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The thesis considers the characteristics of the nursing labour market in which the National Health Service operated from 1948 until I983 and presents econometric estimates of the supply functions of nursing staff. The monopsony of the central government in the market for nurses permits it to depress the pay of nurses. Together with the peculiar budgeting system of the N.H.S., this resulted in a 'shortage' of nurses, in the economic sense of excess demand, from 1948 until 1976, when the market became demand constrained Until 1976, the number of nurses employed was determined by supply. This permits the observed number of nurses employed by the N.H.S. until I976 to be treated as observations on a supply function. The time series of observations until I976 is used to estimate supply functions for six different groups of nursing staff employed in non-psychiatric hospitals in England and wales. These groups are: whole-time and part-time Registered Nurses: whole-time and part-time Enrolled Nurses: whole-time and part-time Nursing Auxiliaries, These six groups are distinct in their response to pay and other factors affecting nurse labour supply. Separate consideration is given to nurse training. Entry to student and pupil nurse training is considered separately. Econometric estimates of the impact of pay, unemployment and the number of young women in the population on entry to nurse training are presented. There are sections devoted to the problem of withdrawal during training. A separate study of midwifery staff uses data which is seldom available to estimate the impact of pay and other factors on the survivor function. The thesis concludes by considering the impact of changing the pay negotiating procedures of the N.H.S. on its cost.

Introduction Randomised controlled trials administering probiotic supplements to preterm infants to prevent sepsis and necrotising enterocolitis are already underway, despite the lack of a robust evidence base of normative values for gut microbiota, bacterial metabolites, and markers of inflammation and immunity. There are increasing calls for observational studies to establish baseline data in these infants. Most of these studies to date have involved the measurement of these analytes individually. In the studies presented in this thesis, we measured a range of stool markers collectively in a cohort of preterm infants in health and disease. Design 56 infants at <32 week gestation and less than 1500g birth weight were sequentially recruited from all three Glasgow Neonatal Units within week one of life after commencement of enteral feeds. Anthropometric, dietary and treatment data were collected. Stool samples were taken once weekly for the first four weeks, testing: short chain fatty acids; calprotectin, secretory immunoglobulin A; and microbial diversity by temporal temperature gel electrophoresis. Results Out of 61 live births meeting the study criteria, 56 infants were enrolled in the study, 62.5% of whom were female. 19.6% were between 24-26 weeks gestation, 28% were 26-28 weeks, 30% were 28-30 weeks, and 21% were 30-32 weeks. 5.3% were between 490-600g in birth weight, 17.8% were 600-800g, 21.4% were 801-1000g, 39.2% 1001-1250g, and 16% were between 1251-1500g. Feed regimen was heterogeneous, comprising 5 combinations of maternal, donor and formula milks. The highest social deprivation level as measured by the Carlisle ‘Depcat’ scoring system of level 7 was significantly higher in the study group than Glasgow or Scotland-wide averages. Sepsis rates were low, with a group median of only 1 per infant. Overall mortality: 7%. 32 with any NEC (56%), 20 with Bells’ ≥2a NEC. 8 (14%) with surgically treated NEC, 5 (8%) underwent ileostomy. SCFAs: (n=56) there were no correlations between gestation, weekly totals, feed type, or NEC and SCFA concentration. Acetate and lactate dominated each sample. Few significant changes were noted with respect to NEC, and these were in the less dominant SCFAs: stage 2a NEC showed higher concentrations of propionate in week 4 than week 3, and lower valerate in week 4 than 2. Stage 3b levels of isobutyrate and heptanoate were significantly lower in week 4 than 3. FC: (n=56) there were no significant differences in FC levels between each week in infants with or without NEC, although the former illustrated a trend to lower levels by week 4. There were no significant differences in NEC before and after clinical signs were apparent, or in those before NEC and after stoma formation for stage 3b NEC. However, significantly lower FC levels were noted in stage 3b NEC requiring ileostomy compared to the immediate pre-operative sample. SIgA: (n=34) Levels rose significantly week on week, and were considerably higher in weeks three and four than week one. There were no significant differences in stool SIgA concentration between infants with and without NEC. A significant increase in mean stool SIgA concentration appeared from week 2 to week 3 in NEC infants, and from week 1 to week 2 for those without. For all breastfed preterm neonates (n=6), the level of milk SIgA was significant higher on week 1 (colostrum) than week 2 and week 3. TTGE: (n=22) There was large variability between number (1-17) and species diversity (25-36 different species). Bacterial composition varied largely between the 2 sample points. No difference in species richness or similarity within the 2 feeding groups was observed. 4 bands were identified in >50% of infants. Intra-individual similarity varied greatly and ranged from a similarity index (Cs) of 0% to 66.8%. There was no statistical difference between the similarity indices of the feeding groups or between those with and without NEC. There were no significant correlations between any of the analytes. Conclusions Only extreme prematurity and extremely low birth weight were associated with NEC, which was at a strikingly high incidence. A limitation was therefore the unexpected onset of severe NEC resulting in prolonged paralytic ileus with low stool production. No correlations were found between analytes, indicating that each set of stool investigations may signify independent physiological, biochemical and immunological gut processes. Despite the severity of NEC, the levels of each analyte were remarkably consistent. High levels of deprivation within the study population may provide the constellation for an as of yet undefined genetic and epigenetic predisposition to NEC in this cohort, similar to that of other illnesses endemic to different geographical areas – notably Multiple Sclerosis in the North East of Scotland – and both follow up of these infants into childhood as well as further analysis of future inborn infants with NEC is planned.

