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Efficacy of instilled saline in conjunction with chest physiotherapy on secretion clearance in adults diagnosed with a ventilator acquired pneumonia: a feasibility study
Get PDFIntroduction
Chest physiotherapy is routinely provided to intubated and mechanically ventilated patients in intensive care units (ICUs) to aid secretion clearance. If pulmonary secretions are thick, physiotherapists will often use normal saline instillation (NSI) as part of a multimodal intervention. However, evidence on the benefits of NSI during chest physiotherapy is limited. This trial aimed to evaluate the feasibility of delivering a definitive trial to examine the efficacy of NSI during chest physiotherapy on secretion yield for patients with ventilator acquired pneumonia (VAP).
Methods
Patients admitted to a large West Midlands ICU and diagnosed with VAP were included in the trial. A randomised crossover feasibility design was employed for the intervention (twice daily chest physiotherapy). On day one patients were randomised to receive either chest physiotherapy with NSI or without NSI during the morning treatment session. Physiotherapy treatment then alternated between NSI and non-saline sessions for three days or until extubated, whichever sooner. Primary outcomes were feasibility measures: patient recruitment, retention, and protocol fidelity. Secondary outcomes included physiological parameters, sputum weight and safety of NSI.
Results
Of 32 eligible patients, 94% (n=30) consented to participate. Of these, 28 (93%) completed the study intervention with only two (7%) patients’ next of kin withdrawing consent during the intervention. Of patients surviving to hospital discharge who regained capacity (n=9), 100% provided consent for ongoing participation. Protocol fidelity was at 100% with no missing data or adverse events related to NSI. NSI was associated with a significant drop in SpO2 two minutes post intervention (p<0.05) and higher sputum pellet weight (p<0.001). Adjusted wet sputum weight is not a reliable outcome measure for measuring secretion clearance when NSI is used.
Conclusion
A trial looking at the effect of NSI during chest physiotherapy on secretion yield for mechanically ventilated patients with VAP is feasible to conduct and acceptable to participants. However, validation of the methodology for processing sputum samples and determining sputum pellet weight is required before proceeding to a definitive trial
What are the similarities and differences in how black American women and black British women of African descent and Caribbean descent experience racism?
Get PDFBlack women have significant and impactful traumatic experiences of racism that are often ignored (comparable to black men), and there are almost no comparative studies exploring black women’s experiences of racism in different contexts. This study examines the similarities and differences in how black women in the United States and England experience racism. The study builds upon the theoretical frameworks of historical trauma theory, microaggression theory, and everyday racism and interconnects them through the lens of black women. Mixed methods were used for data collection.
A survey was conducted as a recruitment tool to gather participants and collect pertinent demographical data. Demographical data were collected from 114 black American women and 80 black British women of African descent and Caribbean descent. Focus group and interview participants were selected from the survey respondents; 30 women gave consent to participate—12 black American women and 18 black British women. Thematic analysis was applied to the findings and resulted in five major themes. Major findings discussed in the thesis include historical racial trauma from childhood to adulthood, frequency of experiences of racism and the most common locales of occurrences, and black women’s resilience.
Areas identified for further research include: expanding literature as it relates to black women’s experiences of racism, comparatively, and experiences of racism by black women with white mothers
Qualitative theory for nonlinear non-local reaction-diffusion equations
Get PDFThis Thesis is concerned with the qualitative properties of nonlinear non-local reaction diffusion equations. We begin by establishing minimum and comparison principles for solutions to inequalities involving the integro-differential operators
and
respectively, with denoting the convolution of with an appropriately chosen integral kernel . The minimum and comparison principles are established under a variety of assumptions on the coefficients , , , and growth/decay rates of . Next, we demonstrate that the Cauchy problem associated with
,
is well-posed, locally in time, when the nonlinear non-local term is locally Lipschitz continuous. Additionally, we prove the existence of solutions when is locally Hölder continuous (obtaining the existence of maximal and minimal solutions when is assumed to be non-decreasing with respect to ). Afterwards we treat the non-local analogue to a problem arising from fractional-order autocatalysis (by taking (, ) (), for (, )) and show its well-posedness (locally in time). We accompany our analysis with numerical simulations, demonstrating the conditional converges of the finite difference scheme, and large- asymptotics. Finally, we consider potential generalisations and extensions of the results presented in the text
Future human-system interaction techniques to influence perceived trust
Get PDFThe maritime defence domain presents unique challenges for the introduction of autonomous systems. With the Ministry of Defence predicting that intelligent information systems are the future of defence, recommending their integration into future systems in order to maintain a competitive advantage, the question is not “if”, but “how”.
