Non-attendance at paediatric outpatient appointments results in delayed diagnosis and treatment, putting children at risk of avoidable ill health, and incurring considerable health service costs. Links between missed appointments and clinical, socio-demographic, and access-related factors have been indicated, but parental cognitions associated with non-attendance have yet to be investigated. The aims of this project were to evaluate the effectiveness and theoretical bases of existing interventions designed to reduce non-attendance; to consider the ways in which missed appointments are managed by healthcare providers; to explore parents’ beliefs and experiences of attending and missing appointments; and to investigate the factors underlying these beliefs. A systematic literature review focusing on non-attendance interventions was conducted Within a mixed methods framework, interviews were conducted with healthcare professionals, subsequent interviews were conducted with parents who had attended or missed a General Paediatric outpatient appointment, and a cross-sectional questionnaire study of parents’ beliefs was implemented. The systematic review revealed that text message appointment reminders are effective at reducing non-attendance rates, but that no interventions have thus far been developed using theories of behaviour. Healthcare professionals recognised both barriers and parents’ beliefs as influences on attendance, but also believed there were ‘types’ of families who miss appointments. Healthcare professionals disagreed somewhat about how non-attendance should best be managed. The parent interview study found six themes. The findings reflect parents’ perceptions about the importance of attending and of their ability to attend. The results of the questionnaire study corroborate this structure of beliefs as the analysis produced two factors, the perceived ‘worth’ of attending and anticipated ‘worry’ when attending. This thesis demonstrates an original approach to investigating non-attendance at children’s outpatient appointments, using mixed methods and adopting a psychological rather than service-use perspective. The findings contribute to Health Psychology theory and offer recommendations for healthcare providers.

This thesis explored the interactions between psychological well-being and male fertility using the biopsychosocial model. The biopsychosocial model proposes that biological, psychological, and social processes interact and impact on health. These interrelationships were investigated in a sample of men undergoing fertility treatment and in a set of experiments using an animal model of stress. It is commonly thought that men with male factor infertility suffer more compared to men in couples with other infertility diagnoses, mainly due to the social stigma attached to being a man unable to father. The inter-relationships among diagnosis, psychological stress, and social environment were examined in men during a twelve month period of fertility treatment. It was found that men, regardless of diagnosis, showed signs of suffering over time and perceived some deterioration in their social environment that was at least partly caused by their psychological well-being at the start of treatment. To better understand how stress and reproductive processes interact, an animal stressor paradigm was developed. Male rats were exposed to a psychosocial cage change stressor (PCCS) where housing alternated every day between being alone, or in a new combination of two or three rats per cage for either 12 or 24 days. The four experiments showed that exposure to PCCS induced a mild physical stress response and consistent effects on reproductive parameters. It was concluded that the psychological and social aspects of the PCCS each have an impact on reproduction. This thesis has provided evidence of biopsychosocial links in the reproductive context supporting a biopsychosocial model of male fertility.

The thesis comprises a literature review and a research report. The review provides a critical evaluation and summary of literature pertaining to associations between emotion dysregulation and medically unexplained symptoms (MUS). Owing to ambiguities in the conceptualisation of emotion dysregulation, the way in which emotion dysregulation is being conceptualised in the MUS literature (e.g. which strategies are being investigated in the disorder) was investigated followed by an evaluation of the associations between difficulties in these emotion regulation strategies and MUS. The researcher concludes that further research is needed to improve our understanding of emotion dysregulation in MUS. The research report investigated emotion dysregulation in psychogenic nonepileptic seizures (PNES). The aetiology of PNES is not well understood, research suggests that the aetiology involves a complex interplay of factors. Recently, high levels of emotion dysregulation have been reported in PNES. In addition, high rates of traumatic experiences have been reported in the disorder. The researcher hypothesised that high levels of emotion dysregulation may be associated with traumatic experiences in PNES. High levels of emotion dysregulation were reported in both participants with PNES and participants with epilepsy but not in healthy controls. Higher levels of traumatic experiences were reported by the participants with PNES in comparison with participants with epilepsy and healthy controls. The researcher’s hypothesis was not supported; traumatic experiences did not account for the variance in emotion dysregulation, only anxiety accounted for this variance. The results are considered in relation to previous research and implications for practice and future research outlined

