Acknowledging adolescent smoking as a current public health priority both in Wales and elsewhere, this thesis investigated the potential role of school smoking policies in moderating adolescent smoking behaviour. The study builds on a literature which suggests that certain characteristics of school smoking policies may be associated with lower adolescent smoking prevalence in schools, but which call for further research into policy contexts. Particularly, this builds on the work of Moore et al (2001) whose Wales-based study recommended the further investigation of policy contexts, particularly referring to policy content and enforcement. This study adopted a mixed-method approach in order to collect more rigorous data on school smoking policies than in many other studies to date. A teacher survey concerning school smoking policies was conducted in schools taking part in the 2001/2 Health Behaviour in School-aged Children (HBSC) study in Wales. Analysis of these data was used to inform interviews conducted with a local 'expert' on smoking policy in the same schools. Interview data were used to investigate key characteristics of smoking policies in schools. Indicator variables were then devised to discriminate between schools on the basis of these characteristics. These were analysed in association with pupil smoking prevalence data collected by HBSC. The multi- level analysis contradicted much of the existing smoking policy literature, discovering no significant association between any policy-level characteristics and pupil smoking. The study concludes that, by using more in- depth data than many other investigations, it has potentially highlighted that the effectiveness of smoking policies in moderating adolescent smoking may be over-stated in the literature or may have changed in recent years. Interview data revealed between-school variation in the prioritisation of smoking policy and the resulting extent to which policy and its enforcement promoted consistent no-smoking messages and suggested potential areas for future investigation and intervention

The research aimed to explore beliefs about influenza and influenza vaccination, and the social influences on decisions whether or not to accept the influenza vaccination in a sample of urban-dwelling Thai adults. It also aimed to test the effect of a Health Action Process Approach (HAPA)-based leaflet on influenza vaccination behaviours among these high-risk individuals, and to evaluate the impact of a HAPA-based leaflet on potential mediators of behavioural change. Additional aim was to examine the predictive utility of the HAPA model in relation to both intention and subsequent vaccination behaviour in a certain high risk group. Firstly, a qualitative study was carried out. In-depth interviews were conducted among 20 high-risk individuals who were either (i) aged 65 and over, or (ii) under 65 years with chronic diseases that had clinical indications requiring influenza vaccination. Findings indicate that most participants had insufficient knowledge about influenza and influenza vaccination. Their decisions whether or not to get vaccinated against influenza were based on a number of factors, including salience of risk, influence of others, perception of the need for preventive health care, and the availability of influenza vaccine. Secondly, a controlled before and after trial was conducted. Participants in the intervention (n = 99) received a HAPA-based leaflet and asking them to form an action plan identifying where, when and how they would seek vaccination. Those in the comparison condition (n = 102) received a standard government information leaflet. The HAPA intervention resulted in greater changes on measures of risk perception, outcome expectancies, self-efficacy, and intention than the comparison condition. No significant difference in vaccination rates was observed between two groups. Influenza vaccination was directly predicted by self-efficacy and intention.

Since 2000 there have been a number of policy changes in the UK to remove barriers that limit access to medicines. Perhaps the most significant of these have been the phased reduction and abolition of the prescription charge in Wales and the efforts of the UK Government to encourage the reclassification of medicines. This thesis explored aspects of both these changes. The percent change in the number of prescription items dispensed over the two year period before and after the first reduction of the prescription charge in October 2004 was determined. There was an increase in the percent change median interquartile range for non-sedating antihistamines 7.3 5.0 - 10.7 to 13.7 10.9 - 17.1, p=0.001 and laxatives 2.2 0.8 - 3.1 to 3.7 1.4 - 6.4, p=0.04, whilst no change was observed for loperamide -1.2 -3.3 - 3.2 to 2.6 -0.9 - 5.2, p 0.11 and fluconazole -7.4 -14.4 - 2.1 to -3.7 -10.9 - 1.4, p=0.52. Over the counter OTC sales of omeprazole and simvastatin were monitored following reclassification and accounted for less than 1 of the volume of their prescription counterpart. In contrast, sales of OTC hyoscine butylbromide and chloramphenicol eye drops were more than 20 of the number of items dispensed. Twelve months after reclassification there was an increase in the percent change in the number of prescription items dispensed for hyoscine butylbromide in Wales 5.8 0.2 - 12.6 to 20.7 4.4 - 25.6, p=0.007, whilst prescriptions for chloramphenicol eye drops decreased 10.0 6.0 - 13.6 to -8.9 -13.1 - -4.4, p=0.001. More OTC chloramphenicol was sold in less deprived areas r=-0.44, p=0.04. The changes in prescription volume and OTC medicine sales varied from medicine to medicine and require a qualitative evaluation to better understand the reasons behind the differences observed.

