Background: Although depression can affect anyone at any time, the first year after the birth of a child appears to be a time when both parents are more likely to experience depression. Research has mainly focussed on maternal perinatal or early depression which has an estimated incidence of 10-15%. Less is known about early paternal depression or early comorbid depression, where both parents experience depression. Methods: I conduct a systematic review on the prevalence of early comorbid parental depression and associated childhood outcomes. Next, I explore adolescent depression recording in UK primary care, and trends over time. Finally, I use structural equation modelling to provide a quantitative analysis of the association between early comorbid parental depression and adolescent outcomes, focussing on the effects of recurrent parental depression and internalizing behaviours in childhood. I examine depression and its intergenerational transmission using data from a large UK primary care database, The Health Improvement Network (THIN). Results: Prevalence of early comorbid depression in parents ranged from 0 to 20%. However, it was not feasible to perform a meta-analysis due to measurement variation and study quality. I identified only two studies assessing child outcomes. Diagnoses of adolescent depression and antidepressant prescribing have increased in recent years despite a temporary drop in 2002-2005. Symptom recording increased steadily between 1995-2009. I did not find evidence for an association between early comorbid parental depression and adolescent depression (OR: 2.02, 95% CI: 0.42-9.67). Early maternal depression does increase the risk of adolescent depression. The effect is mainly indirect, mediated by recurrent parental depression (OR: 1.54, 95% CI: 1.26-1.87), as opposed to direct (OR: 1.06, 95% CI: 0.69-1.63). Childhood internalizing behaviour might be an early indicator of depression risk. Conclusion: Early parental depression increases the risk of adolescent depression, but the effect is strongly mediated by recurrent parental depression.

Background : The NHS in England has been subject to numerous reforms and changes in health policy since its inception in 1948. Such changes often mean that organisational strategies are halted, diverted or otherwise prevented from being completed. To date research in health care settings has considered change in a broad context but there has been limited research which focuses on how organisations respond and adapt to changes in health policy specifically. The objective of this research is to explore how existent change management literature and models can be used to understand how organisations respond to changes in health policy. Methods : In 2010 the White Paper ‘Equity and Excellence Liberating the NHS’ was released. The paper, which proposed ambitious and widespread reform to the NHS, was met with significant resistance and experienced a protracted passage through Parliament. This research utilised the changing policy landscape to conduct a natural experiment, using a commissioning organisation as a case study, to understand responses to these policy changes. The eight factors of receptivity model was used as a medium to explore organisational receptivity to NHS policy changes. Results : A synthesis of the results is presented in the form of a new model to guide organisations in developing receptivity to change. The model identifies four key factors influencing the organisation’s ability to respond to policy change policy system management, organisational context and change agenda and locale. Conclusions : Receptivity to policy change in the NHS is influenced by different factors than traditional management induced change or organic organisational change. Implications : for policy makers have been drawn from this research which includes the need to develop coherent policy with clearly articulated vision, the requirement to manage national political culture, the importance of tackling system issues, and the need for careful management during transitions to avoid loss of valuable skills and expertise.

Background: UK health policy has sought to encourage alcohol screening and brief intervention (ASBI) delivery in primary care, including via pay-for-performance (P4P) schemes. To measure the impact of such policies, a range of data exist, including General Practitioner (GP) Read codes, which record all clinical activity. However, previous studies have highlighted the difficulties of using Read code data for evaluation purposes, with concerns around the distorting effect of P4P on healthcare recording. Against this background, this research investigated whether Read code data can be used to provide a meaningful measure of ASBI implementation in primary care. Methods: Sequential mixed methods design, comprising: (1) systematic literature review to identify what factors influence the recording of routine clinical data by UK primary care physicians; (2) analysis of ASBI Read code data from 16 GP practices in North East England; (3) 14 GP interviews to explore the barriers and facilitators affecting their ASBI recording. Results: (1) Multiple factors shape primary care physicians’ recording of routine data, including structural influencers (such as the design and resourcing of the coding system), and psychosocial factors (including patient characteristics and physicians’ perspectives on their role as care-givers). (2) 287 Read codes exist to record alcohol- related activity however only a small minority are used regularly, generally relating to the identification of alcohol use disorders. Whilst many unused Read codes are associated with relatively rare alcohol conditions, a significant number relate to duplicate or outmoded terminology. Overall, practices associated with higher recorded rates of key ASBI service indicators were signed up to P4P schemes. (3) GP interviews suggested that across all practices, nurse-administered ASBI components were most likely to be provided and coded consistently, with GP-delivery and recording activity far more ad hoc. Conclusion: Whilst routine data may be a valid indicator of more successfully embedded ASBI activity in UK primary healthcare following the introduction of P4P schemes, measuring the impact on delivery at GP level remains challenging due to the deficiency of the available Read code data across a number of quality dimensions.

