Urbanization, which is driven mainly by the expansion of cities and urban migration, is considered one of the key drivers of non-communicable diseases (NCDs) in developing countries. This research aims to investigate the patterns and associations between different levels of urban exposures and NCD risk factors, NCD morbidity and NCD mortality in Thailand, to better understand the mechanisms underlying the link between urbanization and NCD in Thailand. Using several study designs and analytical techniques, the research described in this thesis found that the process of migration and living in an urban environment were associated with lower social trust and higher levels of emotional problems. Urban environments were also associated with behavioural and physiological risk factors for NCDs, including smoking, heavy alcohol consumption, inadequate physical activity, inadequate fruit/vegetable consumption, high BMI, and high blood pressure. Both early life urban exposure and accumulation of urban exposure throughout life potentially play a role in these increases in behavioural and physiological risk factors for NCDs. Early life urban exposure was also found to be associated with an increased risk of developing obesity in adulthood. Increased psychosocial, behavioural and physiological risk factors associated with living in an urban environment may not translate directly into increased prevalence of biological risk factors for NCDs (such as high cholesterol), the development of NCDs, or into NCD-related mortality. It is likely that biological risk factors for NCDs, as well as NCD incidence and mortality are more amendable to change from the positive influences of urbanization through higher socioeconomic status and potential access to better health care.

Introduction: Cardiovascular disease and cancers are the main causes of premature death and disability in England. This thesis uses a microsimulation modelling methodology to examine and quantify the effectiveness and equity of existing primary prevention policies and feasible alternatives. Methods: I created and validated IMPACT_NCD, a dynamic stochastic microsimulation model from first epidemiological principles, to simulate the life course of synthetic individuals under counterfactual scenarios. First, I used the model to quantify the contribution of statins to the observed decline in total cholesterol in England. Then, I examined a national screening programme known as 'NHS Health Checks'. Afterwards, I estimated the effectiveness and equity of the national salt reduction strategy. Finally, I studied two proposed policies for the tobacco 'endgame'; a total sales ban, and a sales ban restricted to those born in or after 2000. Results: The model suggested that statins contributed only about a third of the observed total cholesterol decline in England since 1991-92. Their impact on reducing socioeconomic inequalities in total cholesterol was generally positive, contrary to what was anticipated. NHS Health Checks may prevent or postpone about 19,000 cases of cardiovascular disease by 2030; however, population wide structural policies could be three times more effective and generally more equitable. IMPACT_NCD estimated that the national salt reduction strategy may have prevented or postponed about 52,000 cases of cardiovascular disease and 5000 cases of gastric cancer since 2003. Additional legislative policies from 2016 onwards could further prevent or postpone approximately 20,000 more cases by 2030, while reducing inequalities. Finally, a total ban on sales of tobacco products could prevent or postpone about 90,000 cases of cardiovascular disease, 79,000 cases of lung cancer, and tremendously reduce health inequalities by 2045. The age restricted ban could have small benefits overall within the simulation horizon. Conclusions: Increasing the structural elements of existing policies or complementing them with new structural policies might maximise their effectiveness and equity. Simulation modelling is valuable for the evaluation of existing policies and the design of new fit for purpose policies that will take into account the complex nature and dynamics of the populations.

This thesis comprises of a literature review, a research paper and a critical appraisal of the thesis. The main focus of the thesis is on family members’ experiences of caring for loved ones with chronic illnesses. First, a thematic synthesis explored mothers’ experiences of parenting a child with a chronic illness. Thirteen papers (comprising of twelve studies) exploring the experiences of 176 mothers to children with seven different chronic illnesses were included in the synthesis. The thematic synthesis resulted in four themes: the overarching and pervasive sense of responsibility; the altered maternal relationship: the tension between idealised and actual motherhood; counting the costs: dismissing one’s own feelings in order to maintain the ability to care; and becoming the expert. The aim of the research paper was to explore the experiences of partners of people with chronic pain. Interpretative Phenomenological Analysis was used to analyse ten semi-structured interviews of eight men and two women. Five themes were identified: the process of acceptance and adjustment; the challenge of accessing effective support; pain as a personal, independent and malignant force; loss and growth in the relationship; and controlling ones awareness as a means of controlling the impact pain. The first two themes are already documented in the qualitative pain literature and therefore were not discussed in the research paper to allow for more detailed exploration of the novel findings. Finally, a critical appraisal extended the discussion of the research paper and literature review by exploring in more detail the limitations and how future research can further the current findings. Particular attention was paid to the role of gender in the research findings.

