Background. Hypertension and diabetes have become a major public health challenge in India. This research work aims to develop a feasible and scalable intervention for hypertension and diabetes, tailored to primary care settings in India. Objectives. To conduct a healthcare facility assessment to inform the development of a Smartphone-enabled intervention package for hypertension and diabetes at primary healthcare facilities in India. To pilot the Smartphone-enabled hypertension and diabetes intervention package at primary healthcare facilities in India in order to identify the barriers, synergies and health system strengthening requirements for the feasibility and scalability of such an intervention. Methodology. This research work was carried out in five Community Health Centres (CHCs) in Solan, Himachal Pradesh. The implementation and evaluation of the piloting, guided by a conceptual framework1, was carried out using mixed methods, following implementation science principles. Results. In this research work, a six component intervention was developed comprising a Nurse Care Coordinator (NCC), a structured training programme, clinical management guidelines, a Smartphone-based clinical decision-support system, counselling services and follow-up plan for patients. During piloting, NCCs detected that 37% of the out-patient clinic attendees had hypertension/diabetes. At three months of follow-up, systolic blood pressure had a mean reduction of 10.9+/-13.1 mmHg (p<0.001) in 2974 participants while fasting glucose level had a mean reduction of 26.4+/-49.0 mg/dl (p<0.001) in 717 subjects. Discussion. This research work demonstrated that a six component intervention for hypertension and diabetes care is feasible. However, barriers such as inadequate manpower, insufficient drug supply and inadequate lab facilities need to be addressed for optimal intervention delivery. Conclusion. A Smartphone decision-support-enabled, NCC-facilitated intervention for hypertension and diabetes is feasible for primary care settings in India.

This thesis is focused on the experience of people suffering a particular enduring illness, heart failure. In the heart failure literature exploring self-care, there is an assumption that patients have come to terms with their new condition and are in a position to care for this new self. Consequently, this study explored ways patients come to terms with their new situation, and if this affects self-care behaviours. As a heart failure nurse, I wanted to better understand patients' experiences. Gadamer proposed a methodology about how a better understanding might be reached if sought mutually. This study was therefore conceived as a conversation between researcher and researched. A longitudinal research study was designed to engage participants over a period of time. Three separate groups of patients, including those newly diagnosed and those living with the condition for longer were interviewed on 3-occasions over a 1-year period. Findings from this study revealed new knowledge about an adaptive process concerning individuals' ability to integrate illness with their sense of themselves. How the patients succeed or fail to transition through this not only has significance for their ability to participate in self-care but also highlighted that many experienced a considerable degree of suffering. These findings were then organised within a conceptual framework for clinical practice, providing practitioners with an opportunity to match care around individuals' needs. Whilst the methodology used within the study developed a new framework about self-care grounded from within nursing, it also challenges practice. Gadamer's method, conversation, allowed the patients' the opportunity to discuss whatever they wished, which was not only emancipatory for them, but provided the practitioner with the chance to critically self-evaluate. This iterative method can be used in both clinical practice and research to empower all participants and lead to the development of nursing as a reflective profession.