Exclusive breastfeeding (EBF) for 6 months is recommended as the most cost-effective public health intervention to improve child survival particularly in Sub-Saharan Africa and is central to achieving Millennium Development Goal number 4 for child health. However, despite the benefits of EBF to infants and mothers, the rates continue to decrease as the age of the infant increases in an African cultural context including Malawi. There is increasing literature on the effectiveness of community-based peer counselling on EBF promotion in resource-poor settings but its effectiveness in the context of HIV and experiences of HIV positive women with the intervention remains a gap. The purpose of this thesis was to explore determinants of EBF using MaiMwana infant feeding peer-counselling intervention conducted in Mchinji, Malawi as a case study. Specifically, in this study I explored the effectiveness of the intervention to help HIV positive women to overcome the barriers and examine people’s experiences and perceptions towards the intervention with respect to HIV and poverty. I adopted qualitative in-depth interviews with 39 informants, including breastfeeding mothers, peer counsellors and key informants who were purposely selected. The data was analysed using a framework approach. I found that despite having good knowledge, women from rural communities face considerable challenges while practicing EBF. Cultural beliefs, economic constraints, lack of power and support, and fear of transmitting the virus to their infants were cited as major barriers that prevented them from practicing EBF. Overall, the findings from this study suggest that peer counsellors are well accepted by service-users and other community members as they positively viewed their frequent visits as providing additional support, reinforcing infant feeding messages and provide psychological support to women resulting in improved EBF rates. Furthermore, the presence of peer counsellors was viewed as “bringing services at their door step” which reduced time and cost to travel to the health facility. Nevertheless, the findings suggest that voluntary work in resource-poor settings presents considerable challenges such as: poor motivation due to lack of incentives, overworking, lack of knowledge and time to handle HIV positive cases and poor supervision. In order to effectively promote EBF in resource-poor settings, public health programme designers and implementers need to consider these barriers so as to design community-based interventions that suit the local context and create an enabling environment.