By exploring both lay and professional perspectives on 'healthy eating', this thesis aims to identify the socio-cultural processes which are relevant to understanding the potential for general practice as a setting for providing 'healthy eating advice'. Lay views of 'healthy eating' were explored in relation to their everyday lives, so that their views on advice provided in the general practice setting could be understood within this broader context. For the general practitioners, the focus was upon their professional views of healthy eating work, how this related to their personal views on food and eating, and how this may influence any advice they do provide. Analysis of the lay interviews revealed that lay concepts of 'healthy eating' are deeply embedded within everyday understandings of health and subsequently 'health' is only one priority that explains why people eat what they do on a day to day basis. The lay respondents also distanced themselves from different types of 'healthy eating advice', by evaluating it in relation to 'common-sense' understandings of the relationship between food and health. But although a distancing process was also applied to evaluating the general practitioner's role in this area, they questioned the legitimacy of 'healthy eating' as a discussion topic because they felt that a GP's role was to treat illness. The analysis of the interviews with general practitioners revealed they also drew upon certain models of general practice to evaluate the potential of the setting for providing 'healthy eating advice'. Their accounts revealed contrasting enthusiasm towards preventive work more generally. It was apparent that these models appeared to influence how these general practitioners talked about what preventive work their profession should be undertaking. However, these models also appeared to influence how they talked about their own experiences of the 'healthy eating advice' they did provide.

This thesis is concerned with the investigation of disease patterns at the intermediate or regional level, in relation to the existing framework provided by a number of recent surveys of disease mortality at the national scale. The latter had drawn attention to the particularly poor disease experience of County Durham in relation to the rest of the United Kingdom. A number of previously unmapped data sources, particularly in the case of morbidity, are investigated with the aid of some original cartographi's devices and data handling techniques, which are described in chapters two, three and eight. Chapter four is concerned with a geographical analysis of three consecutive epidemic cycles of measles during the period 1961-65. The epidemiological significance of living density in the determination of diffusion patterns is demonstrated, and atmospheric pollution is invoked as a possible aetiological factor in the initiation of epidemicity. Chapter five deals with a similar detailed study of the geographical distribution of tuberculosis, and particularly the respiratory form of the disease, in County Durham as a whole. The influence of density factors (particularly overcrowding) socio-economic status and housing conditions upon the disease pattern is investigated by means of multiple regression techniques. Chapter six provides a more detailed study of the relationship between housing and respiratory tuberculosis for three selected local authorities in south-central Tyneside. Chapter seven represents a by-product from the main lines of inquiry, and is concerned with the possible involvement of iron ore dust as an aetiological factor in the causation of certain ill-defined stomach disorders at Con sett during the winter of 1964.-65.Section III concludes the study with a preliminary survey of mortality patterns in County Durham, between 1963-6?, for the major causes of death. A number of .tentative conclusions are drawn from those distribution maps, but only where the evidence appears to be consistent with accepted medical theory. It should be noted that two poppers embodying the partial results of this investigation, and in particular chapters two and nine, have already been published.

Previous studies have shown considerable differences at both the population and individual levels in the timing of menopause and the experience of physical and emotional changes related to menopause (generally called symptoms). Attempts to understand this variation have not found a consistent pattern, suggesting that the existing approaches to the study of menopause may have failed to capture some of the complexity of the phenomenon. Previous research on British Pakistanis has not included in-depth study of menopause. The present study has sought to demonstrate that a biosocial research design can improve our understanding of the menopause transition both among British Pakistanis and more generally. This study used a range of methods including semi-structured questionnaire-based interviews and anthropometrics (n=257), life history interviews (n=19), and daily participant observation among middle-aged British Pakistani women in the Leeds/Bradford area of West Yorkshire. Statistical procedures were used on the quantitative data using SPSS 15; qualitative data were analysed using a thematic coding system and NVivo software. This study found that British Pakistani women of a higher occupational social class were more likely to experience hot flushes than women from lower social classes and women who perceive themselves to be of higher status were more likely to have an earlier menopause than their lower status counterparts. Women from the Choudhary Jatt biradari (a caste-related kinship group) were more likely to have a later menopause and were less likely to experience hot flushes than women from other biradaris. Levels of reported anxiety and acculturation were both positively associated with hot flush severity. Women reported a wide range of changes due to menopause and attributed changes to menopause that previous researchers considered to be unrelated to menopause. Attribution of symptoms to menopause was associated with menopausal status, age, and migration status. Women interpreted some items from a standard checklist in ways other than intended by the checklist‘s developers, based on local ideas about menopause. British Pakistani women‘s understandings and perceptions of menopause are intimately linked with their understandings of Islam, sexuality, menstruation, and ageing, as well as their ethnic identity and notions of purity and modesty. Social issues like acculturation, social support, kinship networks, class, and the history of tensions between Pakistanis and the wider society appear to be very important to consider in understanding menopause among British Pakistani women. Social issues such as these may play a role in influencing both the timing and the experience of menopause among women in other groups and thus should be considered in future studies.

