Loneliness and mental health in a randomised controlled trial of a peer-provided self-management intervention for people leaving crisis resolution teams

BACKGROUND: Loneliness is more prevalent among people with mental health problems than in the general population. However, loneliness has not been a particularly prominent focus in recent research on outcomes of mental illness. Loneliness interventions have also received little attention. AIMS: 1) To review literature for the definition and conceptual model of loneliness and its closely related concepts, and for well-developed measures of these concepts. 2) To systematically review the impact of loneliness and perceived social support on mental health outcomes 3) To explore the severity of loneliness among people leaving Crisis Resolution Teams (CRTs), and identify factors cross-sectionally associated with loneliness. 4) To determine whether loneliness at baseline predicts poor outcomes at 4-month follow-up, including overall symptom severity, affective symptoms, self-rated recovery and health-related quality of life. 5) To examine whether there is any difference in loneliness at 4-month follow-up between a peer-provided self-management intervention group and a control group in a randomised controlled trial. METHOD: A conceptual framework of loneliness and related concepts was developed and measures identified of main concepts. A systematic review of longitudinal studies examining the effect of loneliness and perceived social support on mental illness prognosis was conducted. The sample (n=399) was taken from patients participating in a research trial from CRTs. Participants in the trial intervention group were offered up to ten meetings by a peer support worker and a self-management workbook. Participants in the control group were only provided a self-management workbook. Respondents (n=310) completed the follow-up measurement four months after baseline. RESULTS: A model with five domains was proposed to incorporate all terms relating to loneliness. Well-developed measures assessing each domain or covering multi-domains were identified. Perceived social support and loneliness were associated with mental health outcomes. The severity of loneliness was high among people leaving CRTs. Greater loneliness was significantly associated with small social network size, limited social capital, severe affective symptoms and long-term mental illness history. Greater loneliness at baseline predicted poorer health-related quality of life at 4-month follow-up. Loneliness was also a better predictor of clinical outcomes than objective social isolation and social capital. Loneliness at follow-up was not significantly different between the intervention group and the control group. DISCUSSION Loneliness is an important issue in mental health service users. It could be a promising target to improve recovery for people with mental health problems. The efficacy of peer-provided self-management intervention on loneliness was not confirmed. More research is necessary to explore beneficial loneliness interventions so as to aid the development of recovery-oriented mental health services

Neural correlates of consciousness in the complexity of brain networks

How do we define consciousness? Besides philosophical endeavours, the development of modern neuroimaging techniques fostered a principled way of quantifying the neural correlates of consciousness. Acquiring and analysing resting-state functional magnetic resonance imaging (fMRI) and electroencephalography (EEG) data, has allowed neuroscientists to noninvasively map the brain’s functional interactions (or functional connectivity). Based on data obtained during controlled loss of consciousness and in cases of patients with disorders of consciousness, it has now been suggested that multiple, functionally specialized/segregated areas need to interact and integrate information in order to support consciousness. Thus an emerging idea in neuroscience is that the brain needs to balance the coexistence of functional segregation and integration, a property often termed as brain complexity, in order to produce consciousness. A resulting hypothesis is that consciousness is abolished when the balance between segregation and integration is lost and brain complexity is attenuated. In that regard, I use complexity of functional connectivity, an aggregate measure of segregation and integration, as a marker of consciousness. This effort consists of two parts. First, I provide evidence that complexity in the healthy, awake brain is critical in the sense that it reflects a critical balance of segregation and integration designed to support efficient information communication. In turn, I provide evidence that loss of consciousness is associated with decreased complexity i.e. that functional connectivity departs from the critical complexity of the healthy, awake brain towards a more segregated configuration. The structure of this thesis follows accordingly. In the first experimental chapter (3), I show the importance of the critical balance of complexity in the healthy, awake brain by using a structure-to-function association model. Specifically, I show that complexity can be derived upon certain optimal, structural connections (computed as the Nash equilibrium between regions), which promote efficient communication in the brain from the regional to the whole-brain level. Chapter 4 focuses on capturing alterations of complexity in cases of sedation, anaesthesia and disorders of consciousness. Specifically, I show that as one goes from the awake state to anaesthetic-induced unconsciousness and disorders of consciousness, functional connectivity becomes less complex and more segregated. A refined approach that quantifies complexity in different parts of the brain allowed me to see whether this reduction in complexity is more evident in specific regions and networks. Under this framework, at the regional level I provide evidence that sparsely connected regions linking different parts of the brain play a critical role in whole-brain complexity. At the network level I show the importance of the default mode network in whole-brain complexity. Even during rest, the brain is not static and displays rich temporal dynamics. Thus it is not only the complexity at each snapshot of time but also how complexity changes across time that can help us understand loss of consciousness. In chapter 5 I use a dynamic framework to derive and characterize the dynamics of functional connectivity during loss of consciousness. In turn, I provide evidence that brains become less temporally complex as one goes from the awake state to anaesthetic-induced unconsciousness and disorders of consciousness. Moreover, my goal is to see whether the principle of complexity reduction can be also applied to the developing brain. Towards this direction, in chapter 6 I use complexity on EEG connectivity data to examine anaesthetic-induced loss of consciousness in infants. Specifically, I show that complexity in anaesthetised infants aged 0-3 years is reduced compared to a state of emergence from anaesthesia, indicating its importance in supporting consciousness and brain function since infancy. Taken together, these findings show that while the complexity of the healthy, awake brain during rest is critically configured, the unconscious brain is characterized by reduced complexity. Based on the results presented in this work, I propose that consciousness can be assessed on the basis of complexity of resting-state functional connectivity data

