Background Nearly a quarter of UK adults are obese representing a significant public health problem. Motivational interviewing (MI) may be effective in helping people to lose weight. Planning could be a mechanism of action which is related to outcome. The aim is to define the types of planning talk used by clients during an MI session and examine their relation to weight loss maintenance (WLM) outcomes. Also to examine the skills the therapist used prior to a client talking about planning. Methods To define planning talk a literature review was conducted and an expert group listened to recorded MI sessions. Thematic content analysis was used to identify the types of planning talk. Thematic analysis was used to identify the therapist skills prior to planning within 50 MI sessions. Associations between types of planning talk and WLM outcomes were analysed using logistic and linear regression. Results The development of the coding system found several types of plans/goals. The reliability was 86% and 75% agreement with the gold standard, for examples of plans/goals and the transcript respectively. Frequent planners lost on average 2.8 kgs (95% CI) and 1.2kg/m² (95% CI) more than those who were low planners (not statistically significant). Medium goal setters statistically significantly increased on average their weight (8.8kg) and BMI (3.5 kg/m²) compared to low goal setters. Therapist’s skills prior to planning were asking the client planning questions and exploring with the client their planning ideas in order to increase specificity. Conclusion The coding system can be used to code WLM data with acceptable reliability. A possible association between planning and a decrease in weight and BMI was demonstrated. Understanding how MI works could lead to improvements in the practice of MI by therapist, efficacy, focus research efforts and facilitate a better understanding of what helps people to change behaviours.

This thesis explores the transformation of public health and medical structures in the Mediterranean island colonies of Malta, Cyprus and the Ionian Islands during the nineteenth century. It focuses on the Mediterranean region as the centre of British imperial politics where the island colonies played an important economic and political role. In this British 'lake', the island colonies reaffirmed their geo-strategic importance. This thesis explores the idea that the Mediterranean region and the island colonies became a cordon sanitaire between the 'pestilential' East and the Maghreb, and 'civilised healthy' Europe. Here, the limelight is on the European island colonies in the Mediterranean. In these small island colonies, the major English health reforms were enforced by total state intervention and centralisation. Furthermore, this research illustrates the differences in management of hospitals and medical charities, in particular, the dissimilitude between the administration of public health in England and that in the Mediterranean colonies. This work contributes to the history of medicine and public health literature as it questions the notion of the 'West and the rest'. Since Mediterranean colonies were also called European colonies, suddenly the notion of the West (as one single entity) colonising the rest of the World, loses its applicability. These Mediterranean colonies were geographically part of Europe but not part of the dominating European powers. Thus, this research argues that, geographically and ideologically, the study of Mediterranean colonies demonstrates a grey area within colonial historiography and the literature on colonial medicine. This work consists of four chapters, each discussing various selective themes like isolation, segregation, medical travellers, medical charities and state intervention, with the aim of illustrating the major arguments of this thesis.

The potential for decline in acutely ill and injured patients is ever-present. Rapid response systems exist to facilitate timely actions, but there are continued concerns over failure to rescue. Currently there is little understanding of what happens in ward areas when deterioration occurs and how it is recognised and managed. This study aimed to explore what happens when patients deteriorate, how professionals work together, define and communicate deterioration and make sense of what they say and do. Using constructivist grounded theory; data was gathered over 12 months from 33 multi-professional participants on three wards in one hospital. Data analysis, concurrent with collection, utilised theoretical sampling to identify further sources of data. Constant comparison was used to develop codes and concepts from the transcripts, and NVivo© software facilitated data organisation and an audit-trail. During 26 interviews and 48 hours of observation, 85 cases of patient deterioration were identified. Four concepts emerged from the analysis, 1) being vigilant through surveillance, 2) identifying deterioration and recognising urgency, 3) taking action by escalating and responding, 4) taking action by treating, all connected by a core concept, making the link. The need for support, use of subjective and objective indicators, competing priorities and hierarchical issues influenced the process but application of knowledge was crucial for making the link. Collectively knowing the patient and sharing this multi-professional knowledge was key to making the link and the nurse was ideally placed to facilitate a shared mental model of deterioration across the team. New elements were identified: lay person vigilance, where significant others contributed to the rescue process; and fear of harming patients by a rescue intervention was revealed as a barrier to treating deterioration. Recommendations included protecting and prioritising resources for surveillance, valuing subjectivity and the input of all levels of staff.

This study investigates the impact of seasonality on standards of water and sanitation in the mountainous district of Humla, Nepal. The research considers impact on two levels: community level access and service delivery. First of all, it examines annual variation in village level access to water and sanitation. Secondly, it looks at the wider picture of service delivery and considers how seasonal variations present opportunities and challenges for improvement in standards for water and sanitation. Three case studies from Humla are presented which illustrate village level access to water and sanitation over a calendar year. These case studies summarise the content of 45 semi-structured interviews, 9 focus group discussions and 9 months of observational work in the district. Variations in weather, village population, infrastructure functionality, and environmental conditions are found to influence the experienced levels of access to water and sanitation at any given time. The impact of seasonality on service delivery was investigated via 39 key informant interviews. Both climatic (e.g. weather) and non-climatic (e.g. budget timings) sources of seasonality are found to impact programme implementation. The mismatch of local seasonal calendars and those imposed by central hubs is found to cause particular difficultly in effective delivery of water and sanitation services. The findings of this research have theoretical, methodological and practical implications. Theoretically, it is suggested that a mountain community s level of access to water and sanitation varies considerably over the course of a calendar year to the point where it needs to be considered if on the ground standards are to be improved. Methodological guidance is provided detailing means of investigating seasonality and its impact on standards of water and sanitation in other scenarios. Practical suggestions focus on incorporating seasonality into assessments of access to water and sanitation and programme delivery in mountain communities.