Improvements in early detection and treatment of breast cancer and the reduction in mortality rates have led to an expansion in the numbers of patients accessing breast cancer follow-up clinics (Montgomery and Dixon 2008). This has resulted in a need to review follow-up services to address the current situation to the best effect (Burnet, Chapman, Wishart and Purushotham 2004). To meet the aims of the Cancer Plan (Department of Health (DOH) 2000) and more recently the Cancer Reform Strategy (DOH 2007) as well as the needs of the patients a reconfiguration and development of existing services at the study site was required. The primacy of the stakeholder's views was the driving force behind the research design. The research approach was used to involve the views of the patients, GPs, the clinical team and key people based in the NHS Trust. A focus group was used to identify the issues for patients and one-to-one interviews with GPs. These themes informed the patient and GP questionnaires. Key Informant interviews were conducted with members of the Multidisciplinary team (MDT) and key members of the clinical team. The study outlines the nature of breast cancer follow-up services and the complexities associated with a diagnosis of cancer. This is from both the psychological and physical perspective and the impact it has on patients. Key themes emerge from the data about the breast cancer service as it is delivered at present and the expectations and perceived value of breast cancer follow-up. The involvement of the patients as key stakeholders ensured that their voices were heard alongside those of both hospital and primary care staff. Themes from the questionnaires, focus group and key informant interviews concurred with each other. The need for reassurance that the cancer had been treated and participants were well was very important in breast cancer follow-up. Another important element was the continuity of care and the relationship with the MDT (multidisciplinary team). A good relationship instilled confidence in the patient's management rather than continual questioning requiring the same clinical information from the patient. Following a diagnosis of cancer and a period of uncertainty, confidence in the team was paramount. The vulnerability of the women was discussed, due to the sexual nature of the breast examination and the fear of recurrence caused women a lot of anxiety. Moreover the importance of the examination to the women was discussed and the importance of consistency in examination technique. Therefore communication between the MDT and the patients about treatment, health education and the opportunity for the women to talk and ask questions helped to reduce anxiety. All stakeholders discussed a model of shared care but aspects of patient management and resources would need to in place to ensure safe practice. GPs did highlight some disadvantages to hospital based follow-up such as long waits, travel and lack of continuity. There was also dispute between hospital clinicians about clinical expertise and the transfer of care to community services. This was also raised by GPs and an element of developmental work would need to develop in a new model of care. The patients wanted to be seen at hospital but were not averse to being seen in the community setting. To conclude the study findings concurred with the literature related to reassurance gained from attending follow-up clinics. However, NICE (2002) do not appear to take into account the views of the users and the importance of this element of multifaceted cancer care. As at the time of diagnosis of cancer there is time to make a decision, in follow-up there should be set junctures at which to discuss living and coping mechanisms. It may be at the end of cancer treatment some patients will require more follow-up than others. Follow-up may need to be individualised where some patients are discharged but others require more support thus moving away from the exact same follow-up programme for all as happens now.