Core Technologies for Native XML Database Management Systems

This work investigates the core technologies required to build Database Management Systems (DBMSs) for large collections of XML documents. We call such systems XML Base Management Systems (XBMSs). We identify requirements, and analyze how they can be met using a conventional DBMS. Our conclusion is that an XML support layer on top of an existing conventional DBMS does not address the requirements for XBMSs. Hence, we built a Native XBMS, called Natix. Natix has been developed completely from scratch, incorporating optimizations for high-performance XML processing in those places where they are most effective

Conseguimos? de parcerias intersectoriais à qualidade de vida e satisfação do utente, via prestação de cuidados centrados no doente

Doutoramento em Gestão IndustrialThe World Health Organization reports that 15 million people experience cerebrovascular accident annually worldwide, of which 5 million die. Portugal is not an exception in the global tendency, with stroke constituting the principal cause of death. Survivors frequently experience morbidity, disability and dependency in activities of daily living, representing huge costs to individual, family and society. The UK data estimate the annual direct cost of stroke care to around £4 billion, with no data of that type found with respect to Portugal. Stroke, due to its prevalence and incidence, is hence a clear example on how today’s reality puts policy makers under enormous pressure to organize and manage care of the population, given current budget limitations in order to deal with aspects of health that have moved well beyond of what the health sector can handle alone. It is consensual that a survival rate is not a sufficient outcome indicator of quality of care. In case of stroke patients, quality of life after the acute phase may become a huge problem, commonly requiring long-term health and social care, and other assistance, and informal social support which represents both, relevant caregiving patterns and an enormous contribution to a person well-being. This increasing demand for complex, multidisciplinary care services raises a question on their quality and user satisfaction. Nevertheless, a few have deliberated these concepts within a multiple-setting which is turning vital to guarantee and improve coordination and continuity of care. International community has increasingly recognized the importance and potential of intersectoral partnerships in producing sustainable structural and social change as a fundamental element of health and social strategy. A pressing need for collaboration between a broad range and diversity of entities providing mostly fragmented care services in Portugal entails a multidimensional, multistakeholder and cross-sector perspective. Collaborative environment can be approached as a network of organizational relationships between service providers and health and social care entities seem today to be by nature embedded in the network perspective as they represent business and personal relationships. This thesis aims to investigate the status of intersectoral collaborative action for stroke patients in Portugal. Particularly, its objective is to evaluate the impact of existing partnerships on patients’ quality of life, perceived service quality and satisfaction from care, support and assistance services they experienced, and to analyze ways they function in the Portuguese context. To our knowledge, no study of this type has ever been developed, making this work relevant under current circumstances, and for the theoretical and practical contribution it provides.A Organização Mundial de Saúde reportou que 15 milhões de pessoas sofrem um acidente vascular cerebral anualmente, em todo o mundo. Portugal não é excepção na tendência global, sendo o AVC a causa principal de morte no país. Os sobreviventes com frequência experienciam morbidade, incapacidades várias e dependência nas actividades da vida diária, com enormes custos para o indivíduo, a família e a sociedade. Foi estimado que, no Reino Unido, os custos anuais diretos do AVC rondam os 4 biliões de libras, não tendo sido encontrados números referentes à situação em Portugal. O AVC, devido à sua prevalência e incidência, é pois um exemplo claro de como a realidade actual coloca os decisores sob enorme pressão, quando organizam e gerem os cuidados prestados à população, dadas as actuais limitações orçamentais, de forma a lidar com aspectos de saúde que passaram a estar bem para lá daquilo com que o sector da saúde pode lidar sozinho. É consensual que a taxa de sobrevivência nestas situações não é um indicador suficiente para a qualidade dos cuidados prestados. No caso do AVC, a qualidade de vida depois da fase aguda pode tornar-se um enorme problema, requerendo normalmente cuidados de saúde e sociais de longo prazo e outro tipo de assistência, e com o apoio social informal representando não só uma parte muito importante do cuidado prestado mas também um contributo enorme para o bem-estar do sobrevivente. Esta crescente necessidade por serviços complexos e multidisciplinares coloca a questão da qualidade de cuidado global e da satisfação do utente que os experiencia de forma ainda mais premente. A comunidade internacional tem vindo a reconhecer, de forma crescente, a importância e o potencial das parcerias intersectoriais na produção de mudança estrutuctural e social sustentadas como elemento fundamental de estratégias de saúde e sociais. A necessidade urgente de colaboração entre uma ampla variedade e diversidade de entidades que prestam serviços de assistência em Portugal, por norma muito fragmentados, implica uma perspectiva multidimensão, multi-entidade e inter-sector. Um ambiente colaborativo pode ser encarado como uma rede de relacionamentos organizacionais entre prestadores de serviços, sendo que as entidades de saúde e sociais parecem hoje estar, por natureza, embutidas na perspectiva de rede, dado representarem relações complexas de trabalho e pessoais. Esta tese tem como objetivo estudar a acção colaborativa intersectorial disponível para doentes que sofreram um AVC em Portugal. Mais concretamente, pretende-se avaliar o impacto das parcerias existentes sobre a qualidade de vida dos doentes, a qualidade percebida do serviço experienciado e a satisfação com os serviços prestados, e analisar a realidade colaborativa no contexto Português. O estudo representa o primeiro esforço nesta área, não tendo sido encontrado qualquer outro semelhante publicado, o que torna este trabalho ainda mais relevante nas circunstâncias actuais, pelos contributos teóricos e práticos que proporciona

