Dental decay is a worldwide Public Health problem. In the last decade Oral Health professionals in the UK have focused on developing national and regional Oral Health programmes to reduce dental caries rates in young children. Smile4Life is an example of a regional programme, which has been implemented in North West England. Recent research suggests health programmes should have a conscious theoretical base and incorporate multi-sectorial approaches. A literature review was undertaken to identify the differences between the theoretical underpinnings used in Oral Health interventions compared to General Health interventions. This showed that Oral Health interventions have been predominately underpinned by educational approaches and used fewer approaches that consider organisational and environmental factors. However, the literature review did not identify barriers and facilitators to the use of theoretical underpinnings in real-life settings. To understand the barriers and facilitators to developing and implementing interventions in real-life settings, and how barriers and facilitators relate to the theoretical underpinnings identified in the literature review, semi-structured interviews were conducted with nine policymakers who were responsible for developing and ten implementers who were responsible for delivering Smile4Life. The analysis was undertaken using an inductive thematic analysis. The interview findings consist of an overall meta-theme and three themes. The meta-theme refers to ‘intra-group relationships and inter-group boundaries’. Intra-group relationships refer to the relations within the policymaker group or implementer group. The inter-group boundaries refer to divisions between the two groups that meant people within each group perceived themselves to be distinct from people in the other group. The first theme intra-group inclusion and inter-group exclusion outlines that within each group, individuals interacted with one another and had a shared sense of unity and group beliefs. However, there were boundaries between the two groups due to a lack of interactions and feelings of exclusion between the groups. The second theme, different knowledge, experiences, and beliefs identified that each group shared similar knowledge and experiences, but between the groups this knowledge was not shared. The third theme standardised or flexible implementation identified that due to the differences in knowledge, experiences, and beliefs between the groups, these differences prevented the formation of a shared vision of how to implement Smile4Life. The groups divisions led to the implementers making changes to the intended implementation strategy of Smile4Life. This research suggests that the implementers (middle managers) are important in the development and implementation of Oral Health programmes and potentially other interventions. Currently, theoretical underpinnings do not explicitly consider middle managers in the development and implementation of interventions. A set of Implementer Engagement Guidelines, underpinned by the Social Identity Theory, are presented that consider the engagement of middle managers in the development and implementation of interventions, to enable policymakers to develop future General and Oral Health programmes.

Background. Colorectal and breast cancers are two of the commonest malignant diseases. The approach to these two cancers is markedly different with patients suffering from breast cancer having the benefits of screening, specialist nurses and support groups. In contrast, colorectal cancer has received less attention in terms of screening, support and public interest. Purpose. This study aimed to collect prospective data on presentation, predisposing factors, co-existing morbidity and management of patients with breast and colorectal cancer and make comparisons with national guidelines. It examined patient perceived quality of life in both colorectal and breast cancer groups prior to and following surgery. The groups were further divided by gender and into stoma and non-stoma (colorectal cancer) and mastectomy and breast conserving surgery (breast cancer). In addition, the work compared the life quality between the colorectal and breast cancer groups and evaluated the appropriateness of newly developed disease specific QOL questionnaires on a UK population. Methods. This study formed a prospective longitudinal repeated measures design. Patients were evaluated at three time points over a six month period starting at the time at which they underwent their cancer surgery. At the first assessment demographic, clinical and QOL data were collected and at 3 and 6 months clinical data was updated and QOL assessed. Clinical data consisted of pathology, adjuvant therapy, morbidity and mortality. QOL was measured at each assessment using the generic cancer EORTC QLQ-C30 instrument. In addition, the colorectal specific module (EORTC QLQ-CR38) and the breast specific module (EORTC QLQ-BR23) were administered at 3 and 6 months post surgery. Results. The clinical data was compared with national guidelines for each cancer population. Guidelines for colorectal cancer were not followed closely whereas those for breast cancer were more formally adhered to. Over the study period, patients with colorectal cancer reported an improvement in emotional functioning, gastrointestinal (CI) symptoms, pain and weight gain. Males reported more nausea, vomiting, dyspnoea and pain. They also had greater sexual enjoyment, although reported more sexual problems. The stoma group had decreased social functioning throughout the study, increased 31 symptoms and sexual problems at 3 months. The non-stoma group had increased emotional functioning from surgery to 3 months and improved sleep. Over the study period, patients with breast cancer reported deterioration in pain, fatigue, dyspnoea and sexual enjoyment. Additionally, at 3 months they reported poorer physical functioning, role functioning and social functioning. The breast conserving group reported deterioration in cognitive functioning, emotional functioning and global well-being and worse diarrhoea. The mastectomy group reported better physical functioning, but poorer role functioning, body image and future perspective. A comparison of the two cancer groups indicated that there were few QOL differences. The colorectal cancer group had worse pain at the time of surgery and reported more 31 symptoms throughout the study. The breast cancer group had better social functioning, role functioning and physical functioning at the time of surgery, but complained of worse pain at 3 months and had poorer emotional functioning throughout the study. It is interesting to note that for both cancer groups there were generally high levels of functioning. There was difficulty in interpreting some of the data because the questionnaires were not appropriate/sensitive in certain areas for these populations. There were many missing answers to the questions on sexual health. Conclusions. This work has provided an insight into the management of two common cancers at a time when guidelines were being established. Quality of life measures with greater sensitivity are required so that they can be used in all clinical trials and longitudinal studies to provide comparable information. There is a need to generate meaningful QOL data that can be easily understood by all clinicians involved in cancer care and which can be incorporated into clinical management.

