This thesis focuses on the development of a contraceptive decision-analysis tool (My Way) for young people and exploratory research to examine its application in a clinical setting. Decision analysis is essentially a method for breaking down complex problems or questions into manageable components, and then combining them quantitatively and logically to show the best course of action. The rationale for this work is that taking young people's current lifestyles and values into account when selecting and initiating a contraceptive method will increase user effectiveness and acceptability of the method, which will ultimately lead to a reduction in unplanned pregnancies and other negative outcomes, such as acquisition of sexually transmitted infections (STIs). My Way works by combining the best available scientific evidence on the outcomes and effectiveness of available contraceptive options, such as probability of pregnancy while on the pill, with quantitative assessments of the user's own preferences and values, such as how they feel about the consequences of pregnancy. The under-lying decision-analysis model provides a ranking and rating of the various available options for each user, based on both scientific evidence and their own personal values. Best available evidence on each contraceptive method was collected on the following attributes (i.e. characteristics): effectiveness in preventing pregnancy, risk of STI acquisition, other outcomes and factors affecting attractiveness including possible side effects (e.g. weight gain) and 'bother' considerations (e.g. having to go to a health service to obtain a contraceptive method). For the pilot study young people (10 men and 15 women) aged 13-21 years were to be introduced to the program during their consultation with the contraceptive nurse or doctor in a young people's sexual health clinic. The aim of the pilot was to assess the feasibility, acceptability and potential effectiveness of the My Way program.

There are numerous sources of information about drugs, but this does not necessarily mean that the information supplied by any particular source is adequate for the needs of the prescribing doctor. The government, the pharmaceutical industry, members of the health care professions and private business concerns have attempted to provide comprehensive information on drugs. The ways in which the government has both provided and influenced the provision of drug information are described. A survey was carried out to establish which sources of information are used by hospital doctors for prescribing and for learning about new drugs. The majority of hospital doctors use reports of clinical trials published in medical journals to learn about new drugs. A study of the information contained in a sample of trial reports appearing in several major medical journals is reported. Many doctors indicated that promotional material was an important source of information, particularly for learning about the existence of a new drug. Several studies of the information provided by the various forms of pharmaceutical promotion have been made, and these are critically reviewed. Finally, since the majority of hospital doctors had written to a pharmaceutical firm for further information about a drug, at some stage in their medical career, a survey was carried out to discover how medical information staff in the pharmaceutical industry provide information about drugs to the medical profession. There appears to be a need for a regularly updated manual providing the information that doctors require in a concise format, backed up by a drug information service which could answer more detailed questions.

The research on sex-differential mortality indicates that, contrary to the experience of other countries where, in the last century, females have consistently shown an advantage over males in life expectancy, the reverse has been observed in some parts of the Indian Subcontinent. Recent studies in the area have confirmed this female disadvantage in her chances of survival, especially in the reproductive ages. The present investigation is a detailed examination of the hypothesis that: there are sex-differentials in mortality and health care, and low levels of family planning, to the disadvantage of females. The data was collected by means of a census in 22 villages of Daudzai thane and Michni tribal area in the North West Frontier Province of Pakistan. The 2,070 households in the selected villages were interviewed by trained enumerators using a formal questionnaire. A detailed description of the area was given as a background to the study. The analysis of the mortality results by the indirect methods based on retrospective questions on childhood mortality, and on orphanhood, widowhood and siblings status indicated that the standard application of these methods did not take into account the idiosyncrasies of the data. Therefore, the most reliable sections of mortality estimates from the different methods were used to construct the final life table. In the results a higher female than male mortality was observed in the reproductive ages. Supplementary evidence from deaths by cause corroborated these findings. The examination of the health data indicated that there was a significant sex-difference in treatment of illness, cost of treatment and vaccination status to the disadvantage of females. The family planning results showed that, although the majority of the population had heard of family planning, few couples practised it. For those who practised family planning the main source of supply was the family planning centre. In the light of the evidence examined, it was concluded that there was validity in the hypothesis under investigation, and recommendations were made on the basis of the findings for the improvement of the status of women in the area.

