Globally malaria still remains the most important parasitic disease of public health interest. In the recent past, most endemic countries have deployed and scaled up both preventive and curative interventions to reduce malaria transmission and, ideally, eliminate it. This has lead to global reductions in both mortality and incidence of malaria. These declines have been attributed to the reinvigoration of the global malaria control agenda by the explicit ambition of achieving elimination, which has lead to an increase in funding for national control programmes to increase coverage of preventive interventions, field compatible diagnostic tools for confirming parasite infection, and increased access to effective treatment. As a result of declines in malaria transmission, the focal nature of malaria transmission has become much more evident and has lead to consideration of surveillance as a key intervention for malaria control/elimination in its own right. Surveillance systems have been well established in most formal health facilities but the incorporation of these systems at community level and operationalised by community health workers (CHWs) still remains limited. Additionally, these few examples of CHW-implemented surveillance systems have been typically only reporting indicators of malaria infection burden, without capturing indicators of intervention availability, deployment, coverage and utilisation, thus representing a missed opportunity for routine monitoring and evaluation of impact of interventions in “real time” to inform program planning and implementation. The study was established as part of a multi-country study under the Malaria Transmission Consortium Project whose primary objective was to develop and evaluate new or improved methods for measuring malaria transmission. Thus the overall goal of this study was to demonstrate how malaria transmission, and impact of interventions, could be routinely measured through a novel longitudinal community based surveillance system (CBSS) operationalised by modestly paid CHWs. The CBSS included both passive and active surveillance activities using field – compatible test kits for in situ parasitological detection of malaria infections, based on which confirmed cases were treated with anti-malarial drugs, coupled with a detailed questionnaire on access and use of malaria control interventions and population characteristics. Passive surveillance was achieved conventionally whenever community members self-reported to the CHWs and active surveillance was achieved through monthly active visits to all households in their catchment populations to offer testing and treatment. In addition to recording detailed details of each patient contact in a paper patient register, weekly summaries of selected data elements were submitted by the CHWs using a mobile phone platform via short messaging system (SMS). The detailed reference data recorded in the patient register was then used to monitor malaria infection dynamics in the study population, evaluate the impact of preventative measures, such as indoor residual spraying (IRS) and long-lasting insecticidal nets (LLINs) and validate the electronic summaries submitted via SMS. Overall, the CBSS did not routinely capture all malaria infections in the study population and was insufficient to eliminate the human parasite reservoir. This was primarily due to limited study participant participation with the monthly active testing and treatment offered by the CHWs. However, the CBSS clearly demonstrated the incremental and residual impact to supplementation of pyrethroid-treated LLINs with non - pyrethroid insecticides applied by IRS in areas where the dominant malaria vector is highly resistant to pyrethroids. The adequacy of the SMS reports submitted by the CHWs confirms the great potential of mobile phone technology for facilitating and improving the effectiveness of community based reporting. Despite its limitations, the CBSS successfully provided programmatically relevant information regarding malaria infection dynamics across the large study area at a very affordable cost. The CHWs demonstrated their ability to not only provide treatment services but also adequately report their findings both electronically and on paper. CHWs are primarily tasked with providing routine health services at community level but clearly also have a valuable auxiliary role to play in “real time” surveillance of malaria, and most probably a range of other diseases. If the full potential of CHWs as agents of health surveillance can be realized, control programme progress can be measured through spatial and temporal mapping of transmission with greater sensitivity and at finer scales than is possible with health facilities alone, to enable improved, better-informed program planning, resource allocation and implementation.

