This thesis comprises a systematic literature review and empirical paper investigating observational coding systems that have been applied to study interactions between couples where one spouse has a diagnosis of a chronic condition. The literature review offers a critical evaluation of nine coding systems that have been used by 14 papers. A description of each coding system is provided, as well as its theoretical development, evaluation of its application, reliability, validity, generalizability, and utility with a chronic condition population. The review concludes that tailored coding systems need to be developed that focus on specific behaviours that would inform care of someone with a chronic condition.The empirical paper presents the development and psychometric evaluation of an observational coding system for person-centred spousal care. Eleven couples, where one spouse had a diagnosis of dementia, were video-taped completing an everyday task. These videos were coded by three trained raters. Care-giving spouses also completed the Birmingham Relationship Continuity Measure as a measure of relationship continuity. Results suggested that the coding system had good inter-rater reliability, although validity needs to be evaluated. The hypothesis, that spouses scoring high on relationship continuity would relate using a more person-centred approach, was not supported.

It is commonly assumed that the people who are making poor decisions about their health are indeed making an active decision to do so. This means that people are consciously and intentionally making poor decisions about their health. We often compute intention from action and conclude that these people are either unwilling to change their behaviour or that they are unable to do so. The default solution to changing people‘s behaviour therefore has been that since people act in their rational self-interest if we only tell people about the adverse consequences of their misbehaviour they would change it. In reality however, just giving people information does not bring about the desired behaviour change. Through insights from behavioural science, we can develop a better understanding of how and why people behave the way they do which can lead to a better informed design of health behaviour change interventions. In this PhD thesis, I aim to examine one healthcare problem where I believe the application of insights from behavioural science can create a meaningful impact. This problem relates to the issue of medication adherence. In particular, I am interested in adherence to antibiotic medication. Adherence is the extent to which the patient‘s behaviour matches agreed recommendations from the prescriber. Several reviews have found that adherence among patients in developed countries is only 50% (Horne et al, 2005; Haynes et al, 2002; WHO, 2003). Yet this figure is high in comparison with developing countries. For example, in United States, 51% of the patients with hypertension adhere to their medication. While in developing countries such as Gambia, Seychelles and China, only 27%, 26% and 43% of patients with hypertension adhere to their antihypertensive medication regimen (Bovet P et al., 2002; Graves JW., 2000; van der Sande MA et al., 2000; Guo H et al., 2001). Although adherence depends on a lot of factors, there is consistent evidence that regardless of what is being treated; non-adherence is a significant problem (WHO, 2003). The most recent systematic review on medication adherence concludes that: ―increasing the effectiveness of adherence interventions may have a far greater impact on the health of the population than any improvement in specific medical treatments.‖ (Horne et al, 2005). In this PhD thesis, I therefore turn my attention to improving the effectiveness of adherence interventions.

The current portfolio is presented in support of the post-chartered “Top-up” Doctorate in Psychology degree. This portfolio comprises of 3 parts; Part 1 - a research project looking at the efficacy of a combination treatment regimen for smokers (which will be referred to throughout the portfolio as the thesis), Part 2 - a systematic review looking at the effectiveness of smoking cessation interventions in acute care and Part 3 - two case studies reflecting my professional practice which looks at the current clinician and patient perspective of using a combination of treatments in smoking cessation and a reflection on conducting research in an academic setting. Part 1 describes a randomised placebo controlled trial; designed to answer the principal question of whether using a combination of varenicline and nicotine patches reduces post-quitting urges to smoke more than varenicline alone. The study found no difference in post quitting urges between the active and placebo patch groups. Part 2 is a systematic review that was commissioned by the National Institute of Clinical Excellence (NICE) to review the available evidence concerning the efficacy of different types of smoking cessation interventions in acute care settings. Results from a meta-analysis showed that for interventions with hospital patients to be effective, an extended period of support and stop smoking medication provided for over 4 weeks after discharge is recommended. Finally, part 3 is a series of case studies looking at current clinician practice in prescribing combination nicotine replacement therapy (NRT) in UK stop smoking services (UK-SSS); a patient perspective of using combination NRT and varenicline and a reflection on my current clinical practice which gives some insight into my day-to-day role as a practicing health psychologist. These parts are independent of one another but all reflect practice in the field of smoking cessation.

Throughout the Stage 2 training a number of opportunities were negotiated to demonstrate the competencies required to achieve the Doctorate in Health Psychology. This has involved working across local authority and NHS organisations and holding workplace contracts within Children, Young People and Family Services, a Paediatric Diabetes Team and the Department of Rheumatology. This has provided a variety of experiences, which are reflected within this thesis, in order to demonstrate the expertise and skills required to achieve health psychologist status.

The persistence of psychosocial symptoms after severe head injury has been identified as one of the main long-term difficulties facing such patients and their families. Not only have such problems proved persistent, they have been found to present particular problems for community re-entry including return to work. They have been associated in particular with stress on carers and also with disruption of family activities and health. Given that so many survivors of severe head injury rely on their families for long-term support, this topic has attracted increasing attention. The present study described the psychosocial problems after severe head injury and their relationship to various "burdens" on carers and the wider family based on a group of 54 patients studied at 3, 6, and 12 months post-injury. Replication and extension of some findings is made through study of a multi-centre internationally collected group of 562 survivors of severe head injury. Thepersistence of psychosocial problems is noted alongside their differing relationships to various aspects of "burden". Aspects of burden, and especially of social isolation, present challenges especially for those working in rehabilitation and community re-entry programmes

