This commentary is a reflective account of research published over the last eleven years. It highlights the themes underlying the publications and tracks the development of the author's research skills while simultaneously showing the impact of the publications on knowledge in the areas covered. Three themes from the research are highlighted. The first relates to the research participants in the publications who include detained and voluntary psychiatric patients, minority ethnic groups and carers. Members of these groups can all be described as marginalised or disadvantaged and are known to sometimes have poorer experiences of health and health services. Their experiences are the second theme. The commentary then highlights some issues in the research as the third theme, in particular the often unrecognised impact of the methods used and concepts employed on the research findings. Although some limitations of these are described, the commentary demonstrates the complexity of the concepts and issues and suggests that these should be acknowledged more widely. A possible way forward is by greater involvement of service users and altering the research perspectives. The next section discusses the impact of being a contract researcher during a period of greater recognition of the importance of listening to patients and their carers. This has had a bearing on both the research and the author's development as a researcher. The commentary then provides reflections on the individual publications submitted detailing the roles played by the author and recent research in the area. Some overarching ethical issues are also discussed. The ultimate aim of all the research presented here has been to improve the experiences of health service users and it is concluded that in each case it has contributed, even if only in a small way, to this aim whether to the academic literature or more directly to service improvement.

Background: The drive to incorporate best evidence into clinical practice is supported by health policy. The implementation of best evidence requires professionals to change their practice. It is clear that in a health system where resources are finite, change should be prioritised towards an area of high burden on the NHS and where chnage would make a difference to patients. Stroke fulfils this criteria as it is a major cause of mortality and morbidity and therefore a major health issue. Furthermore, studies have shown that storke care is poor and assessment is often incomplete. Change is a complex process requiring a multifaceted implementation strategy as this is more likely to change practice, although specific combinations still need to be evaluated. Aim: To evaluate the use of a combined strategy (an opinion-leader; guideline; a staff education programme; and a new recording system) for implementing multidisciplonary stroke assessment in an acute hospital setting. Methods: A quasi-experimental study design with a pre-test/post-test group which incorporated an evaluation research approach and elements of action research was implemented. Conducted in five inter-related phases over 38 months this encompassed development, implementation and evaluation of the intervention. In Phase 1 (6 months) a diagnostic analysis was conducted using a multi-method approach to identify barriers and faciliatators to change. Phase 2 (9 months) comprised the development of evidence-based guidelines for the multidisciplinary assessment of stroke patients followed by a comparison of current recording practice with these guidelines. This phase also incorporated the collection of patient outcome data (length of stay, hospital mortality and satisfaction). Phase 3 (9 months) comprised the development and implementation of evidence-based guidelines for stroke assessment. Phase 4 repeated the measures of phase 2. Phase 5 comprised a diagnostic evaluation of the change management process and the modelling of 'context-mechanism-outcome' (CMO) configurations to bring together the resiluts of the phases of the study. Results: The major findings were that the combined strategy had a variable impact on the practice of all the professions. The greatest impact was seen with the nursing profession. Pre-test compliance ranged between 0% and 95% (median 60%); post-test 39% and 72% (median 86%) demonstrating a 26% improvement in compliance. Fourteen of the 20 nursing profession specific guidelines reached statistical significance. Least compliance occurred in the medical profession whre compliance in the pre-test period ranged between 2% and 91% (median 45%); post-test 25% and 27% (median 27%). No measurable impact on patient satisfaction or patient outcomes was recorded. Conclusion: The use of the multifaceted strategy had a variable affect on professional compliance with guidelines. Changing professional practice is a complex process requiring leadership with an opinion-leader and professional staff. Furthermore, a strong commitment is needed from professional staff to enable barriers such as professional power to be addressed. A diagnostic analysis is a useful tool for supporting the implementation of organisational change.