Epidemiological studies have shown that chronic pain is a major public health problem, because of the huge suffering of patients and the enormous medical and social resources required to optimise patient care. Currently there is a lot of interest in non-pharmacological, non-invasive therapies for both acute and chronic pain conditions. Transcutaneous Electrical Nerve Stimulation (TENS), by stimulation of Ab fibres peripherally, interrupts the ascending transmission of painful impulses. However, its effects are known to diminish with time. Furthermore, it is not possible to undertake randomised double-blind trials with TENS, as the patients will always feel the tingling sensation when the machine is switched on. For patients with severe chronic intractable pain, a small device may be implanted around the spinal cord, which also interferes with ascending pain transmission - spinal cord stimulation. However this is a costly, invasive procedure with potentially serious complications. The new non-invasive technique of Transcutaneous Spinal Electroanalgesia (TSE) is thought to simulate the effect of spinal cord stimulation. As patients feel no peripheral stimulation when the device is switched on, all trials were double blinded with sham electrodes. Postoperatively, TSE did not reduce the incidence of request for postoperative analgesia or the time or first request for analgesia. However, a trend towards lower pain scores was demonstrated. In the three sub groups of chronic pain patients studied, TSE did not bring about a reduction in pain intensity. Furthermore, there were no significant differences in quality of life following active TSE apart from a difference in the social functioning component of the SF-36 questionnaire in patients with chronic lumbar radiculopathy. TSE treatment did not affect thermal sensation, pain or mood in healthy volunteers. This thesis has failed to demonstrate any effect of TSE treatment in healthy volunteers, in patients postoperatively and patients in the chronic pain clinic.

Unhealthy behaviour often entails short-term indulgence at the expense of long-term health. This thesis examines an hypothesis that temporal discounting, a measure of the extent to which a person devalues delayed benefit, predicts unhealthy behaviour. The work also evaluates temporal discounting as a psychological model for unhealthy behaviour, in particular unhealthy behaviour that is enacted in spite of healthy goals, and behaviour with painful consequences. Studies examining relationships between temporal discounting and health behaviour are systematically reviewed, with the finding that discounting of reward correlates with many forms of appetitive unhealthy behaviour. It is proposed that while steep discounting predisposes to unhealthy behaviour, goal-incongruent behaviour is better explained by the interfering effect of prelearned or innate values. Also, conventional discounting fails to account for the fact that many people prefer to expedite inevitable pain or illness. An explanation is that people dislike waiting for pain, termed 'dread'. The empirical work of this thesis establishes how dread depends on delay, by asking participants to titrate the timing and severity of their own pain or that of others. For the average participant, the dread of pain accumulated at a decreasing rate as pain was delayed. Dread was found to be less marked when deciding on behalf of socially close others. Unexpectedly a tendency to dread future pain in one-off choices did not predict saving a budget of pain relief in sequential choices. Further experiments examined social discounting for pain, finding that participants appear more averse to causing pain in others than in themselves, a tendency that is discounted with social distance. Conclusions are that temporal discounting of reward is a promising marker of appetitive unhealthy behaviour, with a considerable evidence base, while dread offers a candidate marker for engagement in health-promoting behaviour with painful consequences, a possibility which demands further investigation.

Although there is a large body of research literature concerning the impact of childhood chronic illness on family relationships, very little of this has specifically focussed on the impact of childhood Chronic Fatigue Syndrome/Myalgic Encephalopathy (CFS/ME). The current study therefore aims to investigate the impact of having a child with CFS/ME on family relationships from the perspective of parents. This study takes a qualitative approach. Semi-structured interviews were used to explore 18 parents’ experiences of having a child with CFS/ME and the impact this has had on family relationships. Interview data were transcribed and analysed using thematic analysis. The analysis led to the identification of 5 main themes: “Long and Difficult Journey”, “Uncertainty”, “Isolation and Restriction”, “Focus on the unwell person at the expense of family life” and “Parental roles”. They felt that life had become a constant struggle and often felt exhausted. They felt uncertainty, isolation and restriction. These parents talked about feeling like family life had become focussed on their unwell child, such that some expressed a need to escape from the situation. They also described how, as a consequence of managing their child’s CFS/ME, family members could often feel marginalised and the illness could be seen as a destructive force. However, many parents also described working as a team and feeling that family relationships had benefitted in some way. The results of this study are in line with findings of other studies into other chronic illnesses. In addition, this is the first study to focus exclusively on the impact of CFS/ME on family relationships from the perspective of the parents, and is unique in that there is a dual focus on both mothers and fathers. Clinicians should be aware that parents of children with CFS/ME may need additional support, such as information as to what to expect at various stages of the illness and where to access the relevant support.