The topic of this thesis is evidence-based healthcare, EBHC. The thesis has two key aims: to undertake an empirical exploration and analysis of debates around EBHC; and to develop a conceptual theorisation of these debates in terms of power. To fulfil the empirical aim I conduct a reading and analytic re-reading of EBHC-literature from the disciplines of medicine, physiotherapy and sociology. To fulfil the conceptual aim I draw upon the work of Foucault, Bakhtin and Barbalet to produce a ‘dialogical’ model of power. Treating debates around EBHC as ‘EB-discourse’, this thesis follows the tradition of discourse analysis; but breaks ground by deploying writing as a research method and applying ethnographic ideas to discursive study. This novel approach I call ‘literary ethnography’. Being a literary ethnography of EB-discourse, the thesis begins with a descriptive overview of the chosen disciplinary literatures. A methodological section explains the rationale for proceeding along the analytic path of dialogue; and then the thesis becomes gradually more analytical through progressively deeper readings of the same literatures. The thesis is structured into these three levels of review, methodology and analysis; and in each level, the three strands of literary context (medicine, physiotherapy and sociology) run in parallel as comparators for each other. EBHC began in medicine (as EBM), but following its course in other disciplines allows discursive similarities and differences to be explicated. The initially descriptive and gradually more analytical approach reveals the dialogical structure of the discourse, and discovers embodiment and emotion as ideas which, across all three contexts, trouble the terms of the discourse. The key findings of the thesis are that in EB-discourse, power operates through dialogue, by being split into different forms which interact to reinforce each other. Specifically, EB-discourse is built upon dialogical distinctions between mind and body, and between emotion and reason. These are dialogues which powerfully re-produce particular kinds of rationality. They are also in dialogue with each other; embodiment for the repressive aspects, and emotion for the productive aspects of power. The thesis also raises questions relating to the predicament of the patient in contemporary healthcare, and relating to the role of philosophical argumentation in social theory. It finishes with some suggestions for investigating the dialogical-power model in other areas of social life.

Following critical illness patients suffer from significant physical and non-physical sequelae. The aim of the programme of research presented in this thesis was to explore the effectiveness of a programme of exercise in patients discharged from hospital after critical illness. In the absence of an existing intervention, a programme of exercise was developed through synthesis of evidence from a range of sources underpinned by key elements of exercise prescription and provision. The programme consisted of an individually tailored, 6- week exercise programme, supervised by a trained physiotherapist and included a patient exercise manual. A randomised controlled trial (RCT) to investigate the effectiveness of the programme of exercise compared to standard care was rigorously developed and conducted. Sixty participants across Northern Ireland were randomised. The exercise programme did not show significant improvement in the primary outcome measure of patient-reported physical function. However, there were significant improvements demonstrated in a number of secondary outcomes of exercise capacity, health-related quality of life, self-efficacy and behaviour change. Qualitative semi-structured interviews of participants were also conducted and provided an in-depth insight of their perceptions of the intervention, including their intense satisfaction and endorsement of the intervention, perceived benefits, and important facilitators and barriers to impact. The programme of research presented in this thesis contributes knowledge to the limited evidence-base for rehabilitation following critical illness and highlights the real gap in suppOli for these patients. Despite the failure of the programme of exercise to show significant improvement in the pre-defined primary outcome measure, the benefits achieved in important secondary patient-centred outcomes, and qualitative exploration are encouraging and warrant further research. This thesis provides important implications for future research and clinical practice, relating to the target population, recruitment, intervention components, and outcome measures, to improve outcomes for this patient population.