Cystic Fibrosis (CF) is the most common lethal autosomal recessive condition and affects approximately 1/2500 Caucasian newborns in the United Kingdom and 70,000 individuals worldwide. The gene defect classically leads to a phenotype comprising significant respiratory I and gastrointestinal manifestations, however is recognised to have multisystem consequences. Over the past 70 years there has been considerable progress in the understanding and treatment of CF such that it has moved from a poorly understood condition, almost universally fatal in infancy, to a complex multisystem disorder now affecting as many adults as children. This 'evolution' of the disease presents new challenges for clinicians and has increased focus on its extra-pulmonary components. In the general population cardiovascular disease is the leading cause of morbidity and mortality and it is now recognised that progressive changes in the structure and function of the large arterial system are a key determinant of this association. Furthermore these changes lead to alterations in large artery haemodynamics which have immediate physiological relevance for myocardial work and oxygen demand but also perfusion of the distal organs. Modern techniques permit large artery haemodynamics to be evaluated simply and effectively using the non-invasive technique of applanation tonometry with pulse wave analysis. The overall aim of this thesis was to use this technique to provide an evaluation of large artery haemodynamics in a cohort of adult patients with CF. The experimental work in this thesis includes a study assessing the validity of the haemodynamic techniques used in this thesis (study A) and three studies evaluating large artery haemodynamics in patients with CF; at rest (study I), in response to exercise (study II) and finally following a therapeutic intervention (study III).

The Couvade syndrome or pregnancy-related symptoms in men occurs mainly in industrialised countries around the globe. However, a comprehensive review of available literature suggests that there is a notable dearth of research within the United Kingdom. To address this, a 2-phase study was conducted in the UK. Phase I comprised a qualitative phenomenological study of a purposive sample of fourteen .men, who were interviewed to explore the characteristics of the syndrome and explanations for it. The use of interview fieldnotes and summary sheets provided supplementary data. Three themes emerged from an inductive analytical approach: "emotional diversity in response to pregnancy", "nature, duration and management of symptoms" and "explanatory attempts for symptoms". Few, if any, previous study instruments of the Couvade syndrome have been informed by qualitative studies and evidence of their validation is lacking in the literature. Phase II sought to develop and pilot test a structured questionnaire based on the findings of the qualitative study to assess the physical and psychological symptoms of the syndrome in 23 purposively selected male partners of pregnant women. The questionnaire was completed repeatedly over two time periods. The Cronbach Alpha Coefficient of reliability test for the total scale was 0.89. Other tests of internal consistency showed high reliability and validity, except for nine items, which were subsequently removed from the final amended questionnaire. Few studies have investigated the type, severity, distress and duration of the syndrome's symptoms collectively. These were investigated using the newly developed questionnaire and the perceived stress coping scale in an experimental group of men with pregnant partners (n =182) over the 1st and 3rd trimesters of gestation and 4-weeks into the postpartum period. This was compared with a control group (n = 181) whose partners were not pregnant over a 3 and 6-month comparative time period. Results indicated a significantly higher incidence of 26 physical and 17 psychological symptoms associated with the syndrome for those in the experimental group. There were also statistically higher median severity and distress values for the majority of physical and psychological symptoms in the experimental. group. Symptom severity and distress for physical and psychological symptoms commenced in 1st trimester, dissipated in 2nd trimester, returned in the 3rd trimester and then decreased upon the birth or shortly in the postpartum period except for a minority of symptoms. For the control group the median severity and distress scores for physical and psychological symptoms between 3 and 6-month comparative time periods were all non-significant except for "sore gums" which revealed a statistically significant decrease between these periods. In the experimental group the physical symptoms of the longest duration in the 1st trimester were "stomach pain/cramps and "back pain", "weight gain" and, "stomach distension" in the 3rd trimester and, "tiredness" in the postpartum period, The psychological symptom of the longest duration during the 1 st and 3rd trimesters was "sleeping less than usual" and, "early morning waking" in the postpartum period. In the experimental group there no statistically significant associations between age and the severity and distress of physical and psychological symptoms. There was only one significant association between social class and the severity of the physical symptom of "poor appetite" and none for the distress of the remaining physical symptoms. There were statistically significant associations between social class and the severity scores of three psychological symptoms including "early morning waking", "feeling frustrated" and "feeling stressed". There were also statistically significant associations between social class and the distress scores of "sleeping less than usual" and "feeling frustrated". The largest number of associations were evident between the previous number of children and severity scores of "unable to keep food down", "cough"," sore throat", "pain while urinating", "toothache, "sore gums" and "mouth ulcers". Significant associations between previous number of children and the distress scores were also shown for "stomach pain/cramps" (P=O.018), "indigestion, "cough"," urinating more than usual" and "sore gums". There were also significant associations with the severity scores of 2 psychological symptoms namely, "sleeping less than usual" and "unable to cope with daily life" and the distress scores of the preceding symptom and "early morning waking". Binary logistic regression revealed five physical symptoms as strong predictors of the Couvade syndrome namely, "cough", "leg cramps", "headache" and "diarrhoea" and "pain while urinating" and four, which were weak or unreliable predictors with low R2 values. There were also three psychological symptoms, which were revealed as strong predictors of the syndrome including "loss of concentration", "sleeping less than usual" and "lack of motivation" and a further four, which were weak predictors. There was a higher incidence of all perceived stress coping (PSC) indicators as well as statistically higher median scores for the majority of indicators in the experimental compared to the control group. Between the 1st and 3rd trimesters of pregnancy the median scores of all PSC indicators increased, as did seven in the postpartum period where a further two decreased and one remained constant. For the control group the median PSC scores between 3 and 6-month comparative time periods were all non-significant. For the experimental group, the association between total perceived stress coping scores and the severity scores for physical and psychological symptoms showed no statistically significant relationships at all which was surprising. Binary logistic regression revealed 5 perceived stress coping indicators as weak or unreliable predictors of the Couvade syndrome with low R2 values. Thus, the results support the existence of the Couvade syndrome and its time course, and the male partner's of pregnant women in the study confirmed symptoms as severe and distressing. In view of such findings, men's health needs should be accorded a greater profile within the realms of antenatal care as their health can affect pregnancy outcome. In addition, past problems with the syndrome's diagnosis should now be resolved with regression analysis identifying clear symptom predictors for its presence.