Background and Aims: Acute pain services (APSs) have developed worldwide to improve the quality of postoperative pain management (POPM). Although there is evidence that APSs can reduce pain and side effects after surgery and improve nurses’ knowledge regarding pain management, the processes through which APSs influence these outcomes remains unclear. Previous studies regarding the influence of APSs on these outcomes have reported conflicting findings and there has been little research exploring clinicians’ perceptions of the APS, and POPM practice. The development of a nurse-based, anaesthetist-supervised APS in one of Jordan’s hospitals in February 2010 provided an interesting and timely opportunity to investigate the influence of an APS on POPM in Jordan, as compared to a similar hospital that has yet to develop this service. This study seeks to address the gap in our knowledge concerning the impact of an APS on the quality of POPM, the knowledge and attitudes of clinicians relating to pain, and to explore clinicians’ views and perceptions of the APS, and current POPM practice. Methods: A comparative multiple-case (embedded) study was conducted between July 2011 and October 2011 at two hospitals in Jordan (Hospital-A has APS, Hospital-B without APS). The case study utilised a combination of quantitative and qualitative methods. Adult patients who underwent elective major surgery (50 from each hospital) completed the Strategic and Clinical Quality Indicators in Postoperative Pain Management (SCQIPP) questionnaire 24 hours after surgery to examine the quality of POPM in both hospitals. A representative sample of nurses and junior doctors at the two hospitals (89 from hospital-A and 100 from hospital-B) completed the knowledge and attitudes regarding pain (KAP) questionnaire. Documentary evidence including hospital policies and notes of meetings was gathered to illuminate the findings derived from other sources. Finally, a purposeful sample of 25 clinicians (mixture of nurses, anaesthetists & surgeons; 12 from hospital-A and 13 from hospital-B) was interviewed to explore clinicians’ views on the APS and current POPM practice. Results: The total mean SCQIPP scores for hospital-A (57.28) and hospital-B (51.88) did not reach the ‘high quality of care’ threshold of 63 in either hospital. The findings from clinicians’ interviews suggest that the lack of patient involvement, the lack of regular pain assessment, and organisational challenges in both hospitals have prevented the total quality scores from reaching the international standard for ‘high quality of care’. Patients in hospital-A reported a significantly higher total SCQIPP scores, and in the subscales of communication and action, (P < 0.001) than hospital-B. There was no significant difference in the subscales of trust (P=0.927) and environment (P=0.344) or in the patient satisfaction scores (P=0.059). Patients in hospital-A also reported significantly lower pain intensity scores (P < 0.001). Patients in hospital-A used significantly more PCA (P=0.013) and epidural analgesia (P<0.001) whereas patients in hospital-B used significantly more IM analgesia (P < 0.001). The findings suggest that the provision of patient education and the more robust approach to pain assessment in hospital-A have positively influenced the achievement of higher total quality scores when compared to Hospital-B. The qualitative findings indicate that the availability of the APS staff 24 hours in hospital-A, the APS’s ‘round’, the specialist pain nurses’ ‘rapid interventions’ and coordination role, and the introduction of PCA and epidural analgesia, were the main activities of the APS that had an impact on the quality of care and patients’ experience of pain in hospital-A. The median total KAP scores for hospital-A (61.6%) and hospital-B (51.5%) did not reach the internationally recognised scores of 80%. A possible explanation is that the short duration of in-service pain education, lack of education sessions, and the reliance of clinicians on their experience, learning from other colleagues or undergraduate courses to learn about pain management are potential explanations for this shortfall. Clinicians in hospital-A had significantly higher KAP scores than hospital-B (P<0.001). Ongoing education and training provided by the APS; the quality and content of training on different aspects of pain management, and the development of pain policies were the main activities of the APS that had an impact on the knowledge of clinicians in hospital-A. However, clinicians in both hospitals were found to have misconceptions about the side effects of PCA and epidural analgesia, and the use of placebo and behavioural clues in pain assessment. Moreover, clinicians’ interviews indicate that patients refuse to take narcotics because they believe it is Haraam (prohibited) or due to fear of opioid addiction. They also speculate that the presence of relatives (escorts) may lead patients to pretend to be in pain and show Dala’ [spoiled] in front of their relatives. Conclusions: The total quality scores did not reach the internationally recognised standard for high quality pain management in either hospital. The findings suggest that the presence of an APS is associated with better managed pain experience, a higher quality of patient care, an increase in the provision of patient education and an increase in compliance with performing regular pain assessment. To improve the quality of pain management practice, clinicians in hospitals with an APS need to continue their work to promote patient education, regular pain assessment, and pay more attention to interventions promoting patient involvement. Hospitals without access to an APS need to find innovative ways to integrate regular pain assessment, patient involvement, and the provision of patient education into routine clinical practice. They may also need to invest in establishing APSs to introduce advanced pain management modalities into their hospitals effectively and safely. The findings suggest that the presence of an APS is associated with a higher knowledge and a positive attitude of clinicians regarding pain management. Despite hospital-A outperforming hospital-B on a number of measures, the total knowledge and attitudes scores did not reach the internationally acceptable scores of 80% in either hospital. To improve the knowledge and attitude of clinicians, it is necessary to improve the content, quality and duration of pain education offered at both the undergraduate and professional levels. It should be noted that this study was carried out in Jordan, a middle-income and an Arabic Muslim country and the internationally recognised thresholds could be too high benchmarks to achieve. In terms of further research, it would be helpful to validate the suggested ‘high quality of care’ threshold on the SCQIPP questionnaire and explore an adjusted ‘high quality of care’ threshold for low/middle-income countries that are struggling with limited resources. There is also a need for further research to develop a contemporary questionnaire to assess clinicians’ knowledge and attitudes regarding POPM including the use of advanced pain management techniques. In addition, a further qualitative study with patients and relatives is recommended to understand their religious beliefs concerning the use of opioids, and the role of the religious practices in pain management.