Coronary heart disease (CHD) is associated with a high morbidity and a high mortality, especially premature death, in low and middle-income countries, in developing countries such as Iran and in developed countries such as the United Kingdom. CHD affects individuals in their peak mid-life years, altering the future of family dependents and damaging the development of a population by its impact on productivity. Treatment of CHD consumes a significant proportion of health system capacity. Among decision makers, treatment costs can be just as important as the beneficial effects of treatment on health and maintaining quality of life. To control increasing demand, resources need to be allocated most effectively. Cost benefit analysis and assessment of willingness to pay (WTP) are health economics techniques that might be utilised for assigning priority of resource use and to better match costs of and demands for health care. In spite of vast experiences of applying health economics in the west, developing countries like Iran are only at the beginning of this process. A few WTP studies in health in Iran have been carried out but there is no reported use of WTP in CHD. This thesis consists of one study in each of two different communities, which together provide key information on one aspect of the economic evaluation of coronary heart disease in Iran and UK, which potentially can be used in policy-making relevant to a developing nation such as Iran, faced with an impending epidemic of CHD in the next ten years. Different approaches to health economics analysis are described. This 'willingness to pay' study compares patients' preferences with healthy volunteers in both the UK, where healthcare is predominantly publicly funded and in Iran, where a mixture of public and private healthcare is in place. To compare the main health care concerns in the UK and Iran on management of cardiovascular disease using epidemiological factors and a health economics tool; cost benefit analysis. This study is to address the scale of potential risk, losses and benefits of decisions made in the management of coronary heart disease in a developing country like Iran compared with a developed country such as the UK. Objectives ~ To establish what communities may be willing to sacrifice to prevent a heart attack or, in the event of a heart attack, to receive the best treatment and avert death risk ~ To find out whether individuals might be prepared to pay for prevention or new treatment of heart disease before it becomes widely available ~ To establish community preferences if they were required to prioritise the health services Design 1 - Perspective The perspective of WTP study is societal. 2 -Methods Using different elicitation methods in WTP, survey data were obtained from four sources in the UK and six centres in Iran. The WTP values in different scenarios amongst patients, family member of patients and healthy volunteers in each country have been compared. Several predictors influencing on individuals' WTP such as: household income, education, employment, quality of life age, gender and socioeconomic class have been investigated. Individuals' attitudes toward health priorities have been approached. 3 -Setting This WTP study is a comparative survey study, comparing AMI patients, healthy volunteers and members of the family of patients in Iran with the UK. The Nottingham population comprised patients under the care of cardiologists at Nottingham University Hospitals, and healthy volunteers selected from general practices. Iranian patients and volunteers were similarly recruited from Qazvin teaching hospital, Shahid Beheshti hospital and several health centres. 4 - Participants The study populations described in this thesis were selected from adults in British and Iranian communities. Within each community, subjects either were patients with a history of heart attack or were a healthy, volunteer group, comprising family members of patients, not known to have CHD. Data collection Data has been collected from 518 participants in Iran and 309 participants in the UK for WTP. Outcome measures Willingness to pay or willingness to accept for different health gains Data analysis SPSS (version 11.00, 15.00) and Excel software (office 2003) were used. Univariate and multivariate analysis like regression analysis and descriptive statistics were applied as appropriate. Results - Willingness to pay Most participants in both countries were willing to pay for either treatment, prevention of CHD, reduction of mortality and saving life. Education, income, having insurance, quality of life, social class and some other confounders influenced WTP but there were significant differences between the two communities. - Prioritisation The public, whether patients or not, were willing to prioritise and were motivated to rank the CHD as a top priority in healthcare for extra allocation or re-allocation of resources. Conclusion Patients, not usually involved in the prioritisation of health care services, can have an impact on decision-making through willingness to pay and willingness to accept techniques. This study has presented a high community profile for treatment, prevention of CHD in both countries, which will be instructive to decision makers.

The progression of cardiovascular disease (CVD) is largely modifiable through lifestyle behaviours. UK pharmacists are contractually obliged to facilitate patient self-management of chronic conditions such as CVD. Pharmacists are easily accessible health professionals who are well placed to identify “at risk” patients through medication regimes. Research has identified varying attitudes towards and levels of involvement in pharmacist-led health promotion activity. Given the diverse and exploratory nature of the work, a pragmatic, mixed methods approach was used to explore community pharmacists’ role in facilitating patient self-management of CVD. The thesis presents four studies: a qualitative study with pharmacists; a cross sectional questionnaire of community pharmacists; a systematic review and a qualitative study with patients with CVD. The qualitative study with pharmacists gave an insight into pharmacists’ experiences of giving patients with CVD lifestyle advice and the factors underpinning commonly cited barriers to providing public health services. This informed the development of the cross-sectional questionnaire which identified the predictors of pharmacists’ intentions to give two different types of advice to facilitate patient self-management. The systematic review identified a small number of interventions to prepare pharmacists to facilitate patient lifestyle behaviour change and evaluated the theories and behaviour change techniques used in successful interventions; however due to poor study quality and poor reporting of the interventions limited conclusions about the efficacy of the interventions could reliably be drawn. Finally, the qualitative study gave an insight into the experiences of patients with CVD using community pharmacy services and their expectations of the service they receive from community pharmacists. Recommendations about changes to pharmacy policy and practice in order to support pharmacists’ provision of CVD self-management advice are made.