Thesis (Ph.D.)--University of Florida, 2004. / Title from title page of source document. Document formatted into pages; contains 79 pages. Includes Vita. Includes bibliographical references.

The amputation of a lower extremity is a significant and life altering event that has a major impact to a person's mobility and subsequent community involvement. Amputees electing to use a prosthesis benefit from improved mobility, community involvement, and improved fitness due to increased activity, but are reliant on an unyielding prosthetic socket that is often unable to adapt to residual limb volume change. This convergent mixed methods collective self-controlled case study evaluated the applicability of the Technology Acceptance Model (TAM) on a sample of community-ambulator amputees (n = 7) and determined if an experimental Smart Adaptive Socket System (SASS) can improve use of a prosthesis. A mixed methods approach was employed due to its alignment with clinical practice and its strength for research involving small samples. The TAM was adapted using an existing validated scale for amputees. The Prosthesis Evaluation Questionnaire (PEQ) has several subscales that align with variables in the TAM. Non-PEQ values were used to quantify variables that did not align with the PEQ subscales, namely intervention preference and activity data from a StepWatch Activity Monitor (SAM). Additionally, participants were asked for qualitative feedback to better understand their experience with the study and interventions. Participant-reported and performed measures were collected and analyzed. Ease of use and usefulness decreased for the SASS 21.9% and 9.8% respectively while activity increased 22.9%, though none were significant changes. Qualitative analysis found several themes that impacted participants' experience with SASS and identified design features that require improvement in future iterations of the technology. Analyses between the quantitative and qualitative data found weak relationships between qualitative themes present and quantitative findings (positive themes and usefulness r2 = 0.36, positive themes and ease of use r2 = 0.34, combined themes and usefulness r2 = 0.28, and combined themes and ease of use r2 = 0.19). Despite low statistical significance, this study gained useful data that supports use of TAM for amputation research and will positively impact the future development of the experimental system largely due to the selection of a mixed methods research design that facilitated collection, analysis, and triangulation of both quantitative and qualitative data.

