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Aim: To develop and evaluate a training package for community pharmacy personnel to improve the counselling in smoking cessation provided in community pharmacies. Method: A training in smoking cessation counselling, based on the <I>stage of change</I> model, was developed. A randomised controlled trail was used to evaluate the training; additionally, interviews were used to gain an in depth insight into the pharmacy support process. All 76 non-city community pharmacies registered in Grampian were invited to participate. All intervention personnel were invited to attend the training. The effect of the training on the participants' knowledge and attitudes was assessed by questionnaire at zero, two and 12 months. Both groups recruited customers over a 12-month period. The effectiveness of the training was assessed by comparing the smoking cessation rates of the two groups at one, four and nine months. Results: 62 pharmacies (82%) were recruited. The training was well received by the 94 participants (40 pharmacists, 54 assistances). At both two and 12 months the intervention pharmacy teams were more knowledgeable (2 months: p=0.00001; 12 months: p=0.00001), self-confident (2 moths: p=0.046; 12 months: p=-0.026) and positive about the outcome of pharmacy counselling (2 months: p=0.022; 12 months: p=0.069) than the controls. 492 customers (224 intervention, 268 controls) were recruited. Assuming non-responders had lapsed, significantly more intervention subjects were not smoking at each follow up. The one-month point prevalence was 37% intervention and 29% controls (p=0.059); four months' continuous abstinence was achieved by 20% intervention and 13% controls (p=0.021); and nine months' continuous abstinence by 12% intervention and 7% controls (p=0.089). Conclusions: The intervention was associated with greater knowledge and confidence, increased and more useful counselling and higher smoking cessation rates, demonstrating that appropriately trained community pharmacy personnel have the potential to make a significant contribution to national smoking cessation targets.

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The overall aim of this thesis was to understand how new policies are reflected in national policy, and subsequently implemented. It suggests a fruitful way of analysing how policies fare is through exploring the notion of policy transfer - a complex process, mediated by different groups of actors. The focus for this study was on one particular policy: that of integrating management of HIV and sexually transmitted diseases (STD) with primary health care (PHC) services. During the 1990s, after clinical trials showing that HIV transmission could be slowed if STDs were controlled at the PHC level, the international community strongly promoted the idea that management of HIV and STDs should be integrated into PHC services. This thesis explores the trajectory of this impetus: from policy development at international level, to the response at national level. It suggests that integration of these services was driven by strong leadership from women's groups and international donors. New technologies, such as syndromic management of STDs, were perceived to be one of the ways in which integration could be introduced at the primary level. However, reviewing such experience that exists, shows that the enthusiasm for integration of HIV/STDs with PHC services was soon tempered as limited political, financial and technical resources hindered effective implementation. The study argues that limited political interest in integration was due partly to the fact that some countries were characterised by a relatively coercive relationship between external funders and national policy makers. This meant that efforts to introduce policy reforms were not strongly supported by governments, through allocation of financial or other resources, and donors were forced to spend according to their own priorities. Thus while there was agreement at national levels to policies, in fact, at sub-national levels implementation was weak. The thesis then goes on to explore South Africa's experience, which provides a contrast to the experience of many other African countries. Relatively isolated from international discourse until the early to mid 1990s, South Africa developed its own policies on integration, reflecting many of the same concerns and interests of the international community, but generating such concern from within the country, rather than having it imposed from outside. The thesis analyses developments in policy in the country, from agenda setting to policy formulation, and then looks at what happened during implementation in the Northern Province, one of the poorest parts of South Africa, and more akin to its northern neighbours than other areas. It shows that policies were developed in a context of radical and rapid political and economic change and, as a result, national policy makers sometimes failed to take account of impediments to implementation at sub-national levels, or of the constraints to service delivery. The thesis concludes by expanding on an analytical framework for policy which incorporates the notion of policy transfer, as a necessary adjunct to understanding how policies are formulated and implemented. It suggests that where international agendas are not reflected in national policy discourse, they are less likely to be fully absorbed or implemented. However, even where policies are transferred between national and sub-national levels, problems remain with implementation which need to be addressed.

