Background: Behaviour change, if maintained, can lead to significant health improvements. The aim of this thesis was to advance psychological theory of behaviour change maintenance and the design of behavioural interventions to improve health. This thesis used a novel multi-method approach to explore behaviour maintenance, with a particular focus on weight loss maintenance (WLM). Methods: A three stage, multi-method approach included: (1) A systematic review of behavioural theories to identify theoretical explanations for behaviour maintenance and to examine the relationships between these explanations; (2) An N-of-1 study of WLM assessing theoretical predictors of maintained behaviour based on the systematic theory review, which employed ecologic momentary assessment, wireless body scales, and activity monitors in 12 obese people who had lost at least 5% weight in the previous year, analysed through cross-correlations of time series; (3) Data-prompted semi-structured, longitudinal interviews with individuals who participated in the N-of-1 study to explore their experiences of WLM, prompted by personal data including summaries of N-of-1 data, pictures, notes and graphs, analysed using the Framework method. Findings: (1) Systematic review: out of 117 identified behaviour theories, 100 met the inclusion criteria. The main theoretical themes identified to underpin behaviour change maintenance included maintenance motives, self-regulation, habits, psychological resources and environmental/social influences; (2) N-of-1 study: for 12 participants a range of maintenance-related theoretical variables showed differential impact on ability to maintain weight, engage in physical activity and x follow a personal WLM plan. The combination of predicting variables that had significant impact on outcome variables was unique for each individual; (3) Data-prompted interviews: most of the theoretical explanations from the systematic theory review adequately accounted for participants’ experiences. Additional emergent themes included: competing goals, prioritising, and preparatory strategies that enhanced self-regulation. Using personal data summaries proved valuable in evoking narratives regarding unique experiences of WLM. Discussion: A range of theoretical explanations were identified and proved useful in explaining behaviour maintenance in the area of WLM. The main conclusion derived from the thesis is that behavioural interventions need to tap into relevant behavioural explanations and deliver intervention components in a timely manner to support individuals to maintain behaviour change. Interventions should include elements of choice and customisation and should be adaptable to personal needs. The main study strengths included employment of novel methods and technology. The main limitation included N-of-1 analytical challenges and scalability of the applied design. Future research should develop behaviour maintenance theory further and explore which combinations of WLM strategies, in which individuals, support effective WLM.

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This thesis outlines the emerging role of the patient, central in the transition from a volume-driven towards a patient-driven healthcare. Healthcare systems, regardless of region or economic status, must develop new ways to deliver care whilst at the same time improving both quality of care and containing costs. Today's society is increasingly 'horizontal' shaped by affiliations and networks, and this changes the way information flows, increasing people's willingness to participate in the decision- making process. Encouraging more patient involvement by promoting feedback will increase communication between system and users, this is important as it can improve quality of service. The inception and preliminary results of a national programme based around patient-reported health surveys, i.e. PROMs, are discussed together with the potential of the programme and its limited evidence on how this translates to quality of care for patients. The feasibility of PROMs data, in order to investigate important difference as reported by patients in this large national cohort, is tested by segmentation into individual procedures. A subsequent risk analysis of important confounders demonstrates that poor mobility and self-reported depression are significant predictors of poor HRQoL outcomes as well as self-reported adverse events. A further comparison between self-reported and administrative collected comorbidities is undertaken to substantiate the reliability of self-reported comorbidities followed by the development of an accumulated risk prediction score generated from self- reported comorbidities to identify individual patient segments before treatment. And finally, a mixed method study is undertaken into factors behind poor unit response rates by exploring the patients' views on PROMs and their place in quality of care. This thesis demonstrates the limitations of the current data dissemination of national PROMs data and proposes several steps of improvement to increase relevance to both patients and clinicians.