The thesis presents a user-centred design approach to the development of automated sonar decision-support systems. It develops this approach through an understanding of Submersible Maritime Platforms (SMPs) as socio-technical systems, evaluating their informational and user requirements using context from the Trust-in-Autonomy and Human Factors literature. Requirements to produce trustworthy autonomy recommendations for the maritime defence domain are presented.
These requirements are then developed further through interviews with Subject Matter Experts, aimed to understand how they deal with informational uncertainty through the Critical Decision Method interview technique, to create a thorough understanding of the tasks involved in broadband sonar classification. This is built on through developing understanding of how they perform their cognitive classification process, in comparison to novices and other SMP crew members, using the Repertory Grid interview technique.
These literature reviews and interviews lead to the development of the VINAS: A Visual, Intelligent Narrative of Autonomous systems. This visualisation uses the cognitive constructs derived from the repertory grid to create an explanation behind an autonomous classifier’s decision-making processes, to allow an operator to evaluate its performance in a transparent and understandable way, in order to encourage appropriate trust calibration.
The VINAS visualisation is then evaluated through two experiments, which show that VINAS increases performance and trust when performing classifications utilising an autonomous classifier
Investigating unique profiles of positive and negative imagery ability with stress and emotion regulation
Get PDFThe objective of this thesis was to determine whether unique profiles of positive and negative imagery ability exist, and if so, to evaluate the effects of these profiles on stress and emotion regulation outcomes. A thorough review of the literature was first provided in Chapter 1. This was followed by Chapter 2, which investigated the potential existence of imagery ability profiles in a large cross-sectional sample using multivariate cluster analysis. This chapter also examined whether these imagery ability profiles were differentially associated with emotion regulation strategies, perceptions of stress, and general anxiety. Next, Chapter 3 investigated whether the unique imagery ability profiles identified in Chapter 2 could be replicated in a different sample. This chapter also examined whether these profiles differentially impacted stress, anxiety, and emotional responses to experimental manipulations of guided imagery to elicit challenge and threat appraisals. In summary, three imagery ability profiles were identified: Higher overall imagers, higher positive/lower negative imagers, and lower overall imagers. Notably, higher positive/lower negative imagers demonstrated a unique capacity for stress regulation and well-being, marked by adaptive emotion regulation, lower perceived stress, lower general anxiety, skillful utilization of positive imagery, and resilience to negative imagery. This thesis is novel in that it represents the first attempt to identify unique profiles of positive and negative imagery ability, as well as determine whether certain profiles are more (or less) suited to adaptive stress responding and emotion regulation, both in everyday life, and in response to guided imagery of stress-evoking situations. The results of this research could have significant implications for future stress intervention studies, as it may lead to the development of targeted interventions to enhance specific types of imagery ability, which could ultimately improve the optimization of stress responses to reach desired goals, rather than just reducing or avoiding stress
Turkish foreign and domestic policy: the Balkan Pact, the Saadabad Pact, and Nationalism in the 1930s
Get PDFBy examining the foreign policy dynamics of the Balkan and Saadabad Pacts, the thesis demonstrates the agency of signatory nation-states against a historiography that posits the Great Powers as causal in interwar regional foreign policy. There is more specific emphasis on the links between Turkish foreign and domestic policy that connects to regional diplomacy. This includes a new perspective on etatism as a pillar of Republican legitimacy, the state aimed to entrench itself over the territory by promoting the interests of the core nation, identified as Sunni-Muslim Turkish speakers. This included consolidating Ankara as the infrastructural centre of the new Republican order. There is a continuity and change narrative based on Erik Zürcher’s continuity of the state elite and Rogers Brubaker’s concept of the nationalising state. Turkish nationalism revealed itself in dynamic processes that demonstrated a gulf between the civic discursive inclusivity of all citizens and exclusionary practices of the state. CUP-RPP understandings of Ottoman collapse informed Ankara’s practices of active foreign policy to isolate the domestic sphere from external influence. I use the term capitulationphobia as a conceptual shorthand for this practice. Turkey in the 1930s consolidated the state which had been established in the 1920s
An exploration of patient-held health records for improving handover communication and self-management for patients with diabetes and hypertension in outpatient settings in Kerala, India.