Information technology (m has become crucial to the functioning of modern hospitals. It includes a range of human elements, infornlation, equipment, knowledge and systems. It is important to hospitals, as these are complex environments including many systems with diversity of functions, sub-systems, and professionals. The adoption of technology can be explained by four general theories: economic, political, social and globalization theory. Based on these theories five sets of reasons can account for the adoption of IT in a hospital environnlent. They are, practical; to solve existing problems, economic/business; to achieve d profit or reduce costs or both, rational; to achieve efficienL1' and effectiveness, social; to respond to pressure from society for political reasons and to increase positive image, and supply driven forces by which IT producers seek to sell their products and services. However, no one theory or set of reasons can by itself explain the precise drive for use of IT because nluch depends on each hospital's needs and surrounding drcunlStances. The purposes of this research are to investigate the extent to which IT is being used in Gulf Corporation Council (GCC) public hospitals, why IT has been adopted, and the impact of IT on hospital managementThe methods used in conducting this research were based lllainly on three established methods for searching and collecting infomlation; a literature review, the surveyor questionnaire, intervie,,'s and case studies. Five case studies in Qatar, the United Arab Emirates (UAE) and Bahrain were undertaken to cover Gee hospitals and medical centres populations. Most health and medical services in Gee Countries are provided by public hospitals which account for approximately 64% of total hospital provision, employ most medical professionals, mainly expatriates, and contain most patient beds. In Gee hospitals, IT is still in the early stages of implementation. IT has been found to be adopted at a low level due to reasons such as lack of awareness, other priorities in health policy strategies, and the low level of funding allocated. IT can provide hospitals with many benefits, solve many problems and has many inlpacts on human and functional systems, internal power balances and on the social status of hospitals. The benefits are found to be mostly in the areas of processing work. Therefore, the areas which were given priority for IT implementation were medical records, finance, and personnel areas. No significant impacts v"ere found on hospital structure, chain of conlllland, span of control and nUlllber of employees, however, itwas found that IT increased management power, hospitals' social in1age and hospital political power, while there were disagreements about IT impacts on employees' social relations. The evaluation of IT impacts on Gee hospital management shows that the impacts were not at the same level of intensity or direction, for example, sonle impacts ,",'ere positive and some negative; some significant, moderate or nurunlal, some ambiguous or obvious, were some were slow and some fast. Some efforts at Gee States level were made to develop a model of adopting IT but no real results were detected. However, the future role of IT in Gee public hospitals will be increasing perhaps at a slower pace, but two strategic issues should be given proper consideration; first; the role of the education system, research centers, and industrictl foundation, and the second strategy concerns hospital systems and services structure. This later is related to increased privatization of medical services, economic pressure, and changes in governments' employment strategy. The importance of this thesis is to draw the attention of decisionmakers to the role of IT as an efficient managerial tool in some respects and to provide a foundation for future studies

Domestic abuse puts children at risk. There is evidence that the health of these children is compromised. This thesis aims to explore whether specific health services to children living in refuges with their mothers who have fled domestic abuse should be targeted at this group. Method The epidemiological, comparative and corporate methods of health care needs assessment were used. Evidence for effective interventions to address the key health issues for this group of children was sought. Few other service models could be found against which to directly benchmark. Guidance for services to children in these circumstances was thus included in the review as a comparator. Professionals and Mothers were interviewed to explore their perspective on the needs of these children. Results Children in refuge have an increased risk of mental health problems and poor access to health services. They are more likely to have suffered maltreatment themselves. Refuges in Cardiff provide assessment and a programme of work and support for children. The specialist health visitor role uncovers unmet health needs in the under 5s. Professionals working with these children and their mothers are concerned about their mental health and are looking for more specialist CAMHS (Child and Adolescent Mental Health Service) help. A number of barriers stand between children and the health services they need. Referral criteria are not clear and timeliness of services and continuity of care is an issue for mobile families. Conclusions A model for health service is suggested for children in refuge using the logic model method. The Primary Mental Health Worker role should provide the advice and expertise Tier 1 workers require and demystify the referral criterion for specialist CAMHS. Timing and continuity of care for appointments requires joint decision making and a flexible service. Health staff requires training to provide an acceptable and accessible service to vulnerable families.

