This thesis evaluates medical pluralism in central Mexico during the early colonial period, surveying the medical landscape to recognise spaces for and evidence of, medical assimilation and exchange between Spanish, Indian and Black populations. Recognising that medicine during this period was a combination of science, religion and superstition, it explores the dynamic between licensed and unlicensed medicine, evaluating the ways in which they served and were served by mixed colonial populations. The domain of the curandero is re-evaluated in order to better understand what the role and status of such practitioners were, and what the term actually meant to colonial people. Surveying colonial medicine within the context of the attempted imposition of medical structures from mainland Spain, this study demonstrates the ways in which -despite the disenfranchisement of large sectors of colonial society - the huge diversity of personal and cultural preferences coupled with the profound significance attached to healthcare, saw all people, slaves included, able to exert agency in their own healthcare. In short this is an interpretive historical study of medicine in Mexico, combining archival evidence with a wide variety of primary and secondary sources, applied to understand the medical meeting of all colonial peoples, including Blacks, during the early colonial period, which has, to date, been underesearched.

Over the past decades, the Internet and online support groups have had a positive effect on the way people with various health conditions manage their health. The present thesis aimed to explore the role of online support groups on patient empowerment for Individuals living with HIV/AIDS. Four empirical studies have been conducted to answer the research question. The first study aimed to examine the processes through which online support groups might empower Individuals living with HIV/AIDS. A total of 1,162 messages were selected from HIV/AIDS online support groups and analysed using a hybrid approach of inductive-deductive thematic analysis. The second study aimed to explore the empowering processes and outcomes of HIV/AIDS online support group participation from the participants' perspective. A total of 115 HIV+ online support group users were recruited for the present study and were asked to complete an online survey which contained questions about their experiences of and views towards online support group participation. The third and fourth study aimed to explore how different levels of participation In online support groups might be associated with empowering processes and outcomes, and the mechanisms through which participation In online support groups might promote patient empowerment for Individuals living with HIV/AIDS. A total of 340 online support group users living with HIV/AIDS were recruited and were asked to complete an online questionnaire consisting of measures on empowering processes, self care self efficacy, loneliness, optimism, coping, depression, and health-related quality of life. Overall, results suggest that online support participation might offer some benefits for those living with HIV/AIDS. Also, lurking In the online support groups may be as empowering as reading and posting messages to the groups. More research Is needed to Identify the long term effects of online support group use for Individuals living with HIV/AIDS.

To meet a government target (OH 2005a), NHS Primary Care Trusts are required to reduce hospital usage and care home residents have been identified as a group whose admissions may be avoidable. Yet little is known about hospital admissions from care homes as few UK studies have been published. This mixed method study identified factors that led residents to be admitted to hospital as emergencies and unlike previous studies included the perspectives of residents. As the outcome of the research is to inform a local resident-centred hospital admission avoidance strategy their views are important. The research comprised three parts. The first analysed Hospital Episode Statistics data for all admissions from the ten care homes located within a PCT, between 2003 and 2005. This provided an overview and found admissions varied between homes and over time and infections were the most common admission diagnosis. The second part was case stUdies that examined the 19 admissions from a 35 bed local nursing home during 2006. Most residents had dementia and nine died in hospital and three soon afterwards. The final part comprised semi-structured interviews with 13 residents from four local nursing homes following recent hospital admissions to obtain their views on hospital admission and care. Most considered their admissions unavoidable and most expressed high levels of satisfaction with hospital care, but it is nursing home care they valued most. The four nursing home managers were interviewed about each of these admissions to confirm the details and give their opinion on the appropriateness of the admissions. This study found that GPs appear to be responsible for most admissions and although there is potential to reduce admissions, residents continue to need and benefit from care that is only available in an acute setting. The results indicate that new models of care are needed to reduce avoidable admissions and provide better end of life care in care homes. A 'Home for Life' nursing home care model is advocated as a means of achieving both.