published_or_final_version / Dentistry / Doctoral / Doctor of Philosophy

published_or_final_version / Community Medicine / Master / Master of Public Health

published_or_final_version / Medical Sciences / Master / Master of Medical Sciences

published_or_final_version / Community Medicine / Master / Master of Public Health

published_or_final_version / Nursing Studies / Master / Master of Nursing

Promoting a shift from using cars towards walking and cycling (a modal shift) has the potential to improve population health by reducing the adverse health effects associated with exposure to motor traffic and increasing the population level of physical activity through active travel. However, little is known about the effects of interventions which might achieve this by changing urban design, transport infrastructure or other putative determinants of population travel behaviour. I conducted a systematic review of the best available evidence about the effects of interventions to promote a modal shift. I searched twenty electronic literature databases as well as websites, bibliographies and reference lists and invited experts to contribute additional references. I identified 69 relevant studies and devised a two-dimensional hierarchy of study utility based on study design and study population with which I selected a subset of studies for inclusion. I appraised the quality of these studies; extracted data on the effects of interventions on choice of mode of transport, how these effects were distributed in the population, and associated effects on measures of individual and population health and wellbeing; and produced a narrative synthesis of the findings. Twenty-two studies were included. These comprised three randomised controlled trials, seven non-randomised controlled prospective studies, 11 uncontrolled prospective studies, and one controlled retrospective study of interventions applied to urban populations or areas in which outcomes were assessed in a sample of local people. I found some evidence that targeted behaviour change programmes could change the behaviour of motivated subgroups, resulting (in the largest study) in a modal shift of around 5% of all trips at a population level. Single studies of commuter subsidies and a new railway station also showed positive effects. The balance of best available evidence about other types of intervention such as publicity campaigns, traffic calming and cycling infrastructure suggested that they had not been effective. Participants in trials of active commuting experienced short term improvements in certain measures of health and fitness, but I found no good evidence about health effects associated with any effective intervention at population level. Most relevant studies were not found in mainstream health or social science literature databases. Further analysis of the 47 excluded studies did not change the overall conclusions about effectiveness, but did identify additional categories of intervention that merit further research and provided evidence to challenge assumptions about the actual effects of progressive urban transport policies. The contributions of internet publications, serendipitous discoveries and the initially-excluded studies to the total set of relevant evidence suggested that undertaking a comprehensive search may have provided unique evidence and insights that would not have been obtained using a more focused search. I identified an evaluative bias whereby the effects of population-level interventions were less likely than those of individual-level interventions to have been studied using the most rigorous study designs. Understanding of how environmental and policy factors may influence active travel and physical activity currently relies heavily on evidence from cross-sectional studies of correlates rather than intervention studies. I therefore took advantage of the opportunity presented by a local ‘natural experiment’ — the construction of a new urban section of the M74 motorway in Glasgow — to design, develop and complete the cross-sectional (baseline) phase of a new primary study of the effects of a major environmental intervention. Using a combination of census data, geographical data and field visits, I delineated an intervention study area close to the proposed route of the new motorway and two matched control areas elsewhere in Glasgow. I collected and described data from residents in the three study areas (n=1322) on socioeconomic status, the local environment, travel behaviour, physical activity and general health and wellbeing using a postal questionnaire incorporating two established instruments (the SF-8 and the short-form International Physical Activity Questionnaire), a travel diary and a new 14-item neighbourhood rating scale whose test–retest reliability I established in a subset of respondents (n=125). I then analysed the correlates of active travel and physical activity using logistic regression. Using travel diary data from Scottish Household Survey respondents (n=39067), I also compared the characteristics and travel behaviour of residents living close to the proposed route with those living in the rest of Scotland and analysed the correlates of active travel using logistic regression. Overall data quality and the test–retest reliability of the new neighbourhood scale appeared acceptable. Local residents reported less car travel than expected from national data. In the local study area, active travel was associated with being younger, being an owner-occupier, not having to travel a long distance to work and not having access to a car, whereas overall physical activity was associated with living in social-rented accommodation and not being overweight. After adjusting for individual and household characteristics, neither perceptions of the local environment nor the objective proximity of respondents’ homes to motorway or major road infrastructure appeared to explain much of the variance in active travel or overall physical activity, although I did find a significant positive association between active travel and perceived proximity to shops. Apart from access to local amenities, therefore, environmental characteristics may be of limited relevance as explanatory factors for active travel in this comparatively deprived urban population which has a low level of car ownership and may therefore have less capacity for making discretionary travel choices than the populations studied in most published research on the environmental correlates of physical activity. The design and baseline data for the M74 study now provide the basis for a controlled longitudinal study, which could not otherwise have been carried out, of changes in perceptions of the local environment, active travel, physical activity, and general health and wellbeing associated with a major intervention in the built environment. This will, in time, contribute to addressing calls to produce better evidence about the health impacts of natural experiments in public policy.