This dissertation investigates the impact of aspects of the local environment on health. The empirical work relies on data at local authority level- the primary unit of local government in the UK - measured over years, quarters or days. These spatio-temporal data provide an identification strategy that controls for unobserved local area effects, time trends and a number of potential time-varying confounders. Chapter 1 (with Carol Propper and John Henderson) examines the relationship between air pollution and population mortality in England. Using annual data at local authority level for 1998 to 2005 that allow us to control for unobserved time-invariant heterogeneity and common time trends, we find that currently permitted levels of particulate matter less than 10 um in diameter and ozone are associated with population mortality. Chapter 2 investigates the effect of air pollution on hospital emergency admissions for respiratory diseases in children. Avoidance behaviour could potentially bias estimates of the health effects of pollutants. Daily data at local authority level from 2003 to 2007 allow me to control for local authority-year-quarter effects and national year-week effects as well as avoidance behaviour in response to air pollution alerts. Both nitrogen dioxide and ozone at the relatively low levels experienced in England lead to respiratory hospital admissions in children. Avoidance behaviour depends on its costs as parents and children seem to respond to air pollution alerts only if the costs are low. Chapter 3 presents a model of the effects of crime on physical activity. Chapter 4 (with Carol Prop per and Michael A. Shields) investigates the empirical relationship between violent crime and physical activity using a sample of nearly 1 million people surveyed between 2005 and 2011 matched to quarterly police recorded crime data at local authority level. Controlling for local authority effects, local authority specific time trends and national time effects, we find a substantive deterrent effect of crime on walking.

Much work has been carried out on the concepts of care and caring . These contain multiple definitions with little consensus. Despite this they are seen as a prerequisite for nurses and are central in measuring the quality and effectiveness of the National Health Service in the United Kingdom. This interpretivist work set out to investigate the concepts of care and caring from the viewpoint of district nurses in the North East of England, and to examine the factors that influence the caring practices entered into by the participants. The work used grounded theory methods and situational analysis. Data were collected via 22 one-to-one interviews with 14 participants. Situational analysis brought to the fore both post-modernist and Foucauldian perspectives on the caring practices indentified. Findings suggest there are 3 senses of caring practices entered into: fundamental, functional and situational. Each sense of care has distinct defining features which can be linked to the discourses produced from four defined social arenas: historical, professional-modernising, organisational-managerial and media. The power exerted by these distinct social arenas, their social worlds of concern and their related discourses can be either repressive or permissive. When permissive it can lead to practitioners to transit from one sense of caring practice to another. The current caring senses are the contemporary incarnation of conflicts that have been inherent in nursing and district nursing from their inceptions. The implications of these insights can be felt across the National Health Service, the district nursing service, educational organisations and the professional organisations. They centre on the following recommendations:- To articulate how care and caring are constructed across the nursing disciplines. To clarify the position of basic nursing care in the qualified nurses role. The better articulate the role and impact of district nursing patient care. To have educational programmes that reflect academic and emotional intelligence, with the focus on critical thinking skills. And to investigate the current level of bureaucracy, its usefulness and how it influences care and caring.

Health systems of developed countries around the world are facing immense pressure. This is due to an ageing population and an increase in the prevalence of chronic disease. The purpose of this research is to develop the system dynamics Coxian phase-type (SDC-Ph) model which consists of inter-related components each one being a system dynamics model. This will serve as a framework for investigating the change in prevalence of coronary heart disease in Northern Ireland between 2007 and 2027 and the implications this will have on coronary heart disease (CHD) related inpatient admissions. The first component of the framework is the coronary heart disease prevalence model. It incorporates the changes anticipated in population size and age structure, risk factor prevalence, and primary and secondary interventions and the impact this will have on prevalence over the twenty year time period. The second component of the framework is the coronary heart disease hospital admissions model. It is a composite model which combines the system dynamics methodology with the Coxian phase-type distribution to represent the flow of patients with coronary heart disease through hospital and is used to determine the impact of the changing prevalence on the demand for acute care beds. The final component of the framework is the coronary heart disease cost model. It uses the results obtained from the fit of the Coxian phase-type distribution to group patients together according to their likely time of discharge from hospital thus allowing inferences to be made regarding the costs associated with the individual's phase of care. The SDC-Ph model allows testing of different healthcare interventions taking aspects of population dynamics such as the ageing population into account and forecasts future population incidents and associated costs. It allows healthcare providers to model the impact of interventions and thus assist in the decision making process.