This thesis plots my development as a nurse specialist in spasticity management, a relatively new specialism that has not previously been researched. To address this gap in nursing knowledge this thesis demonstrates how guided reflection developed my individual professional knowledge and how this informed knowledge about nursing and caring when working with people with spasticity and complex disabilities. I utilised a novel narrative methodology which combined my clinical and research practice. As an organising structure to research and gain insight into my practice I used the six layers of dialogue (Johns 2006). Through this process I explored my experiences by constructing story texts, then reflective texts, culminating in a narrative. Creating story text involved exploring my experiences through regularly journaling. Using a reflective model I developed the texts and dialogued with other sources of knowing such as literature and art forms. To further extend the text and revea\ aspects 01 se\f that were previously unexplored I would share it with my supervisor(s) and others. To construct the narrative text I assimilated 29 reflective texts into a coherent whole, which represents my unfolding journey, of being and becoming a reflective practitioner. This reflexive journey has changed my perceptions of situations and my practice approach. Significantly I describe that a person with complex disabilities lives in a precarious harmony; a matrix of highly refined strategies, unique to each person and their family, which allows them to effectively function as a family unit. It can be a fragile state, easily disrupted through life events, health and social care practices. Implications for practice include that appreciating a person's precarious harmony, is vital to working in relation and towards a therapeutic alliance. Equally, not acknowledging and working with a person's precarious harmony will limit the uptake and ongoing use of novel technologies. I summarise my practice approach, as the need to sculpt the practice space, tune into the other's wavelength to understand, connect with and flow towards maintaining and improving the balance of the person's precarious harmony.

Background. Low back pain (LBP) is a common and frequently recurrent problem, responsible for substantial costs associated with health care utilisation and work absence. Numerous guidelines for the management of non-specific LBP provide broadly similar recommendations. The attitudes and beliefs that health care practitioners (HCPs) hold may be one barrier to the uptake of guideline recommendations. In the UK, most patients seeking healthcare for LBP consult general practitioners (GPs) or physiotherapists (PTs), but there is little research into the attitudes, beliefs and clinical behaviour of these HCPs. Methods. A systematic review was conducted to identify a suitable attitudes and beliefs tool for inclusion in a survey questionnaire. A nationwide cross-sectional survey of GPs and PTs followed. Further studies established the test retest reliability and the smallest detectable change, and explored the factor structure of the chosen attitudes and beliefs measure in UK GPs and PTs. Results. The systematic review identified five tools of which the Pain Attitudes and Beliefs Scale (PABS. PT) was most suitable for inclusion in the questionnaire. The cross-sectional survey showed that the attitudes, beliefs and behaviour of UK HCPs are diverse. There is generally inadequate uptake of guideline recommendations, especially concerning work advice. HCPs' attitudes and beliefs were associated with clinical behaviour. Those with stronger biomedical treatment orientations were less likely to provide guideline consistent advice compared to those with stronger behavioural treatment orientations. The PABS. PT demonstrated satisfactory reliability and the smallest detectable change was calculated. A two-factor structure for the PABS. PT was proposed in both GPs and PTs, which consisted of a robust biomedical factor and a behavioural factor with unsatisfactory internal consistency. Conclusion. The clinical behaviour of GPs and PTs in the UK often diverges from best practice guideline recommendations and the attitudes and beliefs that HCPs hold about LBP are associated with this.