Older People’s Adherence to Community-Based Group Exercise Programmes: A Multiple-Case Study

Physical inactivity is a global phenomenon, with estimates of one in four adults not being active enough to achieve health benefits, thus heightening the risk of developing non-communicable diseases. In order to realise the health and wellbeing gains associated with physical activity the behaviour must be sustained. Community-based group exercise programmes (CBGEP) utilising social support have been shown to be one means of not only increasing activity levels for older people, but sustaining physical activity. A mixed-methods systematic review revealed a gap in the literature around older people’s long-term adherence to real-life CBGEP within a UK context. This study therefore sought to address this gap by understanding older people’s ongoing adherence to CBGEP with a view to gaining further insight about which factors contribute to enabling people to sustain their physical activity levels. A multiple case study research design was employed to understand older people’s (≥ 60 years, n=27) adherence (≥ 69%, for ≥ 1 year) to three current CBGEP in the South- West of England. Qualitative data (participant observation, focus groups, documents, and interviews) were collected and analysed using inductive thematic analysis followed by the analytic technique of explanation building. In order to gain deeper insights into adherence, the humanisation framework was utilised in an a priori manner to further understand adherence from a humanising perspective. Quantitative data were analysed using descriptive statistics and used to set the context of the study. This study found that older people’s adherence to CBGEP was mediated through six factors: factors relating to the individual, the instructor, programme design, social features, participant perceived benefits, and a humanised exercise environment. These all served to explain older people’s adherence to CBGEP. The humanising qualities of these CBGEP must be considered if we wish to support older people in sustaining a physically active lifestyle as they age. These findings are of interest to practitioners and policy makers in how CBGEP serve to aid older people in maintaining a physically active lifestyle with a view to preventing non-communicable diseases and in maintaining social connectivity

Older People’s Adherence to Community-Based Group Exercise Programmes: A Multiple-Case Study

Physical inactivity is a global phenomenon, with estimates of one in four adults not being active enough to achieve health benefits, thus heightening the risk of developing non-communicable diseases. In order to realise the health and wellbeing gains associated with physical activity the behaviour must be sustained. Community-based group exercise programmes (CBGEP) utilising social support have been shown to be one means of not only increasing activity levels for older people, but sustaining physical activity. A mixed-methods systematic review revealed a gap in the literature around older people’s long-term adherence to real-life CBGEP within a UK context. This study therefore sought to address this gap by understanding older people’s ongoing adherence to CBGEP with a view to gaining further insight about which factors contribute to enabling people to sustain their physical activity levels. A multiple case study research design was employed to understand older people’s (≥ 60 years, n=27) adherence (≥ 69%, for ≥ 1 year) to three current CBGEP in the South- West of England. Qualitative data (participant observation, focus groups, documents, and interviews) were collected and analysed using inductive thematic analysis followed by the analytic technique of explanation building. In order to gain deeper insights into adherence, the humanisation framework was utilised in an a priori manner to further understand adherence from a humanising perspective. Quantitative data were analysed using descriptive statistics and used to set the context of the study. This study found that older people’s adherence to CBGEP was mediated through six factors: factors relating to the individual, the instructor, programme design, social features, participant perceived benefits, and a humanised exercise environment. These all served to explain older people’s adherence to CBGEP. The humanising qualities of these CBGEP must be considered if we wish to support older people in sustaining a physically active lifestyle as they age. These findings are of interest to practitioners and policy makers in how CBGEP serve to aid older people in maintaining a physically active lifestyle with a view to preventing non-communicable diseases and in maintaining social connectivity