The number of people living with multiple chronic illnesses (multimorbidity) is increasing and this trend is set to continue. In recent years, there has been a significant increase in epidemiological and clinically informed research into this patient population. However, the extant literature offers relatively little insight into how lay individuals make sense of multimorbidity. Social resources, or the physical and emotional sustenance provided by others, are recognised increasingly as a means towards affecting health outcomes. Social resources are apparent as a nascent theme at the levels of health and social care policy, service organisation, and increasingly, at the level of primary care delivery. However, the apparent enthusiasm for social resources is not universal, and critics have questioned both the socio-political motives behind this trend as well as its underlying social theory. This study employs in-depth qualitative interviews and applies an interpretive approach to analysis. 15 participants living with (at least) osteoarthritis and cardiovascular disease took part in up to two interviews. In addition, a small number of participants’ spouses (four) were recruited into the study. Findings illustrate the ways in which lay individuals make sense of multimorbidity. This thesis draws attention to certain biomedical assumptions made by clinically informed literature. These assumptions are discussed with regard to the concept of illness prioritisation and the relevance of multimorbidity (in conceptual terms) to lay experience. Findings also illustrate the complexity of social resource exchange during illness. A novel conceptual model is developed to elucidate participants’ accounts of supportive practices. Further, findings highlight the role of morality in shaping the experience of support. These observations are synthesised under the theoretical banner of gift-exchange theory, and implications are identified for the application of social resources in policy and service delivery.

Individuals living with Complex Regional Pain Syndrome (CRPS) often experience difficulties taking part in social and recreational activities, which can leave them with a greatly reduced social network and limited opportunities for obtaining social support. Online support communities may provide individuals with an alternative way of obtaining social support, but few studies have examined these communities in the context of CRPS. Furthermore, most online support community research has focussed on established communities, and little is known about how new communities become established. This thesis examines a bespoke CRPS online support community with two broad aims: to examine the development of online support processes in relation to the launch of a new online support community, and to investigate the provision of social support for CRPS within an online support community. The dataset comprised 221 messages posted by 23 participants. Study 1 used the full dataset to examine engagement with the online support community, focussing on the number of individuals who used the forum (membership growth), how they used it (header analysis) and how they introduced themselves (introductory messages). Study 2 used the full dataset to investigate how support processes became established, the support content of messages, and how this contributed to the CRPS ‘four pillars of intervention’. Study 3 used four longitudinal case studies from the dataset to conduct a linguistic analysis of messages, focussing on support providing behaviour and the number of replies received. The results indicate that support processes start almost immediately when a new online support community is launched, and membership growth is closely linked to promotional strategies. Online support may play an important role in CRPS self-management by contributing to the ‘four pillars of intervention’, and there is a possibility that diffusion of responsibility may occur in forums. The longitudinal case study approach may produce important new insights and suggests that the use of health words is unrelated to the number of replies received, the use of self and other-oriented messages may be linked to health status and support providing activities, and that the ratio of positive-to-negative words could potentially be used to identify individuals who might benefit from additional support.