Amidst a growing recognition that traditional public heath approaches are insufficient to meet the 21st century challenges confronting population health, there are urgent calls for the development of new types of approaches. Despite greater understanding about what determinants influence population health and wellbeing, knowledge about how determinants interact together to create sustainable health outcomes is lacking, and as such the way we think about public health interventions is constrained. With a focus on health creating processes (salutogeneis), this longitudinal qualitative study adopted a complexity perspective and a whole systems approach to examine how two exemplary communities in Cornwall, a factory workplace and a community partnership, succeeded in creating long-term sustainable population behaviour change towards wellbeing. With a multiple case study method where each community was studied as a case in its own right, a total of 45 interviews and 22 observations were conducted over a period of 19 months. For each case an iterative-inductive ethnographic approach constituting purposive and snowball sampling and data collection was conducted concurrently with a six step thematic analyses. The two sets of data were subjected to a cross case comparison where ‘within case’ themes from both cases were grouped together to form sets of ‘higher order’ themes which were translated into five overarching concepts: relational properties, dynamics and processes, identity, learning about and telling stories, valuing and being valued. Finally the data as a whole was interrogated from the perspective of complexity theory, where principles such as self-organization, emergence, feedback loops and attractors were utilized. Whilst the cross case comparison identified a number of conditions in common between the communities, using complexity theory as a sense making tool enabled an explication of how such conditions, related to non-linear processes, were significant for sustainable population behaviour change. The findings of the research delineate non-linear processes that enabled each community to creatively respond to continuous changes in need and resources. Through the decontextualisation and then crystalisation of higher order concepts attributed to sustainable salutogenic behavior change in two distinct communities, the research offers a transferable framework of five domains of conditions, that other communities and organisations may attend to when facilitating such behaviour in their own contexts. Furthermore, the results illustrate a detailed theoretical and dynamic understanding of the interplay between macro and micro levels of a system, that together, and supported by the five domains of conditions, generate sustainable salutogenic change. In a climate of emerging complex public health challenges this research may assist those wishing to develop whole systems approaches that harness non-linear health creating properties inherent in populations within the context of salutogenic settings.

No description available.

Background: The public health and economic literature on individual-level social determinants of health and well-being has largely focused on the role of income. However, it is not clear whether an individual’s income relates to their health and well-being due to material or psychosocial factors. The psychological literature on individual-level social determinants of health and well-being has been concerned with the role of psychosocial factors such as social comparisons and personality variables. However, the use of personality measures as predictors of health and well-being has been limited due to traditional perspectives that personality traits are stable over time. This thesis takes an interdisciplinary approach to advance the understanding of individual-level predictors of health and well-being in these disciplines. Methods: Large scale cohort data were utilised for the analyses in this thesis. Marginal and conditional regression models were used to i) assess whether psychosocial factors associated with income predicted health better than material factors, and ii) determine the specification which best represented the psychosocial influence of income on health. Conditional models were also used to compare the predictive value of changes in income and changes in personality traits for a range of well-being outcomes. Structural equation models examined the nature of the association between changes in personality traits and changes in well-being. Results: Regression models and goodness of fit statistics indicated that psychosocial factors associated with income, specifically an individual’s rank within a comparison group, predicted health better than material factors. Conditional models further indicated that other psychosocial factors such as an individual’s personality traits explained more variation in well-being outcomes than changes in income. Structural equation models indicated that observed changes in personality traits were not due to measurement error and that change in the personality trait neuroticism may be causally associated with changes in well-being. Conclusions: The findings here integrate and advance the public health, economic and psychological literature on individual-level predictors of health and well-being, through identifying a psychological pathway through which income relates to health and by determining the relative contribution of economic and psychological factors such as personality trait change on health and well-being outcomes. Furthermore, the nature of the association between personality traits and well-being is explored.