This PhD project investigated the nature, occurrence , and consequences of alcohol and nicotine use during pregnancy. The main objective bieng to identify those at risk of continued alcohol and nicotine use, to determine the current practice of midwives in Grampian and to identify the consequences in terms of infants' and mothers' health. Study 1 aimed to provide an estimate of the prevalence of pregnant women drinking alcohol and smoking in Grampian, and to determine the best predictors of the behaviours. One hundred and thirty pregnant women took part in study 1. Thirty-five per cent of participants reported drinking during pregnancy. Parity, health locus of control and theory of planned behaviour variables distinguished between pregnant drinkers and abstainers. Seventy-four per cent of participants were non-smokers prior to becoming pregnant. Of the smokers, 47% continued to smoke during and 53% quit. Continued smokers differed from smokers who stopped for health locus of control and theory of planned behaviour constructs. Study 2 involved a questionnaire survey of midwives' knowledge, attitudes and practice regarding alcohol and nicotine use during pregnancy. Almost 30% of community midwives in this sample (n=17/52) reported not routinely asking their patients about their alcohol use and none reported using a screening questionnaire. Over 65% felt they still required training in supporting smoking cessationand over 86% still felt they required training in supporting pregnant patients to change drinking habits. The main barriers to providing advice were a lack of training and a lack of time. Midwives who drank more alcohol per week had more permissive attitudes towards alcohol use during pregnancy that were more permissive than the current government guidelines. Finally, study 3 aimed to take forward the results of study 1 and examine the potential consequences of alcohol use on newborn infants and new mothers. No significant differences were found for infants exposed to low-level alcohol use for a number of health outcomes. First-time mothers who drank during pregnancy reported spending a longer time in hospital after labour and, within all mothers who drank during pregnancy, lower attachment scores were reported at 3 months after birth, despite no significant differences in terms of health outcomes and mental well being. However, these findings are exploratory and factors other than drinking during pregnancy may be influential. The three studies together provide an insight into the incidence and determinants of alcohol and nicotine use during pregnancy and shed light on midwives' practice and barriers to providing advice to pregnant patients. The results yield strategies for intervention work and recommendations for practice and further research.

Background: Policies and guidance on the provision of mental health services to the diverse UK population acknowledge the need for therapists to be able to deliver psychological interventions in a culturally sensitive way to meet the needs of Black and Minority Ethnic groups. The requirements are highly relevant to Cognitive-Behavioural Therapists employed under the national Improving Access to Psychological Therapies programme which was introduced to address common mental health problems. Research rationale: Literature contains a wealth of material relevant to the cultural competency required of psychological practitioners, however writers have tended to focus on different facets of competency. A framework based on the guidance dispersed throughout the literature would serve as useful tool to investigate whether therapists emerging from IAPT training work in a way that is consistent with cultural competency practice guidance. A study could also explore how cultural competency, if evident, is acquired and how training contributes. Method: A narrative review of the literature was conducted to generate a thematic template that could be contrasted with the views and practices of therapists who had recently undergone IAPT training. Focus group interviews were conducted with participants at three IAPT services and the captured data was thematically analysed using Template Analysis whereby the themes from the review could be incorporated into the template used for the analysis. Findings: Participants demonstrated a range of perspectives and practices that were consistent with cultural competency guidance in the literature. Abilities were attributed to personal and professional experience, and to personal motivation to develop the capacity to work sensitively. Training was not considered to have significantly contributed to cultural competency and suggestions for how it may be improved were presented. It was concluded that it was possible for therapists to work in a culturally sensitive way without a comprehensive training based on cultural competency guidance, but that improvements for training could be drawn from the study.

This thesis examines the social and spatial distribution of perinatal mortality in Greater Leicester. The study area comprises the city of Leicester and the surrounding contiguous built up area. Following a discussion of the current status of relevant research in medical geography and perinatal epidemiology the three major data sources used here are described, these being the 1981 Population Census, the Leicestershire Perinatal Mortality Survey to 1982 and the Leicestershire Births records for 1980. The analysis commences with a classification of census enumeration districts into nine socio-economic 'clusters', reflecting demographic, economic and social differences within the study area. The new small areas created by this classification are then used as a basis for mapping census variables and describing the geography of Greater Leicester. In a detailed analysis of the perinatal and births data some 21 variables are found to be associated with adverse perinatal outcome. These describe physical, obstetric, socio-economic and health care characteristics of both mother and infant. Both statistical and cartographical methods are used to examine these in a spatial dimension. It is concluded that neither perinatal mortality nor the risk factors associated with it are uniformly distributed with respect to the 'at risk' population. Further data analysis shows how perinatal, births and census data may usefully be combined. Poisson probability maps are used to show the relative likelihood of perinatal death in different parts of the study area. The thesis concludes with a summary of the main results and some suggestions regarding directions for future research.