Architectural Principles for Database Systems on Storage-Class Memory

Database systems have long been optimized to hide the higher latency of storage media, yielding complex persistence mechanisms. With the advent of large DRAM capacities, it became possible to keep a full copy of the data in DRAM. Systems that leverage this possibility, such as main-memory databases, keep two copies of the data in two different formats: one in main memory and the other one in storage. The two copies are kept synchronized using snapshotting and logging. This main-memory-centric architecture yields nearly two orders of magnitude faster analytical processing than traditional, disk-centric ones. The rise of Big Data emphasized the importance of such systems with an ever-increasing need for more main memory. However, DRAM is hitting its scalability limits: It is intrinsically hard to further increase its density. Storage-Class Memory (SCM) is a group of novel memory technologies that promise to alleviate DRAM’s scalability limits. They combine the non-volatility, density, and economic characteristics of storage media with the byte-addressability and a latency close to that of DRAM. Therefore, SCM can serve as persistent main memory, thereby bridging the gap between main memory and storage. In this dissertation, we explore the impact of SCM as persistent main memory on database systems. Assuming a hybrid SCM-DRAM hardware architecture, we propose a novel software architecture for database systems that places primary data in SCM and directly operates on it, eliminating the need for explicit IO. This architecture yields many benefits: First, it obviates the need to reload data from storage to main memory during recovery, as data is discovered and accessed directly in SCM. Second, it allows replacing the traditional logging infrastructure by fine-grained, cheap micro-logging at data-structure level. Third, secondary data can be stored in DRAM and reconstructed during recovery. Fourth, system runtime information can be stored in SCM to improve recovery time. Finally, the system may retain and continue in-flight transactions in case of system failures. However, SCM is no panacea as it raises unprecedented programming challenges. Given its byte-addressability and low latency, processors can access, read, modify, and persist data in SCM using load/store instructions at a CPU cache line granularity. The path from CPU registers to SCM is long and mostly volatile, including store buffers and CPU caches, leaving the programmer with little control over when data is persisted. Therefore, there is a need to enforce the order and durability of SCM writes using persistence primitives, such as cache line flushing instructions. This in turn creates new failure scenarios, such as missing or misplaced persistence primitives. We devise several building blocks to overcome these challenges. First, we identify the programming challenges of SCM and present a sound programming model that solves them. Then, we tackle memory management, as the first required building block to build a database system, by designing a highly scalable SCM allocator, named PAllocator, that fulfills the versatile needs of database systems. Thereafter, we propose the FPTree, a highly scalable hybrid SCM-DRAM persistent B+-Tree that bridges the gap between the performance of transient and persistent B+-Trees. Using these building blocks, we realize our envisioned database architecture in SOFORT, a hybrid SCM-DRAM columnar transactional engine. We propose an SCM-optimized MVCC scheme that eliminates write-ahead logging from the critical path of transactions. Since SCM -resident data is near-instantly available upon recovery, the new recovery bottleneck is rebuilding DRAM-based data. To alleviate this bottleneck, we propose a novel recovery technique that achieves nearly instant responsiveness of the database by accepting queries right after recovering SCM -based data, while rebuilding DRAM -based data in the background. Additionally, SCM brings new failure scenarios that existing testing tools cannot detect. Hence, we propose an online testing framework that is able to automatically simulate power failures and detect missing or misplaced persistence primitives. Finally, our proposed building blocks can serve to build more complex systems, paving the way for future database systems on SCM

Indexing for moving objects

Master'sMASTER OF SCIENC

Storytelling for healing: A narrative synthesis literature review on storytelling interventions with older adults living in institutions

This literature review uses a narrative synthesis methodology to investigate the fields of gerontology and drama therapy. The aim is to discover storytelling interventions with older adults living in institutions, in these fields. It also aims to find how this intervention approach is a useful mental health tool with this population. A qualitative data collection process is used to collect text and narratives from the accumulated nineteen gerontology and three drama therapy studies. By looking at storytelling interventions in the literature, the review offers theoretical conjectures on how storytelling, as a group intervention, exists to facilitate ego integrity in its participants. Furthermore, the review identifies several narratives of commonality within the literature which suggest useful intervention processes for this population: the use of life-story themed sessions, music/objects/images/photographs as stimuli and creating a concretized depiction of the life-stories. The review also identified common mental health changes across studies, indicating factors such as decreased depression, increased socialization, increased perceived quality of life and greater connection to elements of identity facilitated by this intervention. A final discussion identifies how the above findings can contribute towards research in drama therapy, particularly offering guidance in storytelling intervention design. Keywords: older adults, institutions, storytelling, mental healt