Coronary heart disease (CHD) mortality rates have fallen since the 1960s in the UK. The prevalence of type 2 diabetes (T2DM), in contrast, has increased markedly in recent decades. Few attempts have been made to examine the reasons for these striking, divergent time trends. The CHD mortality and T2DM prevalence trends likely reflect in part contemporaneous trends in incidence of these conditions. The broad aim of this thesis is therefore to analyse recent trends in CHD and T2DM incidence in the UK, in relation to trends in aetiological exposures and treatment use, and in relation to each other. This epidemiological research involves statistical analysis of pre-collected data from different UK-based observational data sources, each used according to their strengths: the British Regional Heart Study cohort, The Health Improvement Network primary care database, and the Whitehall II cohort. The principal findings are that favourable time trends in major modifiable aetiological exposures (smoking, blood pressure and HDL and non-HDL cholesterol) may explain half of a 62% decline in major CHD incidence in men over 25 years. Findings for women are similar. Much of the blood pressure decline, and a third of the non-HDL cholesterol decline was associated with increased preventive medication use. Conversely, unfavourable rising adiposity levels limited the scale of the decline in major CHD incidence, and explain an estimated one quarter of a rise in T2DM incidence since the 1980s. Major CHD incidence declined faster among those with T2DM, than without, corresponding to an attenuation of excess risk of CHD associated with T2DM. By highlighting what can be achieved in terms of reducing CHD, while showing the adverse impact of rising obesity levels, the results provide evidence to help inform future efforts to reduce CHD further and curb the rise in T2DM, in the UK and in other locations.

During the 20 years of political violence in Peru starting in the late 1970’s, Ayacucho, an Andean department, was one of the most severely affected areas. Mass-migration to Lima increased largely driven by escaping from violence rather than by economic reasons. This provides a unique opportunity to study the effects of migration on health since selection biases are likely to be reduced. This study investigates differences in cardiovascular risk factors comparing three groups: i) always lived in Ayacucho (n=289); ii) migrated from Ayacucho to Lima (n=589); and, iii) always lived in Lima (n=199). A cross sectional design was used. A clear gradient of risk was seen for the majority of factors studied: body mass index (BMI), total and LDL-cholesterol, fasting blood glucose and insulin, CRP and fibrinogen, the rural group having the lowest risk, the urban group the highest. The migrant group had intermediate risk, although generally more similar to the urban than the rural group. Blood pressure did not show a clear gradient of difference between groups. The migrant group had similar systolic blood pressure (SBP) but lower diastolic blood pressure (DBP) than the rural group. The urban group had higher SBP but similar DBP than rural group. In the case of lipid profile, no difference was observed between groups for HDL and triglycerides. Obesity, diabetes, metabolic syndrome and estimated absolute cardiovascular risk were all higher in migrant and urban groups than in the rural sample. Within the migrant group, when classified by time since migration or age at migration, differences were observed in total cholesterol, LDL, fasting glucose and insulin resistance. The findings of this study suggest the impact of migration on cardiovascular risk is not uniform across risk factors. The study provides new insights into the increased disease risk associated with migration and urbanisation.