Issues about quality are paramount in the NHS. Part of this, is the Government's declaration of partnership at all levels with user involvement at its centre. Clinical Governance has been introduced as the mechanism to deliver quality, by encouraging professional accountability through one strategic direction. However some argue that this emphasis on clinical quality has been at the expense of users. In a management context, Garvin (1988) developed a model that consists of four views of quality. A strength of Garvin's model is that the user view is equally as important as other views. The first part of the study (M-Phil stage 1996-1999) aimed to investigate the context of the user view of quality by studying the user elements within each of Garvin's views. A taxonomy was developed using Garvin's four views of quality in order to classify the many different quality approaches and techniques in the literature. By classifying the literature in this manner, individual frameworks of quality were devised that could be used to assess approaches and techniques in any new quality models. In addition the taxonomy represented a new way of reviewing literature in this area. This coincided with the introduction of Clinical Governance within the National Health Service in 1997. The frameworks were used to assess to what extent this new development represented the four views of quality. The conclusion from this exploration was that the user view of quality remained under-represented despite the introduction of Clinical Governance. The empirical stage (PhD stage 1999-2003) aimed to investigate whether user involvement is under-represented in PCGs in the North West region of England. The major finding is that the level of user involvement is dynamic. Board members are willing to involve users in discussions and evaluation stages to a large extent compared to lower levels of involvement during priority setting and strategy formulation (key decision-making stages). The results therefore indicate that PCG Board members' interpretation of user involvement is markedly different to that of the Government. This research has contributed to the operational i sation of user involvement by providina: * The first investigation of the degree of development of user involvement agendas within the embryonic PCGs in the North West region of England; * An exploration of the extent that user involvement agendas coincide with other PCG agendas, particularly Clinical Governance; * An exploration of the views about user involvement of different professional groups represented on the PCG Boards. * The development of policy recommendations.

