of the Higgs boson using the razor kinematic variables. We search for anomalous Higgs boson production using proton-proton collisions at center of mass energy √s=8 TeV collected by the Compact Muon Solenoid experiment at the Large Hadron Collider corresponding to an integrated luminosity of 19.8 fb^-1.

In the second part we present a novel method for using a quantum annealer to train a classifier to recognize events containing a Higgs boson decaying to two photons. We train that classifier using simulated proton-proton collisions at √s=8 TeV producing either a Standard Model Higgs boson decaying to two photons or a non-resonant Standard Model process that produces a two photon final state.

The production mechanisms of the Higgs boson are precisely predicted by the Standard Model based on its association with the mechanism of electroweak symmetry breaking. We measure the yield of Higgs bosons decaying to two photons in kinematic regions predicted to have very little contribution from a Standard Model Higgs boson and search for an excess of events, which would be evidence of either non-standard production or non-standard properties of the Higgs boson. We divide the events into disjoint categories based on kinematic properties and the presence of additional b-quarks produced in the collisions. In each of these disjoint categories, we use the razor kinematic variables to characterize events with topological configurations incompatible with typical configurations found from standard model production of the Higgs boson.

We observe an excess of events with di-photon invariant mass compatible with the Higgs boson mass and localized in a small region of the razor plane. We observe 5 events with a predicted background of 0.54 ± 0.28, which observation has a p-value of 10^-3 and a local significance of 3.35σ. This background prediction comes from 0.48 predicted non-resonant background events and 0.07 predicted SM higgs boson events. We proceed to investigate the properties of this excess, finding that it provides a very compelling peak in the di-photon invariant mass distribution and is physically separated in the razor plane from predicted background. Using another method of measuring the background and significance of the excess, we find a 2.5σ deviation from the Standard Model hypothesis over a broader range of the razor plane.

In the second part of the thesis we transform the problem of training a classifier to distinguish events with a Higgs boson decaying to two photons from events with other sources of photon pairs into the Hamiltonian of a spin system, the ground state of which is the best classifier. We then use a quantum annealer to find the ground state of this Hamiltonian and train the classifier. We find that we are able to do this successfully in less than 400 annealing runs for a problem of median difficulty at the largest problem size considered. The networks trained in this manner exhibit good classification performance, competitive with the more complicated machine learning techniques, and are highly resistant to overtraining. We also find that the nature of the training gives access to additional solutions that can be used to improve the classification performance by up to 1.2% in some regions.

Parasite communities of the predatory fish, Acestrorhynchus falcatus and Acestrorhynchus falcirostris, living in sympatry in Brazilian Amazon.

This study investigated the parasite communities of wild Acestrorhynchus falcatus and Acestrorhynchus falcirostris populations living in sympatry in Brazilian Amazon. In these two hosts, a total of 12 parasite species e 1-9 parasite species were found per fish, and 10 of these species are metazoans. Eight species of parasites were common to both host species and four of them exhibited differences in abundance and/or prevalence. Parasite communities of the hosts were taxonomically similar (83%) and composed of both ectoparasites and endoparasites, and characterized by high prevalence and high abundance of endoparasites and an aggregated dispersion pattern. For A. falcirostris, the dominant parasite was Ichthyophthirius multifiliis, and for A. falcatus, it was Piscinoodinium pillulare. Shannon diversity and Berger-Parker dominance were similar for both hosts, while the parasites species richness and evenness showed differences influenced by the ectoparasites species. These two populations of hosts that inhabited the same geographical area had different sizes, but were exposed to the same infective stages, and acquired qualitatively and quantitatively similar endoparasites community, thus indicating that the amounts and types of prey congeneric that they were eating were similar. Therefore, the overlap in the same occurrence area play an important role in the parasite communities to these phylogenetically related hosts.

Synthesis and characterization of low-cost materials for aqueous Na-ion batteries

136 p.

A COST-BENEFIT ANALYSIS OF A 25% RPS IN MICHIGAN

Michigan depends heavily on fossil fuels to generate electricity. Compared with fossil fuels, electricity generation from renewable energy produces less pollutants emissions. A Renewable Portfolio Standard (RPS) is a mandate that requires electric utilities to generate a certain amount of electricity from renewable energy sources. This thesis applies the Cost-Benefits Analysis (CBA) method to investigate the impacts of implementing a 25% in Michigan by 2025. It is found that a 25% RPS will create about $20.12 billion in net benefits to the State. Moreover, if current tax credit policies will not change until 2025, its net present value will increase to about $26.59 billion. Based on the results of this CBA, a 25% RPS should be approved. The result of future studies on the same issue can be improved if more state specific data become available.