Children with Autism Spectrum Disorder (ASD) have difficulties with social interaction that affect their early learning through play. Systematic reviews were conducted on the effectiveness of Social Stories™ (SS™), Self Video Modelling (SVM) and Peer Video Modelling (PVM) to teach social behaviour to such children. Study 1 compared their effectiveness for teaching three core play skills to 18 young children with ASD: initiating play, turn taking and finishing play; using a counterbalancing design across skills and play materials so that each participant received each intervention. At intake, participants’ ages, Vineland Adaptive Behavior Scale and PLS-3 scores were assessed. The three core skills were observed with good interobserver (97.3%) and procedural (100%) reliability and quantified using a specifically designed scale. The social validity of target skills and interventions was assessed using a Likert scale. All interventions showed evidence of significant improvement. Non-parametric repeated measures ANOVA and post-hoc Wilcoxon tests showed that SVM was superior to SS™ and PVM. Such superiority was evident for initiating play and turn taking but not for finishing play. There was no significant association between the intake variables and either the degree of change between baseline and post-intervention or the post-intervention scores themselves for SS™. Change following SVM was positively related to the Vineland composite score and its motor skills domain score. Post-intervention scores for SVM were positively related to the Vineland composite scores and its communication, daily living and motor skills domain scores as well as all three PLS-3 scores. Change following PVM was related to the Vineland maladaptive score. The target skills and interventions had high social validity. Study 2 showed that more sustained intervention over time resulted in improvement for those who did less well initially. Overall, the research provides encouraging evidence that these interventions are effective in teaching play behaviours to young children with ASD.

This thesis identifies the constraints to FP utilisation at the policy, service, community and household levels based on the perspectives of policy makers, providers of services, and men and women in different communities of Jordan. It contributes strategies to widen access to FP that are transferable to other countries of the Middle East and the developing world. The policy environment is analysed to assess whether it encourages or deters FP utilisation. The National Population Strategy is highlighted. Improving co-ordination between the different policy players is a major challenge faced in its implementation. FP utilisation is portrayed in four clinics using different models of provision. Service statistics, clinic observations, in-depth interviews, focus and natural group discussions are used to compare the degree of access to FP. Strengthening co- ordination mechanisms between the service providers is an important strategy to increase FP utilisation. The findings suggest that FP decisions are mostly influenced by men who remain concerned, to a varying degree, with the permissibility of FP utilisation in Islam. A culturally competent strategy proposed to increase utilisation is to communicate to men that FP is permissible in Islam. Religious men are proposed vehicles for implementing this communication strategy, basing their discourse on socio-cultural tradition, namely Islamic jurisprudence. The thesis has three sections introduction, findings and conclusions. Chapter One explores the literature. Chapter Two reviews the Jordanian setting. Chapter Three sets out the methods used in this research. Chapter Four examines the policy environment and policy makers' perspectives. Chapters Five to Eight explore the models of service provision concluding with an evaluation of the strengths and weaknesses of the different models. Chapter Nine elaborates on the community's perspectives. Chapter Ten is the concluding chapter that sets out strategies to widen access to FP, by utilising the socio-cultural context of the region.

This thesis examines the roles adopted by clinical pharmacists in the United Kingdom (UK), the evidence for the effectiveness of the interventions arising from these roles, and the challenges to and opportunities for future developments in clinical pharmacy. The research was undertaken in four phases: problem definition; national survey of services currently provided; in-depth interviews on roles; and a review of literature on effectiveness. A literature search provided background information on the evolution of pharmacy and of clinical pharmacy, particularly in the UK. These developments in have been set in the context of changes in health care provision and in the roles of the other health care professions and occupational groups. Preliminary interviews, meetings and group work were carried out to facilitate clarification of the research questions and to assist in the choice of methods. Two nationwide postal questionnaire surveys were conducted. One inquired about the provision of clinical pharmacy services to the primary care sector and the other about service provision within secondary care facilities in the National Health Service (NHS). The response rates were 91% and 90% respectively. The results show some diversity in the provision of clinical pharmacy services and provide possible explanations for this variation. Subsequently, semi-structured interviews were conducted with pharmacists, pharmacy technicians, doctors, nurses and managers at eight sites selected to represent different characteristics of hospitals. These qualitative data were analyzed by constant comparison. The results provide a picture of the clinical roles that hospital pharmacists are, and should be, providing. In addition, they indicate the potential barriers to, and opportunities for, future role development. An assessment of the evaluative literature on clinical pharmacy services was undertaken. Most literature is descriptive and much of the evaluative literature has shortcomings. The results present the evidence for the effectiveness of clinical pharmacy services in improving patient care and financial outcomes in the UK NHS. Finally, quantitative information gathered in the questionnaire survey, qualitative information from the interviews and the literature evidence were combined to create models of the future role of the hospital clinical pharmacist in the UK.