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Healthcare transition is an important area that is attracting increasing attention from policy makers and clinicians, highlighting the need for transition services to be developed for young people with continuing health needs. This study aimed to examine the healthcare transition experiences of young adults with Attention Deficit Hyperactivity Disorder (ADHD) following their discharge from Child and Adolescent Mental Health Services at age 18, and to elicit their views about what services they would find helpful in the future. Participants comprised four young adults with ADHD. An interview guide aimed to gain personal accounts of individual’s lived experiences of transition. Data was analysed using Interpretative Phenomenological Analysis. Four superordinate themes were identified: personal experience of ADHD diagnosis and treatment; impact on self and relationships; living with ADHD and moving on. It was evident from the participants’ accounts that there were gaps in the transitional care that they had received. Research findings were discussed with reference to existing literature relating to biographical disruption, stigma and transition theory. Despite the national priorities given to healthcare transition and recommendations about best practice, these initiatives do not appear to be translated at practice level or in service provision. These findings suggest that clear protocols should be developed and local services commissioned to ensure young adults are able to access services to support their continuing healthcare needs. Further research into this important area is necessary to further explore transition processes, possible options for service delivery and to determine where services should be located.

Physical health conditions can be traumatic and are often associated with psychological morbidity. Recently, researchers have recognised that people are also capable of experiencing enhanced interpersonal relationships, greater appreciation of life and increased personal strength as a result of physical health problems. Typically, this posttraumatic growth has been conceptualised from the perspective of acute trauma, thus a need to better understand the development of the phenomenon for people with health related trauma and examine the relevance of current theoretical models was identified. This review presents an evaluation of empirical literature relating to four theoretical models of posttraumatic growth. The review highlights the commonalities of the models in their emphasis on distress and cognitive processing as crucial for positive outcomes although the research reflects mixed findings for the role of distress. The discussion explores the clinical implications of the literature whilst acknowledging the need for further, theory-driven research with populations affected by sudden onset physical health conditions. Consequently, the empirical paper examines key predictions of an influential theoretical model of posttraumatic growth in adults after spinal cord injury. Using a cross-sectional design, the study aimed to understand the role of cognitive processing and distress in the development of posttraumatic growth. A total of 102 participants between one and 42 months post-injury completed measures of anxiety, depression, posttraumatic stress disorder, intrusive rumination, deliberate rumination and posttraumatic growth. Overall, participants exhibited comparable levels of posttraumatic growth to other health populations with depression and deliberate cognitive processing significantly predictive of growth outcomes. However, different types of distress showed different relationships with posttraumatic growth. The study findings were consistent with other empirical studies and revealed important clinical implications for the provision of psychological therapy to people after spinal cord injury. The methodological limitations and modifications that would benefit from further research are discussed.

National guidelines for stroke recommend that all patients entering rehabilitation are screened for mood disturbance using a validated measure. The first half of this thesis presents a literature review of 25 self-report screening measures for the detection of post-stroke distress. A total of 26 studies were identified as meeting the search criteria. Fifteen self-report measures met recommended levels of sensitivity (≥0.80) and specificity (≥0.60) when screening for post-stroke depression. The Hospital Anxiety and Depression Scale (HADS) was the only measure to meet recommended levels of accuracy for post-stroke anxiety. At the commencement of this thesis, the Distress Thermometer (DT) had not been validated among stroke survivors despite being recommended by NICE (2009). The study presented in the second half of this thesis investigates the diagnostic accuracy and clinical utility of the DT and associated Problem List (PL), the Brief Assessment Schedule Cards (BASDEC), and the Yale. Relative to the HADS, the area under the curve (AUC) for the DT was significantly greater than an AUC of 0.50. Cut-off scores of at least 4 and 5 on the DT met recommended levels of sensitivity and specificity when screening for post-stroke depression and anxiety. The accuracy of the BASDEC and Yale was non-significant. Due to a small sample size, these results should be taken with caution. However, this study provides preliminary evidence to support the use of the DT and PL as a holistic and person-centred screening tool for the prevention and recognition of post-stroke distress.

Research exploring pain following spinal cord injury (SCI) is largely quantitative, with very little known about what it is like to live with pain after SCI. In response to inconsistencies and the dearth of qualitative literature in this area, this study investigated the lived experience of neuropathic pain (NP), following SCI. This was conducted using semi-structured interviews with 16 people living with SCI-specific NP that had been present for a minimum of three months. Eight participants were inpatients in a rehabilitation centre, aged between 23 and 82, and eight were outpatients living in the community, aged between 26 and 77. Data from each sample were analysed separately using the qualitative methodology of Interpretative Phenomenological Analysis (IPA). For outpatients, three themes emerged: (1) the chasm between biomedical perspectives and patient needs and beliefs; (2) the battle for ultimate agency in life; and (3) the coexistence of social cohesion and social alienation. For inpatients, four themes emerged: (1) using metaphors to describe NP; (2) the spectrum of medication experience; (3) interpreting the hospital environment; and (4) thinking about the future. The results suggest that chronic NP is experienced in a biopsychosocial manner, and should be treated in such a way. In particular, participants felt that medication was heavily relied upon by healthcare professionals, despite limited efficacy, and articulated a desire for collaborative approaches to pain-management. Issues surrounding acceptance of NP, and its social impact, were also discussed. The involvement of significant others in pain management may improve communication and psychosocial outcomes. Promoting acceptance may be effective in facilitating psychological, and social well-being. Cognitive treatment incorporated with acceptance- and mindfulnessbased interventions (MBIs) may encourage adaptive responses to, and interpretation of, pain.