This thesis explores the effects of an innovation aimed at improving Greek primary school pupil's critical thinking on television food advertising and food choices in the context of the declining Mediterranean diet. In a review of the literature, some research demonstrated the effects of TV advertising on children while according to other studies, these effects remained doubtful. Findings were even hazier where food products were concerned. It is possible to sum up the problem as follows: whether sitting in front of the TV makes one eating snacks or eating snacks make one sit in front of the TV. Keeping in mind however, the social context in which Cretan children grow (highly touristic region, TV, working parents, more money) as well as the weaknesses of some of the above mentioned studies (small time span, laboratory settings), this thesis takes the position that advertising does playa part in this changing diet. Although there is no way to measure its exact effect on children, this position is strengthened by the fact that companies keep spending substantial amounts of money on advertising. Unfortunately the difficulty of establishing a causal connection between children's diet and television adverts affects in turn advertising regulations, which depend on the will of each particular country. It also affects the provision of consumer education in schools which is very limited. The study took place in Crete. which was selected mainly because of the researcher's origin and because of the undergoing change in the Cretan diet. During the last decades. the traditional Cretan/Mediterranean diet has shifted towards Western nutritional habits. This issue is largely ignored by the Greek educational system where teaching is fairly didactic and there are very few courses on health and none that relate to the media. Most of these are conducted on a pilot basis and are based on the commitment of individual teachers. The strengths of this research design were first that it took place in the pupil's natural environment and secondly that the education course was designed specifically for the Greek schoolchildren. The total number of children participating in this study was 190 (82 in the control and 108 in the experimental group). These children belonged to five primary schools of Iraklion city. which ranged from middle to working class and from deprived to affluent areas of the city. Data collection included a variety of tools such as questionnaires, interviews with each child, dietary records (completed by parents). classroom observations, children's work, and researcher diary. Data was collected at the start of fieldwork (baseline) after the end of the course (post intervention) and approximately 10 months after the end of fieldwork. The findings of this thesis demonstrate firstly the large differences among the four experimental teacher's teaching style. Although they had all been volunteers and expressed an interest in the programme, and had been informed and provided with the course material, only two were able to successfully implement the course. In the other two classes, the researcher felt obliged to intervene in order to substitute for teacher inadequacy, and to ensure that the pupils received an adequate course. The findings also showed that pupils and teachers were appreciative to progressive pedagogy and did not hesitate to criticize the didacticism of the Greek educational system. Although originally designed within a positivistic framework the researcher found herself increasingly drawn into the action frame of the implementation. This led in turn to participant observation, changes to the research design and new inSights for the researcher. The researcher'S personal change was another dimension of this study's findings as she learned to allow more space to her participants. Finally, the findings confirmed that children's dietary behaviour is not likely to change when addressed simply through a school based intervention. Pupil's critical thinking, though, was enhanced and it must be hoped that it will give the children the power to decide themselves the kinds of foods they wish to consume

The prevalence of Type 2 diabetes mellitus is increasing worldwide and with it, the demands on heath service resources. As the long-term outcomes of this disease are dependent upon reducing lifestyle risk factors, together with effective treatment and screening strategies, much of the responsibility for diabetes management ultimately resides with the patient. Therefore patient education is a key part of the care of this population. A trial of an empowerment based health education programme was underpinned by the theories associated with health protective behaviour and those associated with adult learning. These align patient education to an experiential learning process within which beliefs about self-efficacy and the effects of social-environmental influences are central to outcomes. This view was compatible with current health care policies which see patients taking a more active and informed role in their disease management. The trial utilised a randomised controlled wait-list design to allow for the ethical limitations of excluding patients from educational treatment, and permitted collection of data over a short- and long-term period. A qualitative approach to data collection, using symbolic interactionism, was also integrated into the clinical trial. The two types of data were treated as complementary so that the outcomes of the trial relied upon detailed exploration of how they complemented each other. Eighty-nine patients were recruited from three diabetes centres. All patients recruited were blindly randomised to a 'Look After Yourself education programme. Clinical, behavioural and psychological outcomes were measured at six and twelve months. The relationship between these, the content of the intervention and participants' perspectives was assessed through ten focus group interviews. The combined results showed that the educational intervention had modified participants' personal models of diabetes by increasing their knowledge and understanding, by clarifying their beliefs and by changing their attitudes toward the disease and its management. It facilitated the acquisition of skills and prompted movement into the behaviour change cycle for the majority of those taking part, regardless of socio-economic status. The impact of these changes upon clinical outcomes was most effective where participants perceived their risk factors to be greatest. These findings supported the production of a framework for guiding nursing intervention to enhance patient self-management of diabetes. To adhere to such a model of care, however, the trial highlighted the need to expand the biomedical orientation to patient education so that it allows for patients' self-perceived needs. This demands integration of the medical and behavioural sciences into the practice of diabetes care and recognition of the need to support patients in their lifelong task of maintaining their own health. It recognises that care for chronic illness is an inherently different social enterprise than is care for acute illness. The findings have therefore highlighted the training needs for health professionals so that they can develop the skills that can enhance this process. Whilst these conclusions acknowledge the importance of continuing education and support for patients, such clinical practice will rely upon tailoring nursing intervention to the outcomes of a diabetes-specific assessment instrument. In this way, educational referral can become an integral part of a patient's treatment profile. Only then might health professionals authenticate a culture that supports patient choice so that they can take greater control over their health.