Staffing remote rural areas with health workers is one of the main challenges facing middle and low income countries looking to achieve the Millennium Development Goals including reducing the maternal death rate. Sudan is an African low income country faced with a shortage of health workers. This shortage is coupled with a misdistribution of health workers. Most of the doctors and specialists prefer to work in the capital Khartoum. However, in the last few years, Sudan has succeeded in reducing maternal death. This research aimed to undertake a realistic evaluation of the key strategies adopted by the Sudanese government to staff remote underserved areas by health workers. A literature review followed by documentary analysis aided the construction of two separate but interconnected attraction and retention frameworks and the development of the context- mechanism- outcome-configurations (CMOCs) related to staffing remote rural areas with maternal health workers. Next, qualitative semi-structured interviews were conducted in order to test these CMOCs. The interviewees included policy makers, executive health managers and health workers, both those currently working in rural areas and those who had done so in the past. The findings are presented with respect to identified CMOCs and the proposed attraction and retention frameworks. The findings have been presented in the form of what works, what does not, how, for whom and under what circumstances. The findings were analysed and discussed with respect to the relevant literature to facilitate development of recommendations which need to be considered to achieve better staffing of rural health facilities. This research has explained the past and current initiatives adopted by the Sudanese government to staff underserved areas with maternal health workers. It also showed how the “context” affected the success or failure of these strategies. This research is useful for other low income countries that suffer from inequitable distribution of its health workforce. The research has contributed to new understanding by developing separate attraction and retention frameworks for doctors and midwives. In addition to that effective interventions which are found in Sudan but not previously found in the literature have been identified and summarised.

No description available.

This thesis explores the challenges and controversies that healthcare professionals who work in death and dying settings face when working with service users with religion, belief, and spiritual identities. The secular-minded modern history of the nation has left people precarious of religion and belief, lacking religious literacy (i.e. the ability to talk about it) (Dinham & Francis 2015). Religious literacy is a contested concept which is used as a lens through which this thesis is framed. The study was undertaken in hospices while it reports on data from a triangulation method, including participant observation, interviewing, and focus groups. Healthcare professionals appear to have lost the ability to engage adequately with religion, belief, and spiritual identities of service users. Religion and belief have been approached as problems to be solved, rather than aspects to engage with. Solutions to deal with the religiously diverse service user population include equality and diversity laws that underpin respectful and non-judgmental attitudes, yet mask inclusivity with neutrality. Findings show that healthcare professionals are ambivalent toward discussing religion and belief related issues while the preference is to signpost service users to religious leaders or communities. Additionally, hospice organisations are currently undergoing many and various changes that are often washed down to professional practitioners. The changes include the removal of religious adornments from within the space, as well as amendments in relation to language on signs. The space is more like the portrayal of a largely secular nation that lacks proper abilities to engage with religion and belief. This study is merely opening up the dialogue in end of life care about adequate accommodation of religion, belief, and spiritual identities of service users in professional practice. This is paramount in order to fulfil requirements toward a fundamental aspect of hospice care; comforting service users from a holistic approach, beyond the bio-medical.

This study explores the nature of caring for elderly demented relatives living at home in Thailand. Structured and semi-structured interviews were carried out with 44 pairs of known cases of demented patients (subjects), who received treatment at out-patient departments (OPD) in three selected hospitals, and their principal carers. The Thai Mental State Examination (TMSE) and Behaviour Rating Scale (BRS) were applied to subjects, the Caregiver Strain Index (CSI) was applied to carers, and the Network Assessment tool was applied to both subjects and carers. Significant correlations were found between levels of strain in carers and the cognitive impairment and physical dependence of subjects. Spouse carers experienced significantly less strain, but reported more stress and physical strain and a poorer current relationship than younger relative carers. The vast majority of subjects (94%) and more than half (57%) of carers had a small support network. Three-quarters of carers needed information about dementia illness and how to provide care at home and two-thirds felt the elderly relative should receive financial support. Despite difficulties in caring, three-quarters of carers were still willing to continue to provide care. The primary motivation to care was derived from a strong filial obligation based on Buddhist belief of 'reciprocity.' The effects of the caring relationship and the quality of care need further investigation. Policy recommendations include providing health education, financial support, and carers support groups.