This thesis is concerned with the transfer of prison healthcare to National Health Service (NHS) responsibility, and investigates whether equitable provision has been achieved for prison-based patients. The chronic ill health of prisoners in England has been recognised for centuries. For example, Howard debates the issue in 1784. When released from prison, English prisoners’ abilities to carry ill health and infection into the community is more recently acknowledged as an additional significant concern (Ramsbotham, 1996). Three themes are evident when analysing the policy and legislative background demanding fair and equitable provision for all. These are: Philanthropy and Concern for Prison Healthcare, Prison Specific Policy and Recommendations, and the Wider NHS Policy, National Service Frameworks and Strategies. Three distinct phases of the Public Health Agenda are considered in this thesis: 1784 - 1890, 1945 - 1996, and 1997 - 2010. Investigation of the Public Health Agenda is divided into sub-categories: Health Promotion, Health Education, Disease Prevention, Healthy Settings, and Prisoner Health providing a valuable structure within which the wider literature can be evaluated empirically via this thesis’ fieldwork. Interpretivist in its methodology, this qualitative study adopts Case Study as an appropriate methodology. Research methods include focus groups, interviews, and participant correspondence. Presentation of research phenomena through graphic representation was designed to overcome reported literacy and language issues present within the research population. Combined, these methods offer an opportunity to build a “polyhedron of intelligibility” (Foucault, 1981, p. 6) demanded of this methodological approach. Between 2005 and 2010, this study explored prisoners’ experiences of healthcare post-transfer to NHS responsibility via five distinct phases of fieldwork: the identification of key patient themes of interest within a self-selecting sample, the validation of Phase One material and the generation of 5 | P a g e additional themes, focus group discussions, followed by interviews with participants and wider stakeholders, and finally a discussion group. Data are analysed and structured according to prison category and gender, age, and ethnicity. Resultant analytical themes linked to a central coding category, the overarching topic of Patient Equivalence. Furthermore, there are three analytical Key Themes: Beliefs, Attitudes and Behaviour; Service Commissioning, Delivery and Constraints; and Patients’ Health and Patient Outcomes. Here, the identification of Imprisoned Carers provides a unique and novel finding of this work. From these three analytical categories, a Core Theory emerged. Research data indicates that, despite considerable policy focus and activity, the lack of integrated service commissioning means that equitable provision for this prisoner population has not been consistently experienced by imprisoned patients. In its absence, prisoners have themselves adopted the role of carer for the sick and frail amongst their prison communities. These individuals report that they undertake these caring roles unsupported by the NHS and/or the Prison Service, whilst at considerable risk to both themselves and the person for whom they care. To achieve equitable provision for English prisoners, this thesis suggests the development of a prison multi-agency health and social care integrated service commissioning plan which recognises the needs of imprisoned carers as highlighted in this study.

Health and social care systems, primarily designed for people with single diseases rather than those with multimorbidity (two or more long-term conditions [LTCs]), are becoming more complex. With increases in the older population, a rise of multimorbidity and greater fragmentation in the care landscape, little is known about how multimorbidity affects the patient’s task to find appropriate care in the right place and at the right time (i.e. care navigation). Difficulties in care navigation have proven to cause delays in access and use of inappropriate services. For older individuals with a number of LTCs, there is an urgent need to support them in appropriately navigating the care system to maximise their health and wellbeing. Using a mixed method design, this study aims to map the personal care network (PCN) of older people (aged 55 years and over) with multimorbidity. It explores the use of Information and Communication Technologies (ICT) to support this patient group in finding their way through the care system. The research involves three stages, addressing the overall question: “Navigating the care system: what is feasible and acceptable with regard to the use of ICT to support older people with multimorbidity?” A scoping review brings together the limited literature on care navigation in older people with multimorbidity and identifies gaps in knowledge. The results demonstrate that navigating the care system is perceived to be a daunting task for many patients. Patients have to learn through experience, rather than being able to rely on systems and actors within the care environment. The gaps in knowledge and practice, identified in the scoping review, are the drivers of the second stage of the study. Stage two investigates from a patients’ perspective, the structure and composition of the PCN surrounding older people with multimorbidity. People and services (actors) involved in the care for this patient group are explored through data from self-administered questionnaires (n=62) and semi-structured interviews (n=7). PCNs are visualised through Social Network Analysis (SNA), detailing those actors involved in the network and their relationship. The application of framework analysis enables a definition of roles and responsibilities within the PCN. Stage three of the study outlines the process of creating data-driven personas for the design of digital PCN navigation support for the study population. This study stands at the intersection of care and ICT. With the expansion of research informing design of ICT for care, this study delivers a number of original contributions to the field. First, the study develops and applies a new conceptual framework: Patient-Centred-Design. Patient-Centred-Design is grounded in and connects three distinguished theories (patient-centred care, patient empowerment and user-centred design). Secondly, the use of innovative methods dictated by this conceptual framework provides valuable additions to the field of SNA by comparing pre and post interview maps of PCNs. Thirdly, this study contributes to health and social care by filling current gaps in care navigation in older people with multimorbidity. Finally, theoretical and practical additions are presented to the field of Human-Computer Interaction through the provision of design requirements.