Despite a standard classification and array of self-report questionnaires, there is little consensus about how to define and measure sexual dysfunction. Recently the debate has been influenced by the pharmaceutical industry, leading to an increasingly medicalised view of sexual difficulties. The aim of this thesis was to explore the meaning of sexual (dys)function to those who have and have not experienced sexual difficulties; and to use these meanings to create a conceptual model and population prevalence measure of sexual dysfunction for use in UK community surveys. Thirty-two semi-structured interviews were conducted with individuals recruited from a GP practice, an HIV/AIDS Charity and a Sexual Problems Clinic. The data were analysed using principles derived from Grounded Theory. Variation in individual meaning was expressed in terms of three distinct versions of functional sex - the erotic, the interpersonal and the mechanistic - which framed the purpose of sexual activity, the criteria determining ideal sex, and threats to this ideal. The data highlighted several coping strategies that individuals adopted when their lived reality failed to match their ideal: changing circumstances to fit goals, for instance by seeking a medical cure; changing goals to fit circumstances, for instance by lowering expectations; And living with the gap between ideal and actual experience, for instance by avoiding the problem. Choice of strategy and the likelihood of successful adjustment were influenced by the severity of the problem, causal attributions made about the problem, and the partnership context. Thirty-one potential components of a functioning sex life were identified from the data. Using evidence both from the literature and from this study, 12 of these components were selected for inclusion in a conceptual model of sexual function. This model was transformed into a 19-item draft prevalence measure of sexual dysfunction ready for psychometric testing and validation.

Background: Anecdotal evidence suggests that at least 8 young people (aged 14-35) die of undiagnosed cardiac conditions every week. Cardiac screening will detect the majority of cardiac conditions that could lead to a sudden cardiac death (e.g. Hypertrophic Cardiomyopathy, long QT syndrome, Wolff-Parkinson-White syndrome). However, screening of apparently healthy young people may have adverse psychological consequences on those who have negative test results. Objectives The objective of the current research was to evaluate the psychological effects on young people of screening for cardiac conditions that are partly genetic. Methods: The current study (N=746) was a prospective investigation of psychological responses to screening, involving assessments at the time of invitation (T1), immediately before testing (T2), and 2-3 weeks later (T3), following receipt of results. It was carried out in the context of an innovative screening programme being developed by the charity Cardiac Risk in the Young (CRY). All participants were healthy individuals who had consented to cardiac screening in two different contexts, community (N=303) and school (N=443). Anxiety and self-rated health were evaluated using standard measures, and illness representations were assessed with the revised Illness Perception Questionnaire (IPQ-R). Between group analyses were performed for each of the key factors, gender, age, and number of symptoms at the time of screening. Two groups of young people---adolescents (14-19) and adults (20-35)---were compared. Comparisons were also made with an adolescent age-matched control group not offered screening. Results: Anxiety levels in the screening participants were significantly lower than those of the control group (not offered screening) and population norms. There were no changes in anxiety between T1 and T2, but at T3 (after receiving a negative result) anxiety levels significantly declined. Participants with symptoms were more anxious. Similar results were reported for self rated health. Patterns of response differed between adolescents and adults. Cognitive representations of the cardiac conditions were not associated with anxiety during the testing programme. Emotional representations and genetic worries were associated with anxiety at T1 and T2 and emotional representations predicted reassurance at the end of the programme. A small number of participants had positive results in response to screening, and their experiences were also tracked. Discussion: This research provides strong evidence that the tests were acceptable to the participants. The levels of anxiety reported in this study, and the impact on self rated health, are not excessive. They were reassured after the testing satisfied with the information they received reported qualitative responses that were positive and showed they had understood the process that they were engaged in. Selection factors were probably responsible for the lower levels of anxiety in participants than controls. These results suggest that screening apparently healthy young people (both adolescents and adults under the age of 35) for potentially serious cardiac conditions does not have adverse psychological effects.