Inequities in access to health services has negative consequences on individual well-being, and imposes financial and emotional burden on patients, families, health care systems, and the public. Inequities engendered from differences in socioeconomic status, health insurance coverage, race, and other characteristics can engender disparities. This study aimed to identify the potential predictors of unmet medical need among the civilian noninstitutionalized U.S. adults. Inability to receive needed medical care or receiving medical care after a delay, due to the associated costs, constructed unmet medical need. This study used a four-year (2014-2017) National Health Interview Survey (NHIS) data (sample size: 296,301 adults) and implemented a conceptual framework to study disparities in access to health services and estimate the relative importance of predisposing, enabling, and need factors as the predictors of unmet medical need. Findings from machine learning and logistics regression models highlight the importance of health insurance coverage as a key contributing factor of health disparities. About 60% of variation in unmet medical need was predictable, with over 90% accuracy, solely with health insurance coverage status. Self-rated health status, family structure, and family income to poverty ratio were other statistically significant predictors. Even after controlling for a wide variety of sociodemographic and health status variables such as age, gender, perceived health status, education, income, etc., health insurance remains significantly associated with unmet medical need (OR: 5.03 , 95%CI: 4.67-5.42). To ensure precise national estimates, proper survey data analysis methods were incorporated to account for the complex sampling method used by NHIS. Furthermore, the enabling factors (health insurance and income) exert much more weight on unmet medical need than predisposing factors and need factors. The findings raise the concerns about the existence and magnitude of disparities in health care access and provide a comprehensive framework to a target population for understanding the sources of health inequities with data-driven evidence. Results can be utilized to address potential areas for designing public policy and program interventions by identifying the relative vulnerability of different population groups for lacking access to affordable health services. Future studies using longitudinal panel data are necessary to establish a causal relationship between the predictors and unmet medical need.

<p>Inappropriate ambulance use can be defined broadly as the use of emergency medical services (EMS) transport for non-urgent medical conditions, or when the patient does not use alternate transportation available. It drains health system resources, contributes to low morale among paramedics, and can delay care for patients who may be appropriately treated in alternative settings. An increasing number of studies indicate <em>that</em> inappropriate EMS use occurs, but few studies investigate how perspectives of inappropriate use are constructed. This study explores the construct of appropriateness in the context of ambulance use, and examines the implications of varying perspectives on ambulance billing policies.</p> <p>We present a grounded theory on the construct of appropriate ambulance use from interviews with paramedics in Ontario, national media reports and online reader commentary. Findings show that the role of paramedics varies across regions, and includes various types of care (e.g., emergency response, primary care and preventative care), and transportation (e.g., to the emergency department or urgent care clinics). In turn, constructs of appropriateness vary. In ambiguous cases, paramedics use their perception of the patients’ ability or attempts to cope with the medical situation to evaluate the appropriateness of ambulance use. Unexpectedly, the most frustrating cases of inappropriate ambulance use tend to be initiated by organizations, such as long-term care facilities, rather than members of the general public. These findings raise questions about the potential for ambulance user fees conditional on ‘appropriateness’ to improve either the effectiveness or the efficiency of ambulance services.</p> / Doctor of Philosophy (PhD)

