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Background. Low back pain (LBP) is a common and costly problem. In western society, huge resources have been directed at providing solutions to this problem, yet this ' investment has shown relatively little return. One possible avenue for reducing the societal impact ofLBP is through improving the quality of healthcare. In the UK, the three professional groups of chiropractic, osteopathy and musculoskeletal physiotherapy are involved in the management of 15-20% of all people with LBP, yet previous research suggests that many do not follow 'best practice' recommendations for LBP. Methods. The fIrst study ofthis thesis was an exploratory study, based on'a Grounded Theory approach, in which data were collected using focus groups. The primary aim ofthis study was to develop a theoretical model of factors that influ,ence the behaviour of individual chiropractors, osteopaths and musculoskeletal physiotherapists when caring for . patients with LBP. The second study ofthe thesis was a pragmatic randomisedcontrolled trial that was designed to test whether the reported behayiQur and beliefs of these practitioners would change if exposed to a passively disseminated, printed educational package, relating to the management ofLBP. The data from this trial were also used to evaluate whether the previously developed theoretical model predicted reported behaviour in representative groups ofthese practitioners. Results. The theoretical model formed from the exploratory study consisted primarily of three meta-themes: professional identity, occupational beliefs and clinical behaviour. In the trial, a small but signifIcant overall change in the intended direction in both reported behaviour and beliefs was measured in the intervention group, in response to the educational package. A cross-sectional analysis ofthe baseline trial data showed professional identity, as marked by professional grouping, to be associated with distinct prof11es of attitudes, beliefs and reported behaviour. Furthermore, beliefs were strongly associated with reported behaviour at baseline. Hence, a portion ofthe theoretical model was supported by these data. By contrast, further exploration ofthe trial data showed that professional identity did not predict baseline-to-follow-up changes in the key reported behaviours measured, and beliefs and reported behaviour did not always change in unison. Conclusion. Attitudes, beliefs and the professional identities ofthe healthcare practitioners studied in this thesis are related to their reported behaviour. Behaviour may be changed through exposure to written educational material but, when used in isolation, this change is likely to be small

Genetically predisposed breast cancer, commonly Breast Cancer 1 (BRCA1) . ·or Breast Cancer 2 (BRCA2), accounts for 5-10cro of the 41,000 women . diagnosed with breast cancer in the United Kingdom each year (Breast ~Cancer Care, 2006). The isolation of such genes has resulted in a - .-'perceived mora/responsibility for patients to access, disclose and disseminate information to family members who may be affected (Buller, 2000). This information can be difficult to interpret and poses complex questions of privacy, confi~entiality and discrimination for health care professionals when advising and supporting their patients. To address these questions, this thesis draws in particular on Gilligan's .(1982) research, which suggests that when women are faced with moral . conflicts, they typically focus on their caring commitments and responsibilities towards others (ethic of care), in contrast to men, who frequently adopt a jus+ice/rights oriented approach (ethic of justice). It is not claimed that either ·approach is exclusive to males or females, but that bioethics has traditionally paid little attention to notions of care. To, . address this omission, this thesis builds on the foundation of an ethic of care approach, but concludes that care considerations alone are .. inadequate. Instead, I argue for the integration of an ethic of care with a justice/rights perspective, enabling a fuller analysis of the issues identified. This eclectic approach is further supplemented by a feminist analysis of the traditional autonomy view prevalent within bioethics, .. replacing it with a relational understanding of this concept. This account .. acknowledges the effects of socialisation for individuals and the . «:urtailments to personal autonomy which can result. I argue that the use . of the ethic of care, justice/rights and relational autonomy approach leads to a bett~r understanding of the moral questions being asked. In . practical terms this facilitates a more collaborative approach between health care professionals and their patients, as the 'desires of others, their personal quirks and connections' (Porter, 1999 p.14) become known. This trans-disciplinary approach, in which medicine, nursing and genetics ~. I work collaboratively with the patient, can, I suggest, facilitate a more directive counselling approach which enables health care professionals to advise and support their.patients.