This dissertation for the Degree of Doctor of Psychology (Health) presents three pieces of work: 1) A Re-analysis of a Systematic Review of Psychological Interventions Used to Aid Smoking Cessation; 2) Evaluation and Discourse Analysis of the EC's Health Promotion Programme; 3) A consultancy case study: Evaluation of Educational Needs Assessment Methods Used in General Practices in Barking and Havering and Redbridge and Waltham Forest. The theme that ties these three pieces of work together is evaluation. The re-analysis of the systematic review of psychological methods for smoking cessation shows how errors can be made in evaluation and how different researchers can obtain different results in what is considered to be a method that reduces bias and produces an accurate picture of `evidence' to inform health policy and practice. The evaluation of the EC's Health Promotion Programme gives insight into a case study of an evaluation to inform health promotion policy at an European level. This piece of work presents the results of an independent evaluation. It highlights unexpected difficulties of drawing conclusions from data such as the practical problems of obtaining data and also the pressures that may come from the commissioners of evaluations. The discourse analysis of the Health Promotion Programme reveals how current discourses in health promotion may compel health promotion practitioners to carry out a certain type of evaluation in which in truth they may have little understanding or commitment. As a result, the practice of evaluation becomes a formality or ritual which is a burden to carry out. A panel of health promotion expert assessors found a lack of acceptable evaluation of projects that were funded by the European Commission. This suggests that if evaluation can be avoided, it will be. The same themes of lack of understanding, commitment and time for evaluation were unveiled in the case study. The consultancy case study evaluated educational needs assessment methods used in general practices. The use of evidence-based practice requires that practitioners understand how to evaluate research and incorporate it into their practice. This needs more emphasis in the education and training of health professionals. However there has been a move away from the more didactic approach to education in primary care to one of listening to people's needs and preferred methods of learning. At the same time the ubiquitous need to evaluate to find the best method prevails. This is regardless of obvious limitations to the interpretation of findings. In this case study, it seemed as though the evaluation was an after-thought, rushed to satisfy some other group higher up the hierarchy in the health authority. Similarly, the discourse analysis pointed to a situation in which the Commission's services are constructed as superior, thus leaving no mechanism to question their knowledge or ways of working. While there may be efforts on one level to encourage a two-way flow of information and knowledge, on another level, a construction of decision-makers as being superior means that information and knowledge only flow one way, top down. All three pieces of work have shown that practical limitations restrict the interpretation of evaluations. Lack of time, incomplete data, commitment and knowledge of evaluation revealed here lead to questions about the possibility and desirability of evidence-based health promotion. For evaluation to advance, there is a need for a better understanding of its purpose and for it to have more meaning for all of the stakeholders involved. This requires a rethink concerning evaluation methods in health promotion that recognise the restraints of evaluation and start inquiry from this premise.

Obesity, through a persistent positive energy and fat balance is of major public health significance due to its detrimental health, social and financial costs. Increasing physical activity levels through recreational exercise and decreasing energy intake have been implicated with obesity prevention. However, the addition of exercise to normally sedentary routines will only prevent positive energy balance if it is not tracked b a compensatory response in energy intake and non-exercise physical activity [also termed non-exercise activity thermogenesis (NEAT)]. The current series of studies set out to examine the quantitative and temporal relationship between exercise and energy balance with specific reference to appetite, energy intake and NEAT. These studies were designed using similar methodologies that could be compared and related to existing studies. The results showed that in younger motivated individuals, moderate-high intensity mandatory exercise increased daily energy expenditure leading to a marked negative energy balance. However for periods of up to two weeks, analysis of temporal trends revealed evidence of compensatory changes to re-establish energy balance (re-equilibrium phase). This re-equilibrium was a result of not only increases in energy intake, but also (and to a greater extent) decreases in NEAT. Inter-individual variability in the extent of compensation was evident and independent of age, sex, BMI and restraint status. Decreases in physical activity did not lead to a compensatory reduction in energy intake and lead to a marked positive energy balance. Using an exercise intervention, in line with government guidelines, in a group venerable to becoming obese showed that body mass was largely unaffected since overall energy expenditure was not significantly elevated, primarily due to a lack of motivation to reach the required exercise prescription. The results have public health significance in the formation of policy to increase physical activity in the population.

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Edward D. Goldberg, editor. / Includes bibliographies.