Background (Kenya) Sub-Saharan Africa (SSA) is in the midst of experiencing an unprecedented increase in non-communicable diseases (NCD), specifically diabetes and hypertension. This shift has required public sector health systems, which have historically focused on managing acute diseases, to redesign their services to appropriately serve chronic disease needs. Issue Addressed In order to provide a description of our efforts to bring up comprehensive services for NCDs in rural Kenya within this thesis, I have specifically selected publications which target different aspects of the healthcare system. This includes our efforts related to clinical training for pharmacists, screening for NCDs, medication supply chains, remote phone-based care services, and care delivery based in the community. Prior to the implementation of the programs mentioned in these domains, access to these services was largely not available in western Kenya. Furthermore, the publication of our research from this western Kenyan cohort is designed to supplant the relatively limited research which emanates from rural sub-Saharan Africa. Research Questions For each of these selected publications, we defined a set of primary and, in some cases, secondary research questions focused on identifying the contextualized attributes of service delivery in this setting while also assessing the impact. For the first publication on training for clinical pharmacists, we assessed the impact of Kenyan Bachelor of Pharmacy interns and North American Doctor of Pharmacy interns while providing clinical care in an inpatient setting in Kenya. Our primary research question assessed whether there was a significant difference in the number of clinical interventions documented by interns from the two countries. In the second paper, we shifted our focus to outpatient care and wanted to address the uptake of different strategies of screening for diabetes and hypertension. Our primary research question assessed whether there were any significant differences in follow-up at the public sector clinic after screening positive via home-based screening (community health volunteer provides screening at your home) versus community-based screening (a community wide event is established where people voluntarily show up to receive screening) in a rural setting. In the third paper, we sought to continue to improve aspects of outpatient care by describing our model for improving access to medications. Our primary research question focused on descriptively assessing the change in availability of essential medications before and after implementation of this model. In the fourth paper, we described and assessed our model for providing intensive diabetes follow-up remotely. Our primary research question focused on whether patients experienced statistically significant improvements in blood glucose control after participating in this service for six months. In the fifth paper, we brought together various elements of our prior activities to design and evaluate the community-based model of care called BIGPIC - Bridging Income Generation through grouP Integrated Care. The primary research question for this investigation was to identify the frequency with which patients who screened positive for diabetes or hypertension linked to care. Secondary research questions compared the linkage frequency observed with this model compared to a historical control, along with a descriptive assessment of the loss to follow up, and an assessment of whether this model led to statistically significant reductions in blood pressure after 1 year of implementation. Short Summary of the Individual Papers with Results Linking Them Together Within our assessment of pharmacy training, we found that the Kenyan pharmacy interns provided statistically significantly more clinical interventions per day than their North American counterparts. This result highlighted the potential for Kenyan pharmacy providers to provide clinical services which were largely unavailable in western Kenya prior to this research. Despite the lack of the clinically focused Doctor of Pharmacy curriculum in Kenya, Kenyan pharmacy interns within the Bachelors in Pharmacy program were able to make an average of 16.7 consultations per day with the medical team compared to 12.0 per day for the North Americans. In the second paper we shifted our focus to the outpatient setting and were surprised to find that there weren’t any statistically significant differences in follow-up between home-based versus community-based screening for NCDs. This highlighted the reluctance of rural patients to travel to public sector facilities for care regardless of the screening method utilized. This realization led us to simultaneously focus on improving the reliability of services available in public sector while also trying to implement solutions to facilitate the provision of remote services for care. Within our efforts to improve medication access in paper 3, we were able to demonstrate how our revolving fund pharmacy model was able to improve access to medications from < 40% to > 90%. In paper 4, we were able to implement a self-monitored blood glucose program and demonstrate a dramatic improvement in the blood sugars of patients enrolled in the self-monitored blood glucose program with a statistically significant 31.6% absolute decline in HbA1c. The culmination of these efforts and learnings is described in paper 5, where we implemented the BIGPIC care delivery model which resulted in a statistically significant improvement in linkage to care for screened patients, a retention in care frequency of 70.3%, and a statistically significant mean decline in the systolic blood pressure of 21mmHg (95% CI 13.9-28.4, P < 0.01).