Introduction In this thesis, analytical approaches for the design and evaluation of cluster randomised trials are presented and reviewed. In particular, statistical power/sample size issues relating to the design of cluster randomised trials for which only a limited number of clusters are available are assessed using a series of simulation studies. The use of computer simulation methods made it possible to investigate how well cluster randomised trials with limited numbers of clusters available can be optimised both in terms of statistical power and also the accuracy of parameter estimates. The study design conditions performing best in the simulation studies were then applied to a community intervention study involving informal healthcare providers: the 'Triage Plus integrated tuberculosis (TB) and human immuno-deficiency virus (HIV) community intervention project in Lilongwe rural, Malawi'. Aims and objectives The general aims of this dissertation were to: 1. investigate if it is possible to improve the analytical approach to the evaluation of cluster-randomised trials where the complexity of the intervention demands a small number of clusters and in which the primary outcome measure is a count of events occurring in a specified time interval; 2. investigate the effectiveness of engaging informal healthcare providers in integrated TB and HIV community intervention in treatment initiation rates and testing access rates, a cluster randomised trial was conducted in Malawi for which only a limited number of clusters were available to the researchers. The specific objectives were: 1. to review cluster randomised trials and the statistical methods used in the assessment of the effectiveness of the intervention in this type of trial when the primary outcome measure is a count of events occurring in a specified time interval; 2. to assess the statistical efficiencies of different design conditions in terms of statistical power and the accuracy of parameter estimates when determining the effectiveness of complex interventions with a limited number of clusters in this situation; iii 3. to identify the circumstances under which each of the statistical methods would be most robust in detecting significant intervention effects or providing accurate estimates of intervention effects; 4. to apply these statistical approaches to the data collected in the cluster randomised clinical trial of community based interventions for TB and HIV (the 'Triage Plus' study); 5. to assess the effect of involving non-paid informal healthcare providers in integrated TB and HIV community interventions aimed at improving testing and treatment initiation rates for these two diseases. Methods Two research approaches were used in this dissertation: 1. Simulation studies were used to investigate statistical efficiencies in terms of statistical power and accuracy in parameter estimation under different study design conditions for cluster randomised trials in which the primary outcome measure is a count of the number of events occurring during a specified period of time. 2. These statistical approaches were then applied to obtain robust estimates of the effect of the test intervention using the data collected during the “Triage Plus” study. The Triage Plus intervention, implemented in rural areas of Lilongwe, involved informal healthcare providers in an integrated TB and HIV community intervention. This intervention specifically involved empowering the informal healthcare providers in disease recognition, sputum specimen collection, referral of presumptive TB cases, and conducting community TB and HIV awareness meetings. Results The simulation studies showed that statistical efficiency and power both varied considerably under the different design conditions investigated. Non-coverage rates within the nominal value of 5% and negligible biases in the estimated fixed effects parameters (regression coefficients) were observed for all scenarios investigated including the (minimal) 3 cluster per arm design. However, it was discovered that, in order to achieve adequate power in low incidence disease conditions such as TB treatment initiation rates, more repeated measurement times were required to achieve adequate power of 80% with a true effect size of 20% or lower (for example, 12 measurement times were needed to achieve adequate power in this situation in a 3 cluster per arm design when the ICC was 0.00154). With an ICC of 0.081 iv at least 9 clusters were needed to achieve adequate statistical power of ≥80% with an effect size of 20% with 6 and 12 measurement time points respectively for high and low incidence disease conditions. For an effect size of 40%, at least 3 clusters per arm were needed to achieve adequate power with 4 repeated measurement times in low incidence diseases and 3 measurement times for high incidence diseases. For ICCs of 0.321 and above, no adequate statistical power was achieved with an effect size of ≤40% in both high and low disease incidence conditions. In the analysis of the TB services access data from the Triage plus study, the intervention significantly increased the number of presumptive TB cases accessing testing sites by 15.2% (p=0.003) in the first 12 months of the intervention; however, this was followed by a statistically non-significant reduction of 18.3% (p=0.224) when the intervention was rolled-out into the control clusters. Overall, the intervention was associated with a non-significant increase in TB treatment initiation rates of 18% (p=0.112). In the analysis of HIV services access rates, antiretroviral therapy (ART) initiation rates increased significantly by 34.7% (p=0.048) in the intervention clusters in the first 12 months of intervention, and the ART initiation rates were similar after rolling-out the intervention to the control clusters. Overall, the intervention was associated with a 61% increase in HIV testing uptake rates (p<0.001). Conclusion: To achieve adequate statistical power and improved precision in parameter estimation in cluster randomised trials with a count outcome measure, with the ICC of 0.00154 the simulation results suggested that a minimum of 3 clusters per arm is required with at least 12 measurement times for the estimation of an effect size of 20% (or higher) in low incidence disease situations. However, for high incidence outcomes, a minimum of 3 clusters per arm with 3 or more measurement times may be adequate to achieve a statistical power of at least 80%. For an ICC of 0.081, at least 3 clusters per arm were needed to achieve adequate power if the effect size was 40% after 4 repeated measurement times in low incidence diseases and 3 measurement times for high incidence diseases. With ICCs of 0.321 and above, no adequate statistical power was achieved with an effect size of ≤40% in both high and low disease incidence conditions. For the TB and HIV interventions in the “Triage Plus” study, engaging informal health care providers was clearly effective in improving TB and