The Heartbeat Award (HBA) is a national scheme which attempts to modify the environment of public eating places (cafes, restaurants and public houses) and workplace canteens. The Award is given to premises if one-third of its trading area is non-smoking, it there are high standards of food hygiene and one-third of food provided is 'healthy', i.e. low in fat and sugar and high in fibre. The scheme was implemented locally in 1990 and is an alliance between the Nutrition and Dietetic Service, the Health Promotion Service and Environmental Health Officers of the 9 local councils. This thesis evaluates the scheme as it operated in Leicestershire using both qualitative (interviews and focus groups) and quantitative (surveys) methods, obtaining data from both staff and customers of the premises and the Community Dietitians involved in its implementation. Twenty-three premises were investigated, 6 of which participated in the longitudinal survey in the workplace, 2 of these became controls as they had failed to reach the standard of the HBA. Employees were investigated before the scheme was implemented and 6 months after implementation. Employees acknowledged that it was easier to eat a healthy diet at work after the scheme had been implemented. Even so, there were no differences between the attitudes, knowledge and dietary behaviour of employees in HBA holding canteens and the controls, that could not be attributed to chance or other exogenous factors. The sole expression was an increase in fruit consumption at work in HBA premises. There was considerable room for improving the operation of the scheme, particularly with regard to consistency and compliance with HBA criteria. The thesis concludes that the scheme is not worth continuing locally in its current form unless radical improvements are made, many of which have resource implications.

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This thesis is original in the sense that it examines a relatively new method of collecting data using Social Network Sites, and explores the feasibility of this method for survey research providing valuable data regarding health behaviours among young Saudis. Aims: The primary aim of this study is to assess the feasibility of Social Network Sites (SNS) as a mode of collecting data for health behavioural surveys by comparing data collected from an SNS-based questionnaire with data collected from a traditional paper questionnaire using the same variables. It also aims to provide descriptive information about health behaviours among young people in Saudi Arabia. Methods: The study demonstrated the Young Risky Behaviour Survey 'YRBS' questionnaire cross-sectionaly by two modes for different participants groups. Each mode of participant's recruitment is considered as a sub-study. The first one is the 'offline study' where participants were recruited randomly from schools and universities in Saudi Arabia. The second sub-study is the 'Online study' where participants were recruited using Facebook fan page and Facebook ads. Results from both sub-studies were analysed and compared in order to answer the research questions. Results: The main results of reported risky health behaviours indicated that 15% of participants are current smokers, 41% drank fizzy drinks (4-6 times a week) and 94% did not meet the recommended level of physical activity. Comparison between SNS and PAP indicated that SNS is an effective tool for collecting health behaviour data and yielded sufficient sample size with a wider geographical reach. Moreover, mode effect on reporting risky behaviours was only significant in 8 out of 25 risky behaviours. Conclusion: Comparisons between the approaches suggest few notable differences, and both methods have produced similar figures regarding health behaviours. Though the limitations of both methods are also discussed in this thesis, the results support the argument that SNS can be a very useful tool leading to representable data.

Background: Improving current and future healthcare is heavily reliant on continuous research and the secondary use of data from patients' medical records, particularly from electronic records. Considerable amounts of data are collected during the care and treatment of a patient, and this data can offer many opportunities, not only for supporting and improving individual patient care or making important contributions to research, but also for investigating causes of diseases, establishing the prevalence of risk factors, and identifying populations at risk of adverse outcomes. However, the management of such data poses challenges, which many believe can be mitigated by storing it electronically. The traditional method of storing medical information in a paper-based format has severe limitations, especially concerning the amount of effort needed to extract information. In contrast, data from electronic patient records (EPRs) is much easier to extract and allows healthcare professionals access to the information needed in a timely manner to provide appropriate care to patients and improve the public's health. The UK still faces the hurdle of balancing public interest with individual privacy. There is clearly a benefit regarding the use of EPRs but there is an increasing need for public education in order to be able to reap the maximum benefits they offer. This thesis examines the benefits and impact of EPRs in the contexts of clinical care and epidemiological and health services research. Methods: The methods used for this research project involved reviewing published materials available through electronic searching, grey literature and websites of bodies such as the Department of Health, and the Health and Social Care Information Centre. The use of the main national primary care databases and secondary care databases and their growth over time was also examined. Results: EPRs are extremely beneficial to research and have a significant potential to improve patient overall care. The use of EPRs is growing as technology advances and health systems move from paper to electronic records. Conclusions: The use of EPRs will only be successful when both the public, researchers and healthcare providers agree on their benefits. The use of EPRs will take healthcare to another level, where the accuracy of data entered is of very high quality and standardised, data security is well-controlled, and there is acceptance by the public concerning the use of their data both for providing clinical care and for other secondary uses.

In Benin in mid 2004, radio stations began announcing the forthcoming arrival of a Christian hospital ship. It was going to dock in the country’s main port in Cotonou and provide free surgeries for hundreds of people over a period of four months. Presenting the first ethnographic account of Mercy Ships, this dissertation provides a lens for reflecting on the ever-growing number of faith-based organisations in West Africa. This dissertation addresses the following questions: does sought-out contact with the services and environment of this hospital ship change people – both patients and crewmembers – and the way they live, think about and understand their lives? In those circumstances when changes occur, how do they come about? By addressing these questions, this dissertation contributes to a body of work in the anthropology of faith, healing, medical humanitarianism and international development. It not only explores the personal value and meaning for people volunteering with and treated by this faith-based organisation, but it also explores how the hospital ship is enacted and experienced, and how, perhaps surprisingly, it is both the lives of the crewmembers as well as the patients that are changed, as they project their faith and visions of lives well lived onto their ship experience. The promise of the ship as a catalyst for change in the imaginations of crew and patients; the blend of medical and social care on board; the perseverance through physical and emotional challenges; and the separation of the ship from land all blend to create powerful encounters that shape their experiences. These encounters demonstrate how the act of faith can become a form of healing, and likewise, how healing can create and strengthen faith. Throughout their journeys, patients and volunteers grapple with their faith which is intimately intertwined with their physical, social and spiritual well-being.