<p>The organization of Health Care in Canada is such that many of the crucial decisions affecting the health of our population are made by politicians whose previous experience has not been in the health sector. This thesis is an attempt to present some of the medical and economic issues related to the prenatal diagnosis of disease in a form which can be readily understood by individuals who are neither physicians nor economists.</p> <p>The technology responsible for prenatal diagnosis has developed very rapidly over the past few years and now the need for an evaluation of the potential role of these techniques in, the prevention of serious genetic disease is widely recognized. This thesis evaluates the effects of prenatal diagnosis on Down's Syndrome, which is the most common serious genetic disease identified in this way, but many of the findings can be applied to other serious genetic disorders.</p> <p>The extent of the problem presented by Down's Syndrome was evaluated by reviewing the literature related to the medical, developmental and epidemiological characteristics of the disease. The findings indicate that this serious disorder is fundamentally irreversible despite the major effects that are made to provide special medical, educational and residential facilities for affected individuals. In addition, Down's Syndrome is a relatively common disorder and it is estimated that there are approximately 130 affected infants born each year and that there are 9,000 affected individuals in Ontario at the present time. The specific cause of the disorder remains unknown although the increasing incidence of affected infants with advancing maternal age is well recognized. The new techniques of prenatal diagnosis and selective abortion offer the only effective method of preventing the birth of these seriously and irreversibly handicapped infants.</p> <p>The procedures involved in obtaining a prenatal diagnosis are reviewed in some detail and it is concluded that the techniques are both medically safe and diagnostically reliable when provided by experienced personnel. Parents are offered a therapeutic abortion when a defective fetus is identified and although a mid-trimester abortion is associated with some morbidity and mortality, the risks are not greater than those associated with a full-term delivery. These findings suggest that prenatal diagnosis could be made available to all those parents who would benefit from health information of this sort without imposing unacceptable health hazards.</p> <p>A major section of this thesis devoted to the evaluation of the economic effects of a program proving prenatal diagnosis, using the technique of cost-benefit analysis. The implications of several diagnostic and patient management policies are examined and the results indicate that prenatal diagnosis should be offered to all women aged 35 years or more. The use of less conservative estimates would suggest that the service could be extended to younger women and still remain economically feasible.</p> <p>The final conclusion, based on medical economic and administrative considerations is that the existing prenatal diagnosis programs should be expanded to provide this service to all women aged 35 or over as soon as possible.</p> / Master of Science (MS)

Gender in physiotherapy education is somewhat ambiguous. Physiotherapy is historically a women’s profession, yet in recent decades there has been a growing proportion of men. The mass media portrays a masculine sporty image of physiotherapy, which notably ignores the presence of women. Previous research in physiotherapy education has shown gender differences in student preferences for work and career pathways. Gender differences in attainment in practice components of the course have also been demonstrated, with men doing less well than women and more likely to fail. As a physiotherapy educator faced with these issues, the aim of this study is to explore the significance of gender in students’ constructions of identity. Social constructionism was adopted as an underpinning theory in this professional practice research involving students from one cohort of undergraduate physiotherapy students at a university in the south east of England. Nine male and female participants were interviewed at the beginning of their second year and were asked to record stories about their experiences both on and off campus throughout the academic year using a digital recording device. Data from the interviews and audio-diary narratives were analysed using Judith Butler’s theorisation of gender as ‘performative’ to understand how gender identities were constructed. Foucauldian and critical pedagogical perspectives were employed to further interrogate the gender discourses that emerged. The findings indicate that gender was rarely explicitly discussed; yet participants’ gender identities were constantly negotiated through relationships that were not limited to the university and clinical settings. A range of discourses of masculinity and femininity were identified illustrating a profound gender orthodoxy in physiotherapy education that simultaneously demanded acceptance, assimilation or resistance. As a consequence, students in this study used a number of discursive strategies in the struggle to be recognised within physiotherapy education and practice. The implications from these findings raise questions about gender tensions and contradictions in the physiotherapy programme under scrutiny and about the pedagogic practices that reinforce them. In this context, there is a need to raise awareness amongst peers and managers of the possible sites of gender inequalities within this curriculum. Also, gender needs to come ‘out of the closet’ and be debated within the classroom and the wider social spaces inhabited by students in order to develop more nuanced understandings of gender within physiotherapy and healthcare. Finally this research indicates the need to provide more inclusive spaces within the curriculum for reflecting on the complexity of identity construction and for challenging its institutional forms.