This work investigates the uses of the Internet and email in health care and specifically focuses on the use of these technologies in the management and support of patients following kidney transplantation. Health information websites are recognised to differ widely in quality and reliability of their content. This has led to the development of various codes of conduct and rating tools to assess the quality of health websites. However, the validity and reliability of these rating tools and their applicability to different health websites also varies. In principle, rating tools should be available to consumers, require a limited number of elements to be assessed, be assessable in all elements, be readable and be able to gauge the readability and consistency of information provided from a patient's view point. This study addresses the design and evaluation of a patient-centred transplant online service consisting of a website and e-mail communication. The website focuses on providing health education to patients so that they can conveniently obtain useful clinical information, as needed in home or workplace settings. The online service was assessed for its acceptability and usefulness from patient's perspectives and for its efficacy in reducing patient's needs to contact primary or secondary care services regarding day-to-day health issues. The online service was purpose built, informed by a framework developed during this study. The framework can be used by transplant clinicians to develop and maintain their websites. Work to inform the framework included an evaluation of the quality of information found in kidney and liver transplantation websites. This evaluation used both expert reviews, based on a weighted hformation Scoring (IS) system and involving clinicians in the assessment, and user evaluations where patient's Internet use, and their suggestions about, and interest in, transplant websites were elicited. The use of email in answering health related questions in the group of the patients who took part in the study was also evaluated. Whilst the hflernet has made it possible for patients and their families to access vast quantities of information that previously would have been difficult for anyone but a physician or librarian to obtain, an important finding of the research is the existence currently of many poor quality websites. The results indicate overall that readily accessible Internet websites for liver or kidney transplantation patients provide a large quantity of, but poor quality, material. Based on surveys of patients needs, the study reported in this thesis highlights the fact that transplant websites should include information about life style in addition to purely medical-related topics. Incorporation of web tools, like email, is shown to effectively help solve many of the daily health problems of patients with organ transplantation. The transplant online service developed as a part of this study showed high levels of patient acceptability and effectively helped reduce the need for patients to access primary or secondary care. The results of this research support the potential of online services as an innovative approach for patient-centred care in organ transplantation.

This research builds upon a body of work on the development and introduction of information systems in the UK National Health Service following the implementation of the White Paper 'Working for Patients'. None of the earlier studies examined the use of the information from those systems for costing health care services, the methodologies used by hospitals for costing their products or the comparability of the output from the costing methodologies used, thereby making this study different from prior work. Costing methodologies cited in the literature are described from the perspective of single organisations. This research analyses the development of an aggregated costing approach, focusing on the issues laced when trying to develop a costing methodology that will be applied to a group of autonomous organisations. The research provides a comparison of health care costing methodologies in both the United Kiiigdom and Ontario, Canada. Collected through interviews and a postal survey tool, data from NHS hospital care providers are analysed to identify both the conformity of the approach and the results of the costing methodologies eniployed. Information from an extended field study is used to review the development of a micro-costing framework in Ontario for radiation therapy services. These findings are then synthesised into a generic framework applicable within other health care organisations seeking to implement a comparative costing methodology. This lramcwork is used to identify possible causes of variance in health care costing approaches. Elements of the framework requiring modification to account for local conditions, such as salary rates or provider availability, are identified and suggestions are made for further work resulting from this research to increase understanding about variability in health care costing methodologies and test the implementation of the generic costing methodology.

This research builds upon a body of previous research on health informatics in developing countries. Early research on this area was motivated by a desire to understand the role of different health informatics applications for an effective and efficient health care delivery in developing countries. These applications range from the use of medical expert systems for clinical diagnosis to epidemiological systems at the central level. None of these looked at health information systems at the district level, especially in relation to the information needs of district health staff. Therefore, this research differs from earlier studies in three aspects. First, it looks at the planning and decision-making processes at the district level and how information support could play a crucial role in these processes. Second, it provides a critical evaluation of the existing vertical reporting systems, and through action-research demonstrates the use of an integrated health information system at the district level. Third, it applies multiple perspectives to analyse the research findings in relation to information support for district health care planning and decision making. These three perspectives are the functional perspective, organisational perspective, and the political perspective. To achieve this, the research: • uses a systemic approach to examine the health care system in The Gambia; • uses action-research to design, develop and implement an integrated district health information system in The Gambia; • uses an interpretive evaluation framework to evaluate the impact of the system development efforts in this research; • uses the theory of contextualism to reflect on the research findings over the three year period. Various themes emerged during the research. These themes would be introduced here as the contributions to knowledge arising from the completion of this research project. These include: • a demonstration of the suitability of using a systemic approach for the design, development and implementation of an integrated information system for district health care planning and decision making; • the development of a conceptual implementation framework suitable for the unique characteristics of developing countries; • a manifestation of the implications of an integrated information system for management development, decentralisation, intersectoral coordination and community participation at the district level; • suggestions for further work especially on the need to evaluate the socio-political impact of this research on the existing political and cultural structures in The Gambia.