This thesis is focused on recent developments in health policies in the two jurisdictions of Ireland - referred to here as North and South. The data are drawn from health policies published in Ireland since 1995 to the present day. The theoretical approach selected for the analysis of relevant policy documents is that of narrative. Health policy in any country covers a wide range of issues - however, it is usually the case that in every generation a relatively small number of problems and issues are identified as in need 9f special attention. Thus it is in Ireland where an emergent and growing problem is said to be 'obesity'. Obesity as a problem dominates quite a number of policy documents published since the mid 1990s and along with obesity a variety of other problems are said to be evident - such as low rates of physical activity, and attachment to unhealthy diet. A central aim of this thesis is to study how these things are interlinked and inter- related in policy narratives, and what the implications of the various storylines are for the structuring of health care in Ireland. Most of the relevant policy documents studied contain quite intricate narratives on the origins of obesity, its current distribution in the population, and on consequences of current rates for the future. However, the basis on which relevant storylines rest is never entirely clear. Evidence referred to is sometimes contradictory and at other times inappropriate. Very often the policy storylines are driven by extrapolations from uncertain current data into an unknown and unknowable future. Moreover, it seems clear that although the dominant narrative on obesity is a medical one, elements of moralizing (moral tales) are evident in the narrative mesh. It is such complexities that are explored within.

Background: While there is a body of work describing infection control behaviours and factors affecting compliance with guidelines there has been little investigation into understanding and explaining behaviours that occur in everyday practice. Understanding such behaviours may provide a key insight into the challenges of behaviour change. Consequently the main research question in this study is "How can nurse’s infection control behaviour be explained?" Methods: Using an ethnographic approach this interpretative qualitative study uses vignettes, developed from reported practice, to explore nurses’ perceptions of risk and contagion. Twenty semi-structured interviews using a topic guide and vignettes were conducted with registered general nurses, in three waves. Interviews were transcribed verbatim and analysed using the framework method. Findings: Three main themes of ’The classifications of dirt’; ’Rationalizing dirt related behaviours; and ’Transitions in place and role’ were identified Firstly, the acts and behaviours reported by participants are part of a protective self defence system against dirt and germs. Protection is required more rigorously when the origin of the threat is unknown; dirt, waste products and body fluids from self and relatives are perceived as being less threatening. Furthermore, threat is reduced by social knowledge, as the person and their behaviours become known. The behaviours of others are viewed differently; if others are carrying out inappropriate behaviours it is seen as irrational, however the same behaviours in self are explained as rational in terms of protection from unknown. Secondly, a show is being performed by many nurses, influenced by the perception of patients’ increased awareness of practice and the nurse’s desire to be seen as someone who knows the correct infection control procedures. Participants reported being more. Finally, there is a journey taken by healthcare workers in their working day in which their role and status changes. The participants perceive themselves as entering the unclean hospital environment in a state of cleanliness, achieved by the practices and rituals that are carried out in the home. Because of the protective behaviours they carry out whilst in the hospital they do not recognise themselves as anything but clean until they return to the home environment. It is at this stage that they recognise their state of uncleanliness. A transition has occurred from clean to dirty on entering the home. Now precautions must be taken as the home needs to be protected from any unknown dirt or germs that may have been transported by the participant and order must be maintained. Cleansing is carried out and clothing is dealt with in pre¬determined ways. Conclusions: The participants in this study demonstrated that they had the knowledge and education required to understand the principles of infection control procedures, transmission of disease and risk of contagion. Their behaviour exists outside what is taught and accepted by themselves as correct. It is insufficient to say that education can change this behaviour; this behaviour has to be recognised first and foremost by those carrying it out before any attempt can be made to change it. What is required is an educational programme that is carried out in conjunction with a behaviour recognition campaign. Reflection may also be a way of raising self-awareness, allowing healthcare workers to express their fears regarding dirt and infection before considering whether their own behaviour is based on the scientific rationale and meets policy requirements. Reflection may also be a way of raising self-awareness, allowing healthcare workers to express their fears regarding dirt and infection before considering whether their own behaviour is based on the scientific rationale and meets policy requirements. Following these interventions an examination of whether beliefs have changed and practice has improved should be carried out.