Get PDFHigh-quality health systems need to optimise healthcare delivery based on the changing health needs of the population. Long-term management of non-communicable diseases (NCDs) requires patients, carers, and health care providers (HCPs) to work together for optimal results. Patient medical information is essential for all HCPs to provide quality care. Additionally, patients and carers need information for self-management. Patient-held records (PHRs) are widely used in low and middle-income countries (LMICs) such as India, to document and hand over medical information to HCPs and other HCPs or patients or carers. A previous clinical handover study in India found that handover communication was poor for patients with NCDs in outpatient settings and suggested a structured PHR for patients with NCDs.
The overall aim of this thesis was to synthesise the evidence base, explore the perceptions of patients, carers and HCPs regarding the use of PHRs and understand the factors that affect the use of PHRs for handover communication, information transfer, and self-management; that can
contribute to development or improvement of a future PHR.
In the first results chapter, evidence of the effectiveness and perceived usefulness of PHRs in LMIC is synthesised. Chapter three uses systematic reviews (SR) of PHRs for NCDs and home-based records for maternal and child health records to summarize evidence on PHRs in LMICs. Notably, the above SRs indicate limited studies evaluating PHRs for improving handover communication and self-management. Next chapter details the findings of a qualitative study among patients with diabetes and hypertension, carers, and HCPs from Kerala, India to explore their experiences with current PHRs and reports the similarities and differences in their perspectives on the use and value of current PHRs. Chapter four demonstrates that patients, carers, and HCPs use PHRs in practice; however, their perceived value of PHRs is different. Patients value the PHRs for medication procurement, while carers value them for communication during emergencies with HCPs. However, HCPs perceive PHRs as documents that aid them in clinical decision-making and preventing errors. Patients do not use PHRs for self-management, and HCPs do not use them for communicating self-management information. Chapter five reports patient navigations in the health system, HCP-patient interactions, and lack of agency over illness and overall health as contextual influences that play a role in patients' lack of engagement with PHRs. Chapter six reports a qualitative analysis of HCP data with the theoretical domains framework (TDF) to identify barriers and facilitators for HCPs to use PHRs for maintaining continuity of care in Kerala. Findings indicate that nine domains are likely to influence HCPs' in recording PHRs and communicating with patients and carers in Kerala. Chapter seven presents a plan for co-designing a PHR to be used in Kerala and proposes that an experience-based co-design (EBCD) method may improve user engagement with PHRs.
The thesis findings highlight the complexities and challenges of using PHRs in public health settings in Kerala and indicate suboptimal utilisation of current PHRs for handover communication, information transfer, and self-management. Based on these results, co-designing a PHR is proposed as a potential method to improve handover communication, information transfer, and self-management among patients with diabetes and hypertension in Kerala
The effects of shocks, tobacco sales bans, and COVID-19 restrictions on mental health and wellbeing: evidence from Tanzania, South Africa, and Australia
Get PDFThis thesis comprises three empirical studies that delved into the impact of various shocks on mental health and wellbeing. The first study investigated the relationships between self-reported household shocks, conflict events, and food insecurity, on the one hand, and subjective wellbeing (SWB), on the other, in Tanzania. The second study examined the effect of the 2020 tobacco sales ban on the depressive feelings of South African smokers. The third chapter estimated the influence of COVID-19 lockdowns on mental health in Australia, with a specific focus on how personality traits may moderate this effect. All these studies employed individual-level panel survey data.
Using two waves of the Tanzanian National Panel Survey (TZNPS), we investigated the impact of self-reported household shocks, conflict, and food insecurity on SWB. The data was supplemented by data from the Armed Conflict Location and Event Data (ACLED) Project to match conflict events to households based on their geographical proximity. We firstly estimated the direct impact of the shocks, conflict, and food insecurity on life satisfaction using ordered Probit and linear fixed effects models. The findings suggested that only certain self-reported were negatively associated with SWB. These tended to be more idiosyncratic to the household. Additionally, we found increases in conflict events were negatively associated with SWB, albeit the magnitude of this relationship was relatively small. We further found a significant negative relationship between self-reported food insecurity and SWB. We subsequently tested for factors which moderate or mediate these relationships. We found that labour market shocks had a significantly greater impact on SWB for individuals from food insecure households, whilst receipt of financial assistance mitigated this effect. We further found the effect of food insecurity on SWB was heightened for households in the upper consumption quartile, we which postulated may reflect a greater stigma within their socioeconomic status group. Finally, our analysis largely ruled out significant mediating roles for food insecurity and consumption in the effects of the shocks and conflict on SWB.