This work represents a significant contribution to the body of knowledge in the area of renal transplantation as it brings together the research related to policy analysis, empirical research, and cultural and religious issues related to organ donation and transplantation among South Asians in the UK. The candidate's work in this area is the first in the UK to systematically document and map a national picture of kidney transplant waiting lists and to identify and examine the complex reasons underlying how and why patient ethnicity impacts upon the likelihood of receiving a kidney transplant. The candidate has also developed a new evidence-base exploring the adequacies of the existing procurement arrangements and the implications of introducing any alternative policies within the context of a multi-ethnic and multifaith UK. Finally, the candidate's work has focused on developing an evidence-base of the public perceptions, attitudes, and religious viewpoints towards organ donation and transplantation among a cross-section ofthe South Asian population. The candidate's published works have been the foundation blocks for stimulating and informing the debate on the provision of renal transplant services for minority ethnic groups through the generation of an empirical evidence-base in a subject area which has traditionally relied upon anecdotal evidence. The evidence-base illuminates a very complex issue which has multi-faceted solutions that need to be addressed in different settings.

The Kingdom of Saudi Arabia (KSA) faces an increasing chronic disease burden. Despite the increase in numbers of primary health care centres (PHCCs) current evidence from the KSA, which is limited overall, suggests that access and utilisation of PHCCs, which are key to providing early intervention services, remain unequal with its rural populations having the poorest access and utilisation of PHCCs and health outcomes. There is a dearth (lack) of information from the KSA on the barriers and facilitators affecting access and utilisation of primary health care services (PHCS) and therefore this study aimed to examine the factors influencing the access and utilisation of primary health care centre (PHCC) in urban and rural areas of Riyadh province of the KSA. The behavioural model of health services use (Andersen’s model) provided the contextual and individual characteristics and predisposing, enabling and need factors which assist with an understanding of the barriers and facilitators to access and utilisation of PHCCs in Riyadh province. A mixed methods approach was used to answer the research questions and meet the objectives of the study. The converged qualitative and quantitative findings show that there are a number of predisposing (socio-demographic characteristics; language and communication and cultural competency) enabling barriers such as; distance from PHCCs to the rural residence, lack of services, new services, staff shortages, lack of training, PHC infrastructure, and poor equipment. Facilitators: service provider behaviour/communication, free PHCS, service provision and improvements, primary health care (PHC) infrastructure, manpower, opening hours, waiting time, and segregated spaces and need (increasing prevalence of chronic diseases, PHC developments in the KSA) factors influencing access and utilisation of PHCS. This study highlights important new knowledge on the barriers and facilitators to access and utilisation of PHCS in Riyadh province in the KSA. The findings have some important policy and planning implications for the MOH in the KSA. Specifically, the findings suggest: the need for clear documentation/guidance on minimum standards against which the PHCS can be measured; an audit of service availability at the PHCCs, regular patient satisfaction evaluations of PHCS, that the MOH take a parallel approach and continue to resource and improve buildings and equipment in existing PHCCs, the recruiting of more GPs, nurses, pharmacists, nutritionists and physiotherapists to meet patient demand and more Saudi health care staff, more targeted health education and interventions for the prevention of chronic diseases in the KSA and the need for an appointment system for attending the PHCCs. There is a need for further research into the barriers and enablers to accessing and utilising health care in Riyadh and the KSA overall. This research would be made easier with a clearer definition of rural and urban in the KSA context which would allow a greater comparability between urban and rural PHCS for future research, audit and evaluation as well as comparison with PHCS in other parts of the world. The Andersen model provided a useful conceptual model to frame this research and provided a structure for contrasting and comparing the findings with other studies that have used the Andersen model to understand the barriers and enablers to accessing and utilising health care services.