A community-based surveillance system was developed and implemented in rural areas in Cambodia. The system aimed to provide timely and representative information on major health problems and life events that would permit rapid and effective control of outbreaks and communicable diseases in general in rural communities. In the system, lay people were trained as Village Health Volunteers to report suspected outbreaks, important infectious diseases, and vital events occurring in their communities to local health staff who analysed the data and gave feedback to the volunteers during their monthly meetings. An evaluation conducted one year after implementation of the community-based surveillance system began found that the system was able to detect outbreaks early, regularly monitor communicable disease trends, and to continuously provide updated information on pregnancies, births and deaths in the rural areas. The sensitivity and specificity of case reporting by Village Health Volunteers were found to be quite high. In addition, the community-based surveillance system triggered effective responses from both health staff and Village Health Volunteers in outbreak and disease control and prevention. The results suggest that a community-based surveillance system can successfully fill the gaps of the current health facility- based disease surveillance system in the rapid detection of outbreaks, in the effective monitoring of communicable diseases, and in the notification of vital events in rural Cambodia. Empowered local people and health staff can accurately report, analyse and act upon significant health problems in their community within a surveillance system they develop, own and operate. The community-based surveillance system could easily be integrated with the current disease surveillance system. Its replication or adaptation for use in other rural areas in Cambodia and in other developing countries would be likely feasible and beneficial, as well as cost-effective.

There is a well-established relationship between socioeconomic position (SEP) and health among older adults, but a short-coming of existing research is its failure to link the SEP-health relationship in later life to the gendered histories of work and family life, or the policy contexts in which these histories unfold. Drawing on the life course perspective and welfare state theory, this research investigates: the dominant patterns of labour market and family experiences over the life course for current cohorts of older adults in Britain; whether health dynamics among older adults vary by gender and life course experiences; and whether SEP and social roles at age 65 mediate these relationships. The data come from a sample of individuals born between 1927 and 1940 participating in the British Household Panel Survey (N=1552). I first examined life course experiences in the labour market and the family from young adulthood to retirement age using a two-stage latent class analysis. Theoretical considerations, along with indices of model fit, suggested that four latent life paths broadly characterized the experiences of the older adults in this sample. Consistent with the social policy context in Britain in the post-World War II years, I found evidence of distinct gender patterns in role configurations at various points across the life course and in the life pathways that link these experiences over time. In the second part of the analysis, I assessed health dynamics using latent growth curve models. Only mental health dynamics were patterned by life course histories, and SEP at age 65 mediated part of this relationship. The life course histories did not have an independent influence on trajectories of chronic health problems or self-assessed health. These findings are considered in the context of our current understanding of health dynamics among older adults, including gender differences and their relationship to SEP.

There is a well-established relationship between socioeconomic position (SEP) and health among older adults, but a short-coming of existing research is its failure to link the SEP-health relationship in later life to the gendered histories of work and family life, or the policy contexts in which these histories unfold. Drawing on the life course perspective and welfare state theory, this research investigates: the dominant patterns of labour market and family experiences over the life course for current cohorts of older adults in Britain; whether health dynamics among older adults vary by gender and life course experiences; and whether SEP and social roles at age 65 mediate these relationships. The data come from a sample of individuals born between 1927 and 1940 participating in the British Household Panel Survey (N=1552). I first examined life course experiences in the labour market and the family from young adulthood to retirement age using a two-stage latent class analysis. Theoretical considerations, along with indices of model fit, suggested that four latent life paths broadly characterized the experiences of the older adults in this sample. Consistent with the social policy context in Britain in the post-World War II years, I found evidence of distinct gender patterns in role configurations at various points across the life course and in the life pathways that link these experiences over time. In the second part of the analysis, I assessed health dynamics using latent growth curve models. Only mental health dynamics were patterned by life course histories, and SEP at age 65 mediated part of this relationship. The life course histories did not have an independent influence on trajectories of chronic health problems or self-assessed health. These findings are considered in the context of our current understanding of health dynamics among older adults, including gender differences and their relationship to SEP.

No description available.