Background. The trafficking of women and adolescents into exploitative and forced labour is a growing crime and a severe form of violence against women. Little theory or research-based evidence currently exists on the health risks and consequences associated with trafficking. Objectives. This thesis presents conceptual models and describes systematically collected data on the health risks and consequences of trafficked women and adolescents, and considers methodological implications of research with this vulnerable group. Methods. Two studies, one qualitative and one quantitative, were conducted with women trafficked predominantly for sexual exploitation. The formative research exploring trafficking-related health risks was carried out in five European states with a total of 28 women. The quantitative survey was conducted with a cohort of 207 attending post-trafficking services in seven European States. Semi-structured interviews were carried out over three time periods (0-14 days, 28-56 days and 90+ days) to document reported pre-trafficking and trafficking-related risk exposures and post-trafficking physical, sexual, reproductive and mental health symptoms. Results. Risk exposures included high levels of pre-departure and in-trafficking violence (physical and/or sexual). Perceived physical health symptoms were prevalent, especially at the first interview, with neurological symptoms (e.g., headaches) being the most prevalent and persistent. Most physical symptoms reduced between the first and second interviews. Symptoms suggestive of post-traumatic stress disorder were reported over the three interviews by 56%,12% and 7% of women, respectively. Depression levels remained extremely high throughout the study. Anxiety and hostility levels were also high, but decreased more than depression. Conclusions. These descriptive analyses offer theoretical models and new evidence on risk and health symptom patterns. Findings suggest the need for urgent and longterm comprehensive health care services, an adequate legal period of recovery and reflection, and research methods sensitive to the risks associated with studying this vulnerable population.

The potential for chemoprevention of breast cancer depends on the benefits being achieved at reasonable cost. This study assesses the economics of chemoprevention of breast cancer with tamoxifen within the context of the International Breast Cancer Intervention Study (IBIS) and published data on outcomes. Anonymised trial data are used to measure direct resource costs based on the pattern of service delivery in the IBIS clinics. Changes in morbidity are measured as the differences in use of resources for hospital visits, procedures undertaken in hospital, use of prescribed medications and visits to GPs between women in the 2 arms of IBIS. Changes in quality of life are assessed using the SF 36. Information on the personal costs to the women themselves was gained through a postal questionnaire. A sensitivity analysis assesses the effects on cost effectiveness of alternative assumptions about the duration of the protective effect of tamoxifen (5,10 or 15 years) beyond the treatment period. Other alternative assumptions explored include different models of service delivery, differences in personal costs to the women themselves and in their risk status. Tamoxifen chemoprophylaxis for breast cancer has a cost of less than £5000 per discounted life year gained for women at high risk for the disease assuming that the protective effect persists for at least 10 years. This result is sensitive to the risk status of the women since the number needed to treat (NNT) would be high for women at low absolute risk of breast cancer. The model of service delivery is also important. No significant differences in morbidity between the groups were found. Hospital visits for benign breast disease or gynaecological symptoms and the use of beta blockers may merit further investigation. There appear to be no effects on quality of life. Chemoprevention of breast cancer could be delivered through general practice with minimal specialist support. The potential may be limited because of the need to target women at high risk in order to make efficient use of resources for this common condition.

Malaria is the principal cause of morbidity and mortality in Mozambique, accounting for more than 40% of the attendance in the public health clinics. Insecticide-treated bednets; (ITNs) have proved to be a cost-effective means of preventing of malaria. Most previous ITN projects have been implemented in pilots or trials and with substantial financial, human and technical resources. Presently however, in many African countries services can no longer be provided "free" (at no charge to users). There is still a lack of knowledge of how financially sustainable and equitable a cost-sharing ITN programme implemented through the primary health care system would be. In Mozambique no ITNs were available, and very few households had bednets before the start of this study. Thus before introducing an ITN programme in Mozambique, it was important to evaluate whether the primary health care system could deliver ITNs, and to determine how sustainable and equitable such a programme would be. The study which forms the basis for this thesis took place in Boane, Mozambique from, 1996 to 1998. The aim of the study was to determine how financially sustainable and equitable an ITN programme could be when implemented through the primary health care system, and how the socio-economic level of the community would affect such a programme. Bednets were treated with Lambdacyalothrin and sold at the health centre at price equal to the factory's wholesale price. The willingness to pay of the households, the ITN coverage which was achieved, the total cost of implementing the project, and the financial resources which would be required to implement a national ITN programme in Mozambique were calculated. The main findings of the study were as follows: - The Boane community accepted the ITNs very well. However, the purchase of ITNs was dependent on the socio-economic level of the buyer; poor households were less likely to buy than richer households (p<0.001). Thus, there was not an equitable distribution of ITNs in the community. - Many households whose stated maximum willingness to pay before the project was less than US$5 actually did pay that amount for an ITN during the project. Thus, willingness to pay was not a reliable way of predicting the households' probable purchase of ITNs. - The estimate of the cost of the project demonstrated that the financial cost per ITN delivered ($9.60) was much higher than the price at which the ITNs were sold to the consumers ($5 on average). Thus, the project was not financially sustainable. Moreover, given the cost structure covering a larger area or achieving wider coverage would have required an even higher level of subsidy. - In order to guarantee an equitable national ITN programme through the public health system in Mozambique, the govermnent will have to mobilise external donors to fmance the ITN programme. This study contributes to an understanding of the implications of how the price of ITNs affects the financial sustainability, equity and coverage of the programme, and makes recommendations for obtaining the funds required to heavily subsidise ITN programmes in Mozambique in particular, and in Sub-Saharan Africa in general.