Purpose: A societal response to the existence of substance misuse fluctuates between harm minimisation and prohibition. Until recently, little attention has been paid to the importance of the individual’s substance use experiences, which are vital to understanding the social and contextual reasons to understanding why someone chooses to use, and are therefore of imperative importance to facilitating the design and delivery of a substance use health promotion campaign. The purpose of this study is to investigate the efficacy of the television adverts shown as part of the previously unstudied ‘Talk to Frank’ intervention in relation to an individual’s perceived risk of taking a substance and their intent to use substances in the future. It is also to get a better understanding of the educational experiences surrounding substance use, in order to provide information to health psychologists devising and developing health promotion campaigns concerning substance use in the future. Design: A mixed-methods design was employed in order to quantitatively analyse the data collected from the study testing the efficacy of the ‘Talk to Frank’ intervention. To follow this, semi-structured interviews were conducted with a third of the study population to gain an understanding of their experiences of substance use education, and how this impacted their substance use experiences. Findings: The ‘Talk to Frank’ television adverts were unsuccessful at increasing perceived risk and reducing intent to use. However, a positive correlation was found between participants’ previous substance use scores and their intent to use substances in the future. The results of the qualitative analysis indicated that participants draw on a variety of ‘primary’, ‘secondary’ and ‘tertiary’ learning experiences to enhance their understanding of substance use, which therefore affects their substance use behaviour. Originality/value: This study calls for health psychologists and other health educators to focus on understanding the lived experiences of substance use education so that these findings can be implemented back into designing a more effective intervention. Keywords: Health education, substance use, drugs, Public Service Announcements, Interpretative Phenomenological Analysis, mass media campaigns and substance misuse prevention.

Background: The process of decreasing ineffective or harmful healthcare (deimplementation) may require different approaches than those used to promote uptake of new procedures (implementation) but research into different approaches is currently lacking. It has not been determined if there is a theoretical and evidence-based rationale for designing different interventions for implementation and de-implementation. Objectives: The objectives of this thesis were to: 1) Investigate whether there is a theoretical basis for identifying different mechanisms of change by which behaviour might increase versus decrease; 2) Assess whether predictors of health professional behaviour differ depending on whether behaviour was one clinicians should implement or behaviours clinicians should de-implement; and 3) Identify the Behaviour Change Techniques of published implementation and de-implementation interventions to determine if there is a difference between the techniques reported in these interventions. Methods: Study 1 used Critical Interpretive Synthesis to investigate whether a theoretical rationale exists for identifying different mechanisms of change by which interventions may work for implementation and de-implementation. Study 2 investigated whether the theoretical constructs commonly used to predict health professional behaviour differ based on whether the behaviours should be implemented or de-implemented. It was an exploratory study involving secondary analysis on 13 existing questionnaire datasets from a variety of healthcare professional groups in primary care settings in the United Kingdom and Canada. Study 3 involved the classification and frequency of Behaviour Change Techniques in implementation and de-implementation interventions from selected Cochrane Effective Practice and Organisation of Care systematic reviews. Findings from these three studies were interpreted using the concurrent triangulation approach to report on the key findings. Results: Operant Learning Theory (OLT) proposes different approaches to increasing and decreasing behaviour changes and therefore implementation and de-implementation interventions (Studies 1 & 3), despite a number of commonly used theories being poor predictors of behaviours for implementation and de-implementation (Study 2). Additionally, whilst the range of techniques was limited, the technique Behaviour substitution was frequently used to decrease health professionals’ behaviours (Study 3) and also identified as a strategy commonly used to decrease behaviour in general (Study 1). Conclusion: Whilst the findings suggest that OLT may be promising in developing different interventions for implementation and de-implementation, how best to use these OLT principles is unclear. In instances whereby Behaviour substitution is part of a de-implementation intervention, it is not clear how best to identify the substitute behaviour. Additional investigation is required to better inform the design of implementation and de-implementation interventions.