Next, we used five waves of the South African National Income Dynamics Survey (NIDS) and three waves of the NIDS Coronavirus Rapid Response Mobile Survey (NIDS-CRAM) to estimate the impact of the tobacco sales ban introduced by the South African government in response to the COVID-19 pandemic in March 2020. Using a difference-in-differences (DD) approach, we found that the ban significantly increased frequency of depressive feelings amongst smokers who continued to smoke during the ban, but not amongst those who quit. We attributed the ‘struggling quitters hypothesis’ as a potential driver behind this finding. We subsequently conducted a gender-based analysis which indicated that female smokers were most susceptible to poorer mental health during the ban. We postulated this finding may reflect evidence that women are more likely to smoke to reduce negative emotion and less likely to be successful in cessation attempts than men. Our findings therefore indicated the imposition of the ban may have had an unintended negative mental health effect on smokers and emphasise the need for appropriate cessation support to be provided to smokers.
Lastly, we exploited state-level heterogeneity in COVID-19 policies in Australia to estimate the effect of extended lockdowns on mental health, and further investigated how the ‘Big Five’ personality traits may moderate this effect. To this end, we utilised over 180,000 observations on individuals across 17 waves of the Household, Income, and Labour Dynamics Australia (HILDA) survey covering the period 2005 to 2021. Using an ‘extended’ two-way fixed effects (ETWFE) difference-in-differences design which accounted for staggered treatment timing, we firstly found that extended lockdowns significantly adversely affected the mental health of individuals in affected states, with some variations across cohorts. Moreover, extroversion, emotional stability, and openness to experience traits were found to moderate these effects to varying degrees. Highly extroverted individuals were notably more susceptible to deteriorating mental health during extended lockdowns than highly introverted individuals, although this moderating effect somewhat diminished between the 2020 and 2021 extended lockdowns. Additionally, individuals with high levels of emotional stability were largely protected from the mental health effects of extended lockdowns, as were, to a lesser extent, individuals who scored higher on openness to experience, with this latter effect dissipating in 2021. Our findings add to the growing literature documenting the unintended consequences of lockdown policies, and indicate policymakers need to seriously consider the pros and cons such polices if they were ever again required
Provision of an enhanced road safety financing mechanism through the application of social impact bonds
Get PDFAttempts have been made in low and middle-income countries (LMICs) to reduce the number of road fatalities and injuries through the implementation of road safety programmes. However, the results were not as expected and still tended to increase. It has been identified that weak road safety management causes low road safety performance in LMICs and high-income countries (HICs).
This study investigates the potential implementation of social impact bonds to improve road safety performance in low and middle-income countries, using Indonesia as a study case. A social impact bond (SIB) is an outcomes-based payment tool with a multi-sector partnership among government, private, community, and non-profit organisations.
The study consists of two main parts. Part one assesses the road safety management system, including road safety financing, in terms of the robustness of the road safety target, the efficiency and effectiveness of the institutional arrangement, the effectiveness of road safety intervention delivery, and the financial availability and capacity. Part two investigates the implementation of SIBs for road safety to improve the road safety management system, which consists of assessing the suitability of SIBs to improve road safety management and develop SIB delivery and payment structures.
The findings show that road safety management performance at the national and local levels is still below the margin. Therefore, implementing SIBs is expected to improve road safety management performance by utilising outcome-based payment and multi-sectoral partnerships. Furthermore, the investigation of the potential implementation of SIBs for road safety shows that SIBs may be implemented in Indonesia, with some conditions and structures to address the current road safety management. Three SIB delivery structures are proposed, which can be implemented in Indonesia with specific requirements that must be met before implementation. Two models of investment cases were demonstrated: economic and financial cases. The financial case generates a low rate of return, which may make SIB investment unattractive to potential investors. The economic case generates a higher return payment. However, the benefits of this model are spread to many stakeholders
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