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Aim: To investigate the efficacy of transcutaneous electrical nerve stimulation (TENS) parameter combinations (defined in terms ofintensity, frequency and stimulation site) on experimental pain models in healthy humans. Methods: A systematic review ofthe literature was conducted. This served to inform th~ design ofthe primary studies, which investigated the simultaneous applications of TENS at two sites using different parameter combinations. Randomized, doubleblind, parallel-group, placebo-controlled trials were employed using repeated measurements ofpressure pain threshold. The sample size was defined so as to provide 80% statistical power, at a two-tailed 5% significance level, to detect a large effect (~ 0.08), comparing each parameter combination to both aplacebo group and a control group. Results: Systematic review evidence did not support the use ofcommonly applied TENS applications, such as 'Conventional TENS' and 'Acupuncture-like TENS'. Results ofthe primary studies results revealed, that the concurrent application (TENS at two sites) of such modes (Segmental 'Conventional TENS' and extrasegmental 'Acupuncture-likeTENS') does not achieve maximal hypoalgesia. In concurrent TENS applications, high-intensity TENS is required for maximal andprolonged bypoalgesic responses, along with different frequencies at ea.ch site. Furthermore, continuous stimulation is recommended, the alternating frequency pattern (3 seconds 4H.z13 seco,nds 110Hz) did not achieve optimal effects. Conclusions: Ineffective responses to TENS may be explained in part by inadequate TENS parameter applications. The results ofthese investigations further contribute to the evidence base concerning the hypoalgesic efficacy of this modality.

This thesis is focused on interferential therapy (IFT) protocols for pain relief and consists of four studies. The first is an experimental study investigating the hypoalgesic effects of different IFT parameter combinations upon pressure pain threshold (PPT) in healthy participants. The results of this study showed that active IFT delivered in specific combinations did not produce significantly different hypoalgesic effects compared to control and placebo groups. The second study assessed the inter-rater reliability of measuring PPT on healthy participants using seven newly-trained raters. The scope of this study was to inform the first experimental study of this thesis and to provide new evidence regarding the inter-rater reliability of measuring PPT using a hand-held algometer. The results showed that the inter-rater reliability of this tool and protocol among seven newly trained raters was good. The third study was a narrative review of the accessible published literature which can inform the practice of IFT in terms of protocol selection for the treatment of pain in the United Kingdom. The results of this study demonstrated that the existing journal-based published evidence on IFT protocol selection is limited and inconclusive and the nonjournal published literature appears to be poorly substantiated. Finally, the fourth study of this thesis described the use and application of IFT for pain relief in private physiotherapy practice in the United Kingdom using a questionnaire-based survey approach. The results of this study revealed that IFT is still a frequently used modality for pain relief in the UK, but its application appears to be empirically based. The collective outcome of this thesis challenges the role of IFT in pain management and suggests that further robust clinical research is required to demonstrate whether the use of IFT in pain management should be continued.

This study is designed to evaluate the effectiveness of using PU RASs(the Braden scale) on patients' outcomes in terms of PU incidence. The study aimed to examine the effects of RASs (the Braden scale) compared to the effects of PU training and nurses' clinical judgement on patients' outcomes in terms 6fPU incidence. A non-equivalent pretest posttest controlled groups designs were used and the data were gathered using an observational checklist, the Braden scale for PU risk assessment, and nurses' clinical judgement rating scale. 719 hospitalised patients at Riyadh Military Hospital in Saudi Arabia were selected from 9 Medical-Surgical wards and were divided into 3 groups (A, B and C). In Group A, nurses received training on the Braden scale; in Group B, nurses received PU training, ,and Group C was control. The Braden score of:s 18 was used as a cut off score to determine at risk patients. The Agency for Health Care Policy and Research (AHCPR) (1992) classification system was used to consider PU incidence. Data were collected by one tissue viability specialist and two researchers. The findings showed that 22.9% of the patients developed PU (stage one to stage four). The PU incidence was relatively similar between the study groups (24.4% in Group A, 23.4% in Group B, a,nd 21.1% in Group C) which demonstrates no significant effect for using RASs (the Braden scale) compared to PU training and nurses' clinical judgment on PU incidence. The findings also pointed out a significant difference in PU incidence among pretest (31%) patients and posttest (19%) patients which suggest the clinical benefit of the PU prevention programme implemented by the RMH. Logistic regression analysis revealed that age, clinical judgement scores, Braden scores, standard hospitalbed mattress, neuro-surgical diagnosis, and skin barrier creams have predictive function in relation to PU development. The ROC analysis showed a relatively similar performance for Braden scale and nurses' clinical judgement in relation to PU development. The study concluded no significant effect of using RASs (the Braden scale) on patients' outcomes in terms of PU incidence reduction. In respect to this, the study suggests that .RASs (the Braden scale) and nurses' clinical judgement can be used together to improve patients' outcomes in terms ofPU development.