Studies conducted both in the UK and World-wide have consistently reported an association between exposure to ambient air pollutants and ill health, most notably respiratory and cardiovascular disease. Although respiratory disease is one of the major causes of death in the City of Manchester, with mortality rates in some areas of the City approximately twice the national average, the possible relationship between air pollutant exposure and the observed health effects has not previously been assessed for the Manchester population. To assess the short-term health effects of air pollutants the study used a time series design where daily variations in selected causes of mortality and morbidity in the City of Manchester were compared with daily variations in air pollutants. To assess the longer-term (chronic) effects of pollutants on health the approach adopted was to map standardised mortality ratios (SMRs) and standardised hospitalisation ratios (8HRs) for specific diseases in Manchester and to examine the relationship between these and the air pollutants. In both methods, the relationship between the two variables was assessed using Poisson regression techniques whilst adjusting for the potential confounding effects of other environmental and social variables. The results of the time series study indicated that there was small, but significant associations between exposure to air pollutants and acute adverse health effects in the Manchester population. With respect to mortality, the most significant finding was an association between ozone (03) concentrations and both all cause mortality and cardiovascular mortality (warm season only) with an increase of 10ppb in the 1-hour or 8-hour maximum 0 3 concentration associated with an increase in the number of deaths of approximately 3-4%. In both cases, the association persisted after adjustment for the effects of meteorology and other potential confounding variables and appeared to be independent of the other air pollutants. A significant association between mortality (all cause and disease specific) and the other air pollutants: particulate matter (PM1o), black smoke (88), nitrogen dioxide (N02) and sulphur dioxide (802) was not observed. The results of the time series study also indicated a significant association between a number of the measured air pollutants and both total respiratory hospital admissions and asthma admissions. For both disease groups, the stronger predictor was the daily mean BS concentration (lagged by three days) although associations were also observed between these groups and the daily mean N02, PM10 and S02 concentrations. For these two disease groups, an increase in the daily mean BS concentration of 1 O~gm3 was associated with an approximate 3-5% increase in hospital admissions. The main finding of the cross-sectional study was a significant association between ill health (as measured by the age-sex SMR and SHR) and socioeconomic deprivation (as measured by the IMD2000 or the DOE Index). In pollutant only models (Le. no adjustment for the effects of deprivation) a significant association (p<O.05) was observed between all cause mortality SMR and N02, PM10 and carbon monoxide (CO), with PM10 being the stronger predictor. A significant association was also observed between the SHR for COPD and PM10 levels. However, after adjusting for the effects of confounding by deprivation, a significant association between the air pollutants and the standardised mortality ratios (SMR) or standardised hospitalisation ratios (SHR) was not observed. In conclusion, this study has presented evidence that exposure to relatively low levels of air pollutants are associated with small but significant acute adverse health effects. The strongest relationships were observed between 0 3 and mortality (all cause and cardiovascular) and between BS and both total respiratory admissions and asthma admissions. However, associations between respiratory admissions (total and asthma) and a number of other pollutants were also observed. In view of this, it would be imprudent to conclusively assign the observed effects to any single pollutant. In contrast, the study found no evidence of an association between long-term exposure to air pollutants and chronic respiratory or cardiovascular disease, although a strong association between socio-economic deprivation and ill health was observed. However, due to the lack of data at the individual level, the ecological study design is limited in its power to detect small pollutantlhealth associations. Thus, the lack of a significant association between the air pollutants and ill health, as observed in this study, should not be viewed as conclusive evidence against such an association.

No description available.