No description available.

This thesis explores the implementation of an area-based health improvement initiative in the north west of England called Target Wellbeing. In the decades before Target Wellbeing was commissioned in 2007, health inequalities between people living in different areas of the UK had been widening. ABIs were identified by the Labour Government as a key tool for improving the health and wellbeing of residents in areas of socio-economic disadvantage and addressing inequalities in health. ABIs such as this have been well evaluated but there remains no firm evidence about the ability of such initiatives to improve health or to reduce health inequalities. In addition to the problems associated with evaluation, the processes through which ABIs might be used to influence change are not well understood and the value of using area-based services to improve health has been taken for granted. There is little understanding about the processes through which service provider partnerships might develop and limited knowledge about the processes through which residents might develop relations with providers. The key aim of this research was to examine the social processes through which ABIs develop over time. Using a case study approach, the research examined one Target Wellbeing programme as a social figuration of interdependent people. Ethnographic methods, including documentary analysis, non-participant observation and interviews, were used to explore the processes and networks that mediated the planned public health development. The study also drew on relevant quantitative data to describe changes over time. Ideas from figurational sociology were used as sensitising concepts in the development of a substantive theory about the processes through which ABIs develop. The study developed theoretical insight into processes of joint working that helps to explain why, in the context in which services are commissioned and performance managed, provider co-ordination is unlikely to be implemented as planned. It also provided a more sociologically adequate account of the ways in which relations between residents and providers were influenced by the history of relations in the town. Changes to residents’ relations with other residents and providers in the town influenced a greater sense of control over their circumstances. These findings demonstrate that, in relation to public health policy and practice, ABIs might more usefully be conceptualised as a series of interrelated processes that might be used to establish the preconditions for influencing change among residents. However, the study showed that interventions targeted at a small part of much wider networks of interconnected people are unlikely to influence sustained changes for residents in deprived areas.

Yes / Despite increasing evidence of the impact of health inequalities on mental health (Pickett and Wilkinson, 2015) there is only limited recognition of the potential role for mental health social work in addressing ‘upstream’ as well as ‘downstream’ challenges of poverty, disadvantage and oppression affecting many people experiencing mental health difficulties. This paper presents some of the current evidence concerning mental health inequalities and the opportunities for mental health social workers to promote wellbeing. A theme throughout the paper is the need to avoid the many examples of dichotomous thinking that frequently characterise thinking about mental health and mental health practice. Additionally the limitations of an individualised recovery discourse are acknowledged. Drawing on Krieger’s (2011) ecosocial model, the social determinants of mental health are considered and the concept of embodiment is examined for its contribution to a more nuanced understanding of the relationship between inequality and health. Finally, the paper offers a version of mental health social work that ‘faces both ways’, involving issues at both the individual and the wider societal level. This includes developing and extending partnerships with service users and carers and with other professional and agencies.

In the New Zealand context, considerable academic and government attention has been given to the socioeconomic and ethnic disparities in health, and how they have evolved over time. Despite evidence of clear regional health patterning within New Zealand, there has been very little research monitoring how the geographical trends in health have evolved over time. The period 1980 to 2001 is very important in New Zealand's contemporary history, as it was a time of rapid social and economic change. For this reason, researchers are motivated to examine the extent to which health differentials evolved during the same period. The reduction of health inequalities are at the top of the Government's health agenda, it is therefore important not only to monitor the success, or otherwise, of a reduction in social inequalities, but also, geographic inequalities. This thesis examines the extent of geographic inequalities in mortality in contemporary New Zealand, and whether or not mortality has become geographically polarised between 1981 and 2000. This thesis builds on research carried out in New Zealand, and seeks to delve deeper into the specifics of the geographic variation of mortality. Importantly, it fills several knowledge gaps during this period, which include: the geographic inequality of cause-specific mortality, the difference in regional cause-specific mortality between males and females, and the inequalities of mortality at a finer geographic resolution. A significant debate revolves around the relative contribution of compositional and contextual explanations for the geographic variation of health outcomes. The research undertaken in this thesis examines the contribution of population change and deprivation to the geographic inequalities of mortality. Numerous key findings were identified in this research, four of which are as follows: In 2000, significant geographic inequalities in cause-specific mortality existed within New Zealand; between 1981 and 2000 the geographic mortality gap remained relatively stable; and when the geographic areas are sorted by deprivation, the results indicate that there has been a widening of the mortality gap. Analysis of the relationship between population change and mortality provide cautious support for the finding that mortality rates are higher in areas that have experienced population decline and conversely, that mortality rates are lower in areas where there has been a growth in population. The high and stable levels of geographic inequality should be of great concern to policy makers as the results of this research indicate that policies addressing health inequalities in New Zealand are not sufficiently potent.

