The thesis grew out of the recognition that there is a dearth of information on the users of mental health services. It set out to describe the characteristics of users across a range of health settings and to consider the role of such characteristics in the mental health referral process. The early phases of this research project were strongly influenced by a model of the referral process developed by Goldberg & Huxley (1980). They conceptualized users of health care existing on 5 levels ranging from people living in the community to users in hospital. Hypothetical filters are said to operate between each level to govern who is referred on to the next level of services. This research project borrowed the notion of filters and their arrangement of services in a referral sequence. However, the focus of this research is on the characteristics of users, and not the detail of the filters per se. What is described is the effect of the referral process not the mechanism. This thesis also moves substantially beyond the five settings in the Goldberg & Huxley model to produce a uniquely comprehensive analysis of the users of all the main mental health care providers in one health district. The research project uses a wholly quantitative methodology. The challenge has been to design a range of compatible survey forms to collect data in seven separate study settings, to collate information on over one thousand one hundred users, to describe the user profiles in each study and to develop a comparative analysis of users across a range of settings. The emphasis throughout has been to align the research with contemporary developments in health care policy, and as the project has progressed, to make a practical contribution to the important debate about information systems in mental health service planning. The thesis has been divided into four parts. Part I introduces and sets the context of the research, and describes the methodology. In seven chapters, Part II of the thesis reports the .findings of each of the seven study settings. Part III of the thesis reports the demographic and utilization characteristics comparatively across all the study settings. The conclusions of the thesis are reported in Part IV of the thesis, where the theoretical, research and policy implications are discussed.The research project makes a contribution to knowledge on 4levels. Firstly, it identifies and describes the characteristics and the typical profiles of mental health service users in a range of study settings, in one area. Secondly, it identifies the differences between users in each study setting. Thirdly, it identifies the overlap in use of one service and another. It is argued that the findings have profound implications for both developing a clearer picture of the referral processes and for highlighting for planners, producers, and providers possible complementary or inefficient service utilization patterns. On the fourth and macro level, this research project has developed a revised model of mental health service referral routes. This model provides a framework for further investigation, and has potential as a planning tool in and beyond the geographical boundaries of the current study area.

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.

No description available.

No description available.

Thesis (MAppSc)--University of South Australia, 1998

Bibliography: p. 375-401. / xiv, 402 p. : maps ; 30 cm. / Title page, contents and abstract only. The complete thesis in print form is available from the University Library. / The main objective of this research has been to analyse the role of local organisational and social factors in community-level health system development in two Australian regions. The thesis argues that health system development at the interface between service and community is a political process which becomes more tangible in the face of an organisational change. / Thesis (Ph.D.)--University of Adelaide, Dept. of Public Health, 1999

Thesis (MAppSc)--University of South Australia, 1998

This thesis is a qualitative study exploring the role of case managers in the evolving Australian case management models. It represents the perspectives of front-line case managers based on their first-hand knowledge of the models’ effect on their own role as well as the perceived effects on the clients. (For complete abstract open document)