This study explores Jordanian health professionals' and family members' attitudes towards FWR in adult critical care settings. Leininger's cultural care theory was used as a theoretical framework for this study. The study was conducted in six hospitals in two major Jordanian cities. A purposive sample of 31 health professionals from several disciplines who had experience in critical care units in Jordanian hospitals, and 5 family members, who had experience of having a resuscitated relative, was recruited over a period of six months. An individual semi-structured interview was utilised as the main data collection method in this study. The study findings revealed three main categories: the health professionals' concerns regarding FWR, whether health professionals allow families to witness CPR or not, and hearing the voice of family members. Health professionals' concerns included concerns regarding the impact ofFWR on the CPR team members, such as increasing the level of stress, concerning ofbeing attacked, fearing that they would be distracted when working, and concern regarding litigation. In the second category, the novelty of this subject to Jordanian health professionals contributes to raising such factors that might atTect professionals' attitudes, such as the impact of culture and religion. To implement this issue in Jordan, health professionals suggested improving health professionals' knowledge and skills, preparing family members by providing good education and enough support, and focusing on organisational factors such as guidelines and the state of the resuscitation room Three themes were raised under the third category: the role of family members during CPR, families' needs, and barriers to allowing FWR. Families' needs for information and proximity were their main needs during CPR. Generally, most of the healthcare professionals were against FWR. They raised several concerns as a result of allowing this practice. Some of these concerns were raised in the existing literature. However, using a qualitative design helped in producing more details and explanations about these concerns. The findings of this study show that fear of litigation as a result of allowing FWR is influenced by presence of an etTective legal system. It was found that most of the professionals underplayed the importance of litigation in the practice of FWR, as they have not effective medical law. This study shows that most of the participants have concerns of being verbally and physically attacked if they allow FWR. This is a unique and original theme that was emerged in this study. The [mdings of this study parallel [mdings of many studies that FWR is traumatic for family members. Despite this consistency, my research explains that healthcare professionals particularly worried about allowing highly emotional people from attending CPR. In contrast to the findings of several studies, my research asserts that patient's privacy and confidentiality are not invaded in case of allowing the close relatives to witness their loved one's CPR. Despite the several concerns that were raised, many professionals stated that FWR has several advantages. Uniquely, this study shows that FWR gives family members the opportunity to practice their religious and cultural beliefs. This was viewed beneficial by most of the healthcare professionals. The findings of this study show that any FWR should consider the specific cultural and religious dimensions. Despite the necessity of considering these dimensions, this study shows that the influence of these dimensions was perhaps not as significant as it might first appear. More importantly, the key issue to improve people's attitudes toward FWR is simply the need for education and improving awareness. This study includes several suggestions to facilitate FWR such as the importance of education and presence of supporting staff. To implement FWR, it is essential to consider the available resources, as FWR requires extra staff and a well-prepared environment. All interviewed family members wanted the option to stay beside their loved one during CPR. Distinctively, most of family members want this option for some religious and cultural reasons such as praying and supplicating to support their loved one. All family members expressed several needs at time of CPR. The need for information about patient's condition was the most important need. Updating family members about patient's condition would reduce their tension and improve their acceptance for the end result of CPR. This study emphasizes the importance of considering the cultural and religious dimensions in any FWR programs. The study recommends that family members of resuscitated patients should be treated properly by good communication and involving them in the treatment process. The implications concentrate on producing specific guidelines for allowing FWR in the Jordanian context.

No description available.

This thesis aims to investigate new functions for ciliopathy proteins and identify candidates for therapeutic application. The ciliopathies form a class of genetic diseases whose aetiology lies in the primary cilium. Over 30 genes have been identified as mutant in ciliopathies and their proteins localise at the primary cilium. When mutated they can cause kidney disease, obesity, polydactyly, and retinal degeneration. In this project, I have studied craniofacial dysmorphology related to Bardet-Biedl syndrome (BBS) in humans, mice, and zebrafish, and shown there to be consistent midfacial flattening and hypoplasia. Bbs8, a causative gene of BBS, has a key role in neural crest migration and possibly in cell migration in general. This accounts for the frequent observation of Hirschsprung’s disease, a gut immotility disorder, in BBS. I identified new roles for BBS and other ciliopathy proteins in Sonic hedgehog (Shh) signal transduction and showed that they are important in the downstream processing of the transcription factor Gli3. I modelled ten different ciliopathy genes in the zebrafish and identified specific ciliary phenotypes, such as laterality randomisation, otic vesicle anomalies, and kidney cysts. Administration of two drugs, Rapamycin and Roscovitine, were sufficient to rescue formation of kidney cysts and restore the filterative capacity of the kidney. This paves the way for studies in mouse models and, ultimately, in humans, where no treatment for ciliopathic renal disease exists. I examined whether FTO, a gene associated with obesity in the general population, functioned in ciliary processes. I provided some evidence that its protein was involved ciliary processes and glucose homeostasis. I also showed that fto interacted with its neighbouring ciliary gene, ftm, in the zebrafish. I performed similar interaction studies to show that a non-synonomous SNP in a gene associated with lipid accumulation in C. elegans had deleterious effects on protein function, explaining its high degree of association in BBS patients.