Stable Angina Pectoris (SAP) pain is caused by decreased blood flow to the heart muscle. It is exacerbated by exertion and eased with rest. Research indicates the need to improve support given to sufferers (NACR, 2008) that considers ethno-cultural factors (King et al., 2006) and close relational influences (Dalteg et al., 2011). However, delivery of appropriate care in isolated rural communities remains challenging. Despite agriculture being recognised as one of the most dangerous occupations, with above average incidence of chronic conditions and mental health issues, the profession remains medically under-served, due to geographic and attitudinal restraints (Anderson et al., 2012). The impact SAP has on male farmers, who rely on a physically active body, and their female partners who sometimes, though not always, work on the farm, is poorly understood. Hence, this study sought to investigate the lived experiences of eight Herefordshire male-female farming couples where the man had SAP, to help inform future care. Using a longitudinal, hermeneutic phenomenological research design, data were obtained through semi-structured interviews, on three occasions, over twelve months. Lifeworld existential dimensions, corporeality, spatiality, temporality, relationality were used to categorise findings and draw analytic interpretations, alongside the embodied reflections of the researcher. This study found that couples practised bodily subterfuge, in order to manage vulnerabilities inconsistent with their worldview. The men with SAP attempted to hide body disruption, to maintain their sense of self and social standing. The women became body invisible, to conform to dutiful care-giving, supplement their partner’s farm-work, and distance themselves, inter-corporeally. Disharmony between body, self and world, during illness, also eroded the participants’ sense of existential trust. This research demonstrates the importance of acknowledging the existential lifeworld of both the individual farming male with SAP and their female partner. It also offers a threshold whereby more targeted, humanised healthcare may proceed.

According to the World Health Organization (WHO), 17·3 million people died from cardiovascular disease worldwide in 2008 and more than 23 million people will die annually from cardiovascular disease by 2030. In the UK, the prevalence of cardiovascular disease is high — over 3 million people currently suffer from this disorder. There are a number of cardiovascular researchers in the UK population who access the National Health Services, but little evidence has been gathered from those who access the private medical insurance. According to figures from the Association of British Insurers, the number of people covered by private medical insurance rose to 6 million in 2008—about 10% of the UK’s population. Due to an increasing large number of this population, there is an urgent need to investigate their health, especially cardiovascular health in this affluent group. This PhD study used a retrospective cross-sectional design, and aimed to examine the modifiable cardiovascular risk factors—BMI, waist circumference, WHR, systolic blood pressure, diastolic blood pressure, total cholesterol, HDL cholesterol, and LDL cholesterol—in a population who attended Nuffield Health, a private medical insurance company. The dataset provided by Nuffield Health is one of the largest UK datasets specifically in a commercial setting. When examining the association of socioeconomic status and cardiovascular risk factors in this affluent population, the findings show that the likelihood of having high blood pressure was lower in the most deprived area than in the least deprived area. The likelihood of having low HDL cholesterol was not significantly different between groups, but the likelihood of having high total cholesterol and LDL cholesterol was statistically significantly lower in more deprived groups. In the study assessing the effect of geographical variations on cardiovascular risk factors, no North-South effect was detected in this relatively affluent population. This finding might be generalisable to affluent populations in other European countries. In order to see the difference between this affluent population and another population from an affluent region in England, data provided by Hampshire Health Record were analysed. Although the two datasets are comparable, people living in the south England region were more likely to develop obesity and hypertension, but less likely to have elevated cholesterol and LDL, as well as low HDL, compared with those from Nuffield Health on the basis of socioeconomic status. Evidence-based population-wide policy interventions exist, and these interventions should now be urgently implemented to tackle persistent inequalities of cardiovascular health in the UK effectively.