Type 2 diabetes mellitus is a chronic and debilitating disease whose prevalence continues to rise inexorably. Type 2 diabetes is usually preceded by a condition called prediabetes, which is characterised by impaired glucose regulation. Those with prediabetes have a significantly increased risk of developing type 2 diabetes compared to those with normal glucose control and therefore represent a key population in the prevention of type 2 diabetes. Physical inactivity is thought to be one of the key factors driving the increasing prevalence of prediabetes and type 2 diabetes and consequently forms a pivotal focus of initiatives aimed at their prevention. The principal aims of this thesis were to: 1) conduct a systematic review investigating the effectiveness of lifestyle and physical activity interventions at promoting physical activity in individuals with prediabetes and the effect of physical activity change on the risk of developing diabetes; 2) investigate the effect of walking activity on markers of chronic low grade inflammation; and 3) design and evaluate with objectively measured endpoints a physical activity intervention for adults at risk of developing type 2 diabetes that is suitable for implementation in a health care or community setting if found to be effective. The main findings are listed in the order of the stated aims. 1) Due to the dearth of controlled exercise training studies in those with prediabetes and the absence of evidence that previous diabetes prevention programmes have been successful at initiating clinically significant increases in physical activity, the evidence for the efficacy of physical activity behaviour change at prevention or delaying the progression to type 2 diabetes in those with prediabetes is equivocal. 2) Walking at levels that are consistent with the current physical activity recommendations is associated with reduced chronic low-grade inflammation, independent of other forms of physical activity. 3) The PREPARE programme, developed after a review of health behaviour theory and the current health care climate, is a theorydriven, group-based structured education programme designed to promote increased walking activity in individuals with prediabetes in a health care setting. A randomized controlled trial was conducted to test two versions of the PREPARE programme, a standard version and a pedometer version, against control conditions (advice leaflet). The standard version encouraged participants to set time-based goals based on generic exercise recommendations, whereas the pedometer version enabled participants to set personalized steps-per-day goals and to objectively self-monitor their daily physical activity levels using a pedometer. One hundred and three individuals were recruited to the study and follow-up was conducted at 3,6 and 12 months. At 12 months both intervention conditions were successful at achieving significant increases in objectively measured ambulatory activity; compared to the control group, those who received the pedometer version of the PREPARE programme increased their ambulatory activity by 1952 steps per day (95% CI 953 to 2951) and those who received the standard version by 1480 steps per day (95% CI 436 to 2522). However, significant improvements in glucose tolerance were only seen in the pedometer group, where 2-h glucose levels decreased by -0.94 mmol/l (95% Cl -1.79 to - 0.10) compared to control conditions, despite no significant change in body weight or waist circumference. This thesis has identified important limitations in the current evidence linking physical activity to the prevention of type 2 diabetes in those with prediabetes and has addressed several of these limitations by developing a theory-driven structured education programme which was shown to be successful at promoting physical activity and improving glucose tolerance in those with prediabetes to levels that are equal to or greater than previous multifactor diabetes prevention programmes. This is likely to have important implications for future diabetes prevention trials and clinical practice in the United Kingdom.

Empathy is an important concept associated with positive outcomes for healthcare practitioners and their patients. In order to identify the best methods to develop and sustain empathy in healthcare professionals there is a need for greater understanding of the antecedents and behaviours involved in empathic responding towards patients. This thesis used a multidimensional model of empathy as a guide for research aimed at understanding the antecedents and behaviours involved in empathic interactions between patients and healthcare professionals. Studies one to three were cross sectional and quantitative in design. Studies one and two investigated relationships between self-reported empathy, personality and emotional intelligence. Findings suggested that (1) perspective taking and empathic concern were closely associated with agreeableness and extraversion, and also loaded on to the single factor of emotional intelligence (2) fantasy was associated with with openness to experience but not emotional intelligence, and (3) personal distress was positively related to neuroticism and negatively related to emotional intelligence. Study three went on to investigate the relationships between emotional intelligence, propensity to empathise and empathic behaviour amongst doctors. Propensity to empathise was positively related to observer ratings of empathic behaviour, but not when doctors had qualified in a different country. finally, study four qualitatively examined empathy in the healthcare context, from patients' perspectives. Situational and patient characteristics were also identified as antecedents to empathy, further relating to employee engagement and work design. The specific behaviours associated with empathy as judged by patients included helping and prosocial behaviours. Implications for the development of empathy are discussed in terms of possible training , development and work design interventions. Finally areas for future research are identified.