The problem chosen for this Thesis is the challenge facing professionals working in protected areas to find ways of demonstrating that the conservation of biodiversity and its sustainable use have a fundamental relevance to the daily lives of people, including those who may never visit a protected area - and the need to emphasise the purposes of protected areas as contributing to the quality of life. The hypothesis raised is two-fold: (1) in-situ biodiversity conservation, promoted by protected areas, benefits human health, whereas human health is holistically understood as quality of life; and (2) when quality of life is improved, people's perception towards the protected area is also improved. The three key-concepts of this study - Human Ecology, Biological Diversity and Human Health - are reviewed. The concept and methods of Human Ecology, as well as the implications, history and needs for in-situ conservation of Biological Diversity are highlighted. The holistic and official definition of Human Health is reinforced, as a paradigm shift to the dominant disease-oriented approach, and its validity as a conceptual alternative for sustainable development is argued. Eight ways in which protected areas can improve human health are developed. Four of these health benefits of protected areas are briefly described and remain as anecdotal evidence, while the other four are better explored through fieldwork in Brazil, Costa Rica, Poland and Kazakstan. These health benefits of protected areas constitute a contribution to academics, decision-makers and protected-area managers interested in improving the relation between local communities and in-situ biodiversity conservation, world-wide. The example of the Integrated Conservation-Development Project (ICDP) carried-out at the Serra da Capivara National Park, Brazil, is chosen to be further scrutinised. A case-study is performed, combining qualitative and quantitative data. The village that suffers more impact - both in terms of time and intensity of contact with the conservation-development activities locally performed - is compared with a control-village. Changes in lifestyle, education levels, access to health-care, employment opportunities and health standards were evidenced by the qualitative data. The quantitative analysis suggested that the improvements in the housing conditions, water supply, storage and treatment, as well as in the perception of the villagers towards the Park and the ICDP activities were more significant in the village affected by the ICDP, than in the control village. Finally, the assessment of the research findings and the contribution of this work are summarised. What has been discovered, by pulling together the research questions; the achievements, limitations and difficulties; as well as the opportunities for further work are identified.

This study examines how inflammatory bowel disease sufferers manage the comparatively routine and regimented task of working given the intermittent and unpredictable nature of the condition. It addresses a lack of qualitative research on social aspects of IBD, and is also an empirical study on the body that explores the experience of a specific chronic illness, relating these issues to embodied social regulations that apply more generally. A postal questionnaire was administered to 400 members of a local patient support network, and from these, 21 interviews were conducted. In addition an email-based `virtual focus group' was developed and administered to reflect and harness active computer mediated support networks for IBD sufferers. Most do disclose information about their condition at work, and profess to prefer this over non-disclosure. Reasons for decisions about disclosure relate to the organisation and running of the workplace, how well the condition could be explained, how apparent the condition was, possible impacts on others' perceptions of them, and motivations to `be honest'. Disclosure strategies are identified which are associated with two styles of talking about the condition. `Event' accounts are based on events (e. g. medical treatment) marking out the course of the condition, while `physical' accounts draw primarily on felt experiences of symptoms. Three elements define capacity to work: condition severity, work environment factors and role status factors. Translating this capacity into full and competent worker status depends largely on whether work tasks can be performed without the breaking of social rules relating to the natural functions. The study demonstrates the importance of work in the lives of sufferers, and examines conditions that allow or prevent successful functioning at work. These factors rest primarily with neither medical aspects of the condition, nor social aspects arising from them, but from a complex and fluid dynamic constituted by both. iv

This grounded theory research explores patients' experiences and the supportive care implications of living with the incurable and progressive bone marrow cancer multiple myeloma. Patients (n=17), family members (n=11) and healthcare professionals (n=12) participated in the research. A total of 46 semistructured and recorded interviews were undertaken and transcribed verbatim (three couples were interviewed twice n=6). Some participants were interviewed individually while others were interviewed as a couple or small family group. The methodology employed aimed to generate theory in an area of limited qualitative exploration and findings were determined through the procedures of theoretical sampling and constant comparative analysis. 'Contention' was the core category that emerged in the form of 'struggle' with close affiliation to other prominent interrelating concepts such as 'battle' or 'fight', 'disruption' and 'disharmony'. The findings are described within four categories of 'Ways of communication', 'Nature of the disease', 'Impact on life' and 'Supportive care needs'. This research provides insight of individuals' life experiences living with a complex haematological malignancy that is poorly understood. Implications for practice relate to development of collaborative approaches to healthcare and the identification of supportive care needs. This work contributes increased awareness and understanding of multiple myeloma and the impact that the disease has on the individual and on family life. It also highlights the value of effective communication and collaboration between patients, families and healthcare professionals to identify supportive care needs at specific times along the illness trajectory and inform service provision and the development of effective care pathways. Indications for further research are included. A Family Self-Assessment Referral Plan and Model of Supportive Care, based on the research findings, are currently being developed in collaboration with patients, families, professionals and Myeloma UK.