This study concerns carers and their expectations of their spouses' functional recovery and the burden of caring post stroke. Many studies have demonstrated that carers experience high levels of burden and psychological distress 12 months past stroke. However, to date carers' expectations and the potential drivers of these expectations have not been explored. Furthermore, the evidence indicates that the focus of the support provided by professionals has been on the person that has had the stroke rather than on the carer. Previous research has also not explored reasons for variation in depressed mood, although the fact that not all carers become depressed or overburdened would suggest that some carers are less susceptible to depressed mood than others. There are two main themes in this research: to establish the potential predictors of carers' expectations; and to examine whether carer expectations of their spouses' functional recovery and carer burden acted as potential drivers for level of carer's depressed mood 12 months post stroke. Analysis of the study's findings demonstrated that carers' expectations of their spouses' recovery were mainly driven by the current functional ability and quality of life of their spouses. Carer expectations of burden were also partly influenced by their spouses' current abilities but carers' dispositional optimism and depressed mood played an additional role here. The results of this study also indicated that carer's psychological wellbeing at 12 months post stroke was not in fact influenced by their expectations of their spouses recovery but rather by their expectations of burden in terms of their level of depression, anxiety and negativity. Moreover, multivariate analysis indicated that unmet expectations of burden also contributed towards carer's depressed mood and negative affect at 12 months post stroke. Interestingly, over time carers' mood was shown to improve where mean levels of depressed and anxious mood dropped. Despite these positive changes in carer's mood some carers' became less optimistic over time and support the finding of other studies that this construct is perhaps not as stable as previously thought. Further examination of carers' psychological wellbeing at 12 months post stroke demonstrated that their level of depressed mood, negative affectivity and anxiety were to some extent predicted by gender, dispositional optimism, expectation of burden and current mood status measured in the acute phase of stroke. To conclude some carers in this study were shown to have raised revels of depressed mood and anxiety levels. The findings suggest that carers' depressed and anxious mood at 12 months post stroke is predominantly influenced by baseline (i.e. acute phase of stoke) mood and dispositional optimism and also to some extent predicted by their baseline expectation of burden. There results suggest that carers who are depressed in the acute phase and who have high expectations of burden are at a higher risk of being depressed at 12 months post stroke. It could therefore be argued that it is particularly this group of carers who could benefit from early psychological intervention.

The purpose of the thesis is to illuminate the meaning of quality nursing care in the three major inpatient cancer care centres in Cyprus as seen from the standpoint of patients with cancer, patients' advocates and nurses. The data are based on: a) interviews (narratives) with 25 patients with cancer and two focus groups b) a focus group with patients' advocates and c) interviews with 20 nurses working in the cancer care departments. . . The rational for this study echoed a conceptualisation problem among patients, nurses and patients' advocates in relation to quality nursing care. The different interpretations held by the informants around this issue often creates problems of communication and understanding between nurse-patients and between nurses-patients' advocates. It also prevents a commonly shared concept to be adopted in the clinical setting. In order to investigate this issue, a philosophical approach was adopted based on the philosophy of Paul Ricoeur and using the "lived experiences" of the informants as the basis of the investigation. The data were analysed using a hermeneutic phenomenological approach based on Ricoeur's interpretation theory but modified to suit the nursing paradigm. What stands out from the study is the overlapping of the patients', patients' advocates and the nurses' experiences of quality nursing care. Based on the attributes that the informants have used to interpret the concept of quality nursing care, a shared understanding of the concept materialised. This shared understanding formed the basis for developing a theory of quality nursing care. Simultaneously, the study reinforced the importance of "getting the basics right" for providing quality nursing care to patients with cancer. Based on the informants' lived experiences a set of guidelines of best practice were developed, as a means for influencing nursing practice.