Thalassemia major is a recessively inherited haematological disorder, which involves a complete lack or reduction of beta protein in the hemoglobin, causing life-threatening anemia. Management requires patients to have life-long access to a treatment regimen of fortnightly blood transfusions and daily chelation therapy, imposing major demands on children and their families. Much of the research in the area of paediatric, chronic illnesses such as thalassemia major has investigated psychosocial impact and adjustment to the illness. However, the lived experiences of children and their families and the meanings assigned to these experiences have received little empirical attention. Additionally, the experiences of specialist healthcare professionals have been particularly neglected. Despite the high prevalence of thalassemia in Pakistan, the majority of existing research has been conducted in Western countries. Therefore, the present research adopted a multi-perspective approach, to explore the experiences of key people involved in thalassemia in Pakistan, namely, children, their mothers and healthcare professionals. Study 1 explored the experiences of 12 children (aged 8-12 years) living with thalassemia, viewing them as active agents (Prout & James, 1997). Studies 2 and 3 explored the experiences of their mothers (N=12) and healthcare professionals (N=4) as the primary and professional caregivers, respectively. All of the participants were recruited from a treatment centre in Multan, Pakistan. Each of these groups were studied in two phases; in phase 1, five focus groups and two role-plays (with children only) were conducted and analysed using thematic analysis (Braun & Clarke, 2006). The purpose of phase 1 was to obtain an understanding of the participants’ core concerns in order to develop the interview guide for phase 2, which aimed to provide an in-depth understanding of these experiences. In phase 2, 28 in-depth individual interviews were conducted with each participant in all three groups and analysed using interpretative phenomenological analysis (IPA). For study 1, the findings consisted of three superordinate themes: ‘Loss of normal childhood’, ‘Minimizing differences’, and ‘Redefining self’. These themes were interrelated and reflected the burden of living with thalassemia and the wide array of coping strategies used by children living with thalassemia. Study 2 (mothers) resulted in four superordinate themes. Across the first two themes; ‘Living with a chronic heartache’ and ‘Child becomes the focal point’, mothers shared the difficulties associated with being a primary caregiver. The remaining two themes; ‘Focus on normalization’ and ‘Vigilant parenting’ were reflective of the coping strategies adopted by mothers to deal with caregiving stress. The findings of study 3 with healthcare professionals were composed of four superordinate themes where the first two themes; ‘Making sense of work-related frustrations’, and ‘Blurring of boundaries’ shed light on the frustrations, helplessness, emotional distress and dilemmas of professional caregiving. In particular, the healthcare professionals related the tension between empathetic behaviour and distress. The latter two themes; ‘Seeking satisfaction’, and ‘Ascertaining and re-ascertaining boundaries’ illustrated the coping efforts of the healthcare professionals to address the stress of professional caregiving. The current research provides unique insights and expands our understanding of the experiences of the main people directly involved with the illness. The findings of all three studies revealed a complex interplay of themes, which highlight the fluctuating and dynamic nature of attempts to manage the condition and caregiving, and which is in contrast to the progressive, linear approaches of adjustment often employed in the chronic illness literature. Participants vacillated between feeling overwhelmed by the burden of illness/caregiving and adaptation. This vacillation was influenced by their personal and social setting; any change in these contexts could potentially disrupt the coping process. The findings also elucidate the paradoxes of coping efforts since, at times, coping itself contributed towards the burden associated with thalassemia major/caregiving. Moreover, the coping strategies of the participants in all three groups remained vulnerable. The multi-perspective account was achieved by comparing the the experiences of children, mothers and the healthcare professionals at the group level. It highlighted various similarities as well as differences in the accounts of the participants in the three groups. It revealed a complex interaction between their experiences and described how coping strategies/stress of one group was sometimes perceived as stress-inducing by the other group. Such insights highlight the importance of a multi-perspective approach, which allowed the identification of areas for improvement in healthcare provision. The theoretical, methodological and practical implications of the current research are discussed.

This thesis gives an account of ten years work in Brent which has utilised community development methods to initiate a range of health education and counselling initiatives for sickle cell disorders. As a background the social, political and medical experiences in the United States of America are described in an attempt to analyse the role of institutional racism and the failure of conventional health planning systems to provide black and ethnic groups with relevant services. The major part of the thesis describes a systematic programme of local development work in Brent, which was conducted on the basis of collaboration between the local voluntary organisation and the local health authority. The absence of any systematic data concerning the prevalence of the disorders in Brent prompted research to establish a register of local patients. A survey amongst community nurses in Brent and Paddington identified a low level of awareness about the condition mainly due to a lack of information in basic training. Taped interviews with 22 local parents of affected children revealed harrowing experiences, reflecting the lack of information and support from within the National Health Service. These findings indicated the need for an alternative, community development approach to promote sensitive, non-racist health education and counselling initiatives. This led to the setting up in Brent of the first Sickle Cell Counselling Centre in Britain. Educational initiatives have been developed for the local community, for affected families, and for health professionals. The experience in Brent reveals how black health workers, committed to community development strategies, can effect change within the NHS in relation to the health needs of black and ethnic groups. The significance of the Centre as a possible model for other health districts is examined, in particular as an approach to redressing inequality, encouraging community participation, and promoting inter-agency collaboration.