Knowledge of HIV transmission risk behavior, and perceptions of risk among Haitian women living in Miami, Florida

This study was conducted to gain a more comprehensive understanding of HIV risk among Haitian women. The variables measured were: knowledge of HIV transmission, sexual risk behaviors, and perceptions of risk among Haitian women. The sociocultural aspect of the Haitian women's lives with regard to their risky behaviors was also examined. A total of 101 Haitian women (aged 25-53) who attended two comprehensive health clinics were interviewed. A combined questionnaire derived from both the ARM-Q and the RBA was used. In general, the women had good knowledge of the sexual transmission of HIV I AIDS and indicated that they were susceptible to HIV infection. However, knowledge and perceptions of risk were not translated into sexual risk-reduction behaviors with their partners. Multiplicity of partners and low incidence of condom use were the two major sexual risk factors isolated in this study. Results indicate Haitian women were more likely to use condoms if they possessed greater HIV knowledge and their sexual partners held more positive attitudes toward using condoms. Also, Haitian women may have failed to protect themselves because behavior changes could have involved threats to their social and economic survival, relationships and culturally sanctioned roles. This suggests the need to include male partners in HIV prevention interventions with Haitian women. Future research should focus on preventing high-risk behavior by improving knowledge, altering the male partners' attitudes toward condoms, and enhancing communication and negotiation skills. Nursing implications and recommendations for culturally sensitive and relevant AIDS prevention efforts are discussed.

Ecology of west Iberian kelps: Laminaria ochroleuca and Saccorhiza polyschides living near their distributional limits

Tese de Doutoramento, Ecologia (Ecologia das Populações), Faculdade de Ciências e Tecnologia, Universidade do Algarve, 2015

Abuse and neglect of elderly and independence in instrumental and basic activities of daily living.

Introduction: One of the known risk factors for abuse and neglect of the elderly is the decrease in functional capacity, contributing to self care dependency of instrumental activities of daily living and basic activities of daily living (OMS, 2015). Methods: Cross-sectional study with non probabilistic sample of 333 elderly, performed in a hospital, homes and day centers for the elderly. The data collection protocol included socio-demographic data, Questions to elicit Elder Abuse (Carney, Kahan & Paris, 2003 adap. By Ferreira Alves & Sousa, 2005), scale of instrumental activities of daily living Lawton and Brody and Katz index to assess the level of independence in activities of daily living. Objectives: To evaluate the association between abuse and neglect in the elderly, instrumental activities of daily living and level of independence in activities of daily living. Results: Emotional abuse is significantly correlated with the level of independence in activities of daily living (p = 0.000), older people with less independence tend to have higher levels of emotional abuse. The total abuse is significantly correlated with the levels of independence in activities of daily living (p = 0.002), less independent elderly tend to suffer greater abuse and neglect. There were no statistically significant associations between abuse and neglect and instrumental activities of daily living. Conclusions: The less independent elderly are more vulnerable to situations of abuse and neglect, being more exposed to emotional abuse. These results point to the need for health professionals/ nurses develop prevention interventions, including strategies to support carers and early screening in less independent elderly.

Abuse and neglect of elderly and independence in instrumental and basic activities of daily living

Introduction: One of the known risk factors for abuse and neglect of the elderly is the decrease in functional capacity, contributing to self care dependency of instrumental activities of daily living and basic activities of daily living (OMS, 2015). Methods: Cross-sectional study with non probabilistic sample of 333 elderly, performed in a hospital, homes and day centers for the elderly. The data collection protocol included socio-demographic data, Questions to elicit Elder Abuse (Carney, Kahan & Paris, 2003 adap. By Ferreira Alves & Sousa, 2005), scale of instrumental activities of daily living Lawton and Brody and Katz index to assess the level of independence in activities of daily living. Objectives: To evaluate the association between abuse and neglect in the elderly, instrumental activities of daily living and level of independence in activities of daily living. Results: Emotional abuse is significantly correlated with the level of independence in activities of daily living (p = 0.000), older people with less independence tend to have higher levels of emotional abuse. The total abuse is significantly correlated with the levels of independence in activities of daily living (p = 0.002), less independent elderly tend to suffer greater abuse and neglect. There were no statistically significant associations between abuse and neglect and instrumental activities of daily living. Conclusions: The less independent elderly are more vulnerable to situations of abuse and neglect, being more exposed to emotional abuse. These results point to the need for health professionals/ nurses develop prevention interventions, including strategies to support carers and early screening in less independent elderly.

Reducing the global burden of depression : population level analysis of intervention cost-effectiveness in 14 world regions

International evidence on the cost and effects of interventions for reducing the global burden of depression remain scarce. Aims: To estimate the population-level cost-effectiveness of evidence-based depression interventions and their contribution towards reducing current burden. Method: Primary-care-based depression interventions were modelled at the level of whole populations in 14 epidemiological subregions of the world. Total population-level costs (in international dollars or I$) and effectiveness (disability adjusted life years (DALYs) averted) were combined to form average and incremental cost-effectiveness ratios. Results: Evaluated interventions have the potential to reduce the current burden of depression by 10–30%. Pharmacotherapy with older antidepressant drugs, with or without proactive collaborative care, are currently more cost-effective strategies than those using newer antidepressants, particularly in lower-income subregions. Conclusions: Even in resource-poor regions, each DALYaverted by efficient depression treatments in primary care costs less than 1 year of average per capita income, making such interventions a cost-effective use of health resources. However, current levels of burden can only be reduced significantlyif there is a substantialincrease substantial increase intreatment coverage.