This thesis investigated the longitudinal role of defeat and entrapment in populations where these factors were expected to be particularly relevant (a sample of individuals from areas of socioeconomic deprivation and a sample of formal caregivers). The thesis then considered whether defeat and entrapment influenced reward sensitivity on a gambling task and lastly, designed a short scale measuring defeat and entrapment suitable for use in clinical populations. The research incorporated a review of the literature, two longitudinal studies, a behavioural study and the development of a scale. The literature review presented in Chapter 1 provided evidence of a well-established link between defeat, entrapment and poor mental health, suggesting that defeat and entrapment may act as a transdiagnostic process; contributing to the development and maintenance of a range of mental disorders. However, the review also demonstrated that defeat and entrapment relate to the same experiences, suggesting that logically these constructs may equally co-occur, although the structure of the constructs is currently debated. The studies presented in Chapters 3 and 4 demonstrated that perceptions of defeat and entrapment predicted poor mental health (depression and anxiety, and depression and caregiver burden) at a second time point, 12 months later. These chapters presented the first longitudinal evidence for samples recruited from the general population and occupational settings. Furthermore, these chapters provided evidence that the relationship between defeat, entrapment and poor mental health operates in a bidirectional way within a sample recruited from community settings, but a linear way within a sample of formal caregivers, suggesting that further research is needed to confirm the direction of this relationship. The research presented in Chapter 5 found a non-significant relationship between defeat and entrapment and reward sensitivity among a sample of undergraduate students. This may have arisen due to the generally low levels of defeat and entrapment within the sample despite highly varied performance on the task. Replication of this research within a sample where a wider range of defeat and entrapment experiences would be expected might be beneficial. Additionally, this thesis aimed to confirm the factor structure of defeat and entrapment amongst various populations. Exploratory and confirmatory factor analysis demonstrated that defeat and entrapment are best conceptualised as a single psychological construct (Chapters 3 and 6), supporting one-factor theories of defeat and entrapment (e.g. Taylor et al., 2011a). During the course of conducting research for this thesis, it became apparent that the length of existing scales used to measure defeat and entrapment were not suitable for use with clinical populations. Despite evidence that defeat and entrapment may reduce symptoms of mental health problems, their measurement has not yet translated to clinical practice. Although several reasons underlie this, a lack of short measurement tool is a major factor. To address this, an eight-item scale was developed, which demonstrated good psychometric properties across four samples from clinical and non-clinical settings. The current research was supported by a discussion of the clinical implications of the work, specifically identifying how defeat and entrapment could be implemented within therapeutic interventions for mental health problems. The current thesis represents a significant contribution to original research considering defeat and entrapment as predictors of mental health problems. The thesis presents the first longitudinal evidence that defeat and entrapment impact on mental health problems for individuals recruited from community and occupational settings and first application of defeat and entrapment to a behavioural task. Through development of a short scale, the thesis also presents a potential avenue to increase the measurement of defeat and entrapment in clinical settings.

Pour les personnes vivant avec le VIH (PVVIH), leur maladie constitue une expérience subjective susceptible d’influer sur leur qualité de vie (QV). Cette thèse explore l’influence de la perception que les PVVIH ont de leur maladie, ainsi que des stratégies de coping, l’auto-efficacité, les stratégies de contrôle en matière de santé, le soutien social et l’ajustement des buts sur la QV et troubles anxio-dépressifs. Une approche comparative entre des personnes françaises avec et sans VIH d’une part et avec des PVVIH françaises et brésiliennes d’autre part a été entreprise. Les participants (France : PVVIH n=206 et sans VIH n=220 ; Brésil : PVVIH n=128) ont répondu à un ensemble de questionnaires évaluant chacune de ces variables. Tout d’abord les résultats ont conforté la plus faible QV et des troubles anxio-dépressifs plus élevés chez les PVVIH comparativement aux personnes sans VIH, mesurés ici à l’aide d’odds ratio. Par ailleurs, les modèles d’équations structurelles ont permis de vérifier l’influence de la perception de la maladie, de l’auto-efficacité et de l’ajustement aux buts des PVVIH françaises sur la QV. Enfin, les régressions hiérarchiques ont montré que la perception de la maladie, l’auto-efficacité et le soutien social étaient des variables prédictives de la QV tant en France qu’au Brésil. La discussion souligne la nécessité de prendre en considération la perception de la maladie dans la compréhension de l’ajustement des PVVIH / For people living with HIV/AIDS (PLWHA), their illness is a subjective experience that may affect their quality of life (QOL). This thesis explores the influence of the perception that PLWHA have of their illness, as well as coping strategies, self-efficacy, health engagement control strategies, social support and goal adjustment on QV and anxiety/depression. A comparative approach between French with/without HIV and PLWHA in France and Brazil was undertaken. Participants (France: PLWHA n=206, without HIV n=220; Brazil: PLWHA n=128) completed questionnaires assessing each of these variables. The results confirm, with the use of odds ratios, that PLWHA have a lower QOL and more anxiety/depression when compared to people without HIV. Moreover, structural equation models were used to verify the influence of illness perception, self-efficacy and goal adjustment on QOL of French PLWHA. Finally, hierarchical regressions showed that illness perception, self-efficacy and social support were predictive of QOL both in France and Brazil. The discussion highlights the need to take into account illness perception to understand the adjustment of PLWHA