Worldwide, asthma is a chronic condition which is prevalent and neglected and Scotland has a high prevalence of asthma compared to the rest of the world. In their report on the global burden of asthma, the Global Initiative for Asthma (GINA) Program ranks Scotland as having the highest asthma prevalence in the world, with almost one in every five people affected and 6.3 % of the population in Scotland are seeking treatment at General Practices. The aetiology of asthma is complex and it remains a persistent and chronic problem affecting many people, and prevention and treatment are not working. This thesis makes a unique contribution utlising an interdisciplinary approach from Geography and Public Health to explore the nature and role of the socio-environmental context in relation to the prevalence and management of asthma at Scottish General Practices located in areas of dissimilar deprivation levels. The key focus of the research is the way that health professionals (and related stakeholders) understand the factors that shape the causation and prevalence of asthma (including social and environmental contexts), and how this in turn shapes their management of the condition in their practice. Aim: The overall aim of this research is identify, understand and interpret the nature and role of the socio-environmental context in relation to asthma prevalence and management at the Scottish primary care setting. Methods: The research employed quantitative analysis of a secondary dataset on asthma and a case study analysis of two General Practices located in areas of dissimilar deprivation levels in Scotland. Practices were selected after quantitative data analysis comparing the deprivation scores (SIMD) against crude prevalence rates of asthma. The case study employed in-depth semi-structured interviews with stakeholders involved in asthma care. The results of the study contributed to the understanding of what a conventional deprivation measure does/ does not reveal about asthma–place contexts. It also gave insights on how health professionals perceived their area, patient population and how they integrated these perceptions it into their practice as their understanding or lack of understanding or their inability to act upon their understanding on the importance of the socio-environmental context was one of key factors that shape their management of asthma. The study concluded imparting policy implications and renewed approaches to asthma care and management practices within the Health Services.

Research Doctorate - Doctor of Philosophy (PhD) / The Equity Assessment Cardiac Rehabilitation (EACR) study uses a hospital outpatient cardiac rehabilitation (CR) program as the vehicle for demonstrating ways of using evidence to inform equity assessment in health services. This is achieved by demonstrating methods which policy and decision-makers can use to measure, deconstruct and interpret inequalities in service access, defined by selection and utilisation. Some of these methods are familiar in epidemiology and health services research and others less so. Chapter 1 defines equity and equality in health, and introduces the conceptual classification used here to analyse socio-behavioural factors that impact upon utilisation of the hospital outpatient CR program. Chapter 2 reports the results of a search of the international literature on ways of similarly addressing inequalities and inequities in healthcare services and programs, and also factors associated with the recruitment and retention of patients to hospital outpatient CR programs. Chapter 3 describes the methods used in the development and construction of the EACR patient cohort. Chapter 4 explains the theoretical basis for the statistical applications demonstrated in this dissertation. Analyses are conducted on the cohort in accordance with patients’ index hospitalisation. Chapter 5 applies multi-variable logistic regression to analyse factors associated with CR invitation and Chapter 6 uses similar methods to analyse factors associated with attendance for invited patients and Chapter 7 tests the effects of invitation and attendance on survival in accordance with age and gender. Using the results of the regression models presented in Chapter 5, Chapter 8 demonstrates post-estimation non-linear decomposition of gender-based inequalities in invitation to CR. This is a novel application in health services research. Chapter 9 concludes this body of work.