Introduction: Adaptive designs (ADs) are underused, particularly in publicly funded confirmatory trials, despite their promising benefits and methodological prominence given in the statistical literature. Research Question: This thesis investigates why ADs are underused in the publicly funded setting, explores facilitators, and proposes recommendations to improve their appropriate use. Methods: Confirmatory ADs are reviewed from a statistical and practical perspective. Cross-disciplinary key stakeholders are then interviewed to explore roadblocks to the use of ADs. Based on the interview findings, follow-up quantitative surveys are undertaken to explore wider perceptions on barriers, concerns, and facilitators aimed to generalise the findings. The surveys targeted CTUs (Clinical Trials Units), private sector organisations, and Public Funders in the UK. In view of some of the findings, case studies of applied confirmatory ADs are reviewed to highlight their scope and characteristic, and to investigate the state of reporting of the most common AD. The design and implementation of selected ADs is demonstrated using retrospective and prospective planned case studies. Lessons learned are highlighted to enhance the design of future trials of similar characteristics. Results: The main barriers to the use of ADs include the lack of funding support accessible to UK CTUs to aid their design; limited practical knowledge; preference for traditional mainstream designs; difficulties in marketing ADs to key stakeholders; limited time to support ADs relative to other competing priorities; lack of applied training; and insufficient access to case studies of undertaken ADs, which would facilitate practical learning and successful implementation. Researchers’ inadequate description of AD-related aspects (such as rationale, scope, and decision-making criteria to guide the planned AD) in grant proposals was viewed among the major obstacles by Public Funders. Suboptimal reporting of the design and conduct of undertaken ADs appears to influence concerns about their robustness in decision-making and credibility to change practice. Conclusions: Most obstacles appear connected to a lack of practical implementation knowledge and applied training, and limited access to adequately reported case studies to facilitate practical learning. Assurance of scientific rigour through transparent adequate reporting is paramount to the credibility of findings from adaptive trials. There is a need for a consensus guidance document on ADs and an AD-tailored CONSORT statement to enhance their reporting and conduct. This thesis provides detailed recommendations to improve the appropriate use of ADs and areas for future related research.

Background: This study compares the cost-effectiveness of using an online assessment tool (ePAQ) in advance of a face-to-face (control) versus a telephone (intervention) consultation. The trial suggests statistically significant differences between groups for three PEQ (Patient Experience Questionnaire) dimensions. However, it is unlikely that these differences were captured by the cost-effectiveness outcomes (Incremental cost/QALY). This is consistent with other work that has suggested the QALY does not capture all outcomes relevant to interventions, particularly where the outcomes are non-health outcomes e.g. associated with processes of receiving care. Aim: With this issue in mind, the ePAQ trial was a vehicle for the exploration of process utility. The overarching aim was to utilise ePAQ trial data, to improve the relevance of the cost-effectiveness outcomes by incorporating process utility into the QALY. Methods: This thesis includes: a literature review of process utility studies; a process utility bolt-on study; the application of the findings to ePAQ trial data; revised cost-effectiveness estimates incorporating process utility. Qualitative methods were used to explore participant’s reactions to health states including health and process outcomes. Results: The valuation study captured process utility. The inclusion of process utility in the ePAQ EEACT moved the intervention from being dominated by the control, to a position where it falls within the willingness-to-pay threshold of £20,000/QALY, indicating its inclusion can impact on cost-effectiveness results. Respondents’ were able to value health and process scenarios within the think aloud study. Conclusion: This study indicates that patients do care about both health and process outcomes. The valuation study provided a mechanism for capturing the amount of utility people have for these processes, however, the qualitative study raised questions on the validity of utility estimates derived from health and process scenarios. This thesis is an exploratory study, and highlights a need for further research into the topic.

Health systems internationally are attempting to address the issue of how to monitor and regulate quality of care in order to maintain and drive up standards. In the UK, policy initiatives focused upon revalidation for clinicians and incident reporting raise questions around how best to feedback and use data to support improvement at professional level. Considerable research has been undertaken to outline the processes by which valid, reliable and useful quality indicators can be defined. The evidence base for how to maximise the influence of feedback on professional behaviour, however, remains heterogeneous. Greater research effort needs to be devoted to understanding the underlying mechanisms through which feedback achieves its goals. This PhD therefore aims to describe and investigate the characteristics and mechanisms by which feedback influences professional behaviour in healthcare. Two perspectives are selected to provide alternative viewpoints. The first is focussed upon personalised feedback interventions in anaesthesia and the second centres around organisational level feedback from incident reporting systems. Within the thesis case study feedback interventions from each of the two perspectives are investigated and evaluated using a mixed methods approach. Qualitative analysis draws upon inductive and theoretically informed deductive reasoning whilst both descriptive and inferential statistics are employed to explore survey data. Participants include consultant anaesthetists, safety science experts and risk managers, among others. Synthesis of results demonstrates that providing feedback is a complex, social, quality improvement intervention. Its influence on professional behaviour is a multifaceted interaction between design characteristics/pre-conditions, psychological processes and intermediary outputs. These mechanisms can be better understood from a sociotechnical perspective drawing upon the fields of psychology, human factors, organisational studies and health services research. This thesis presents an integrative model for understanding the mechanisms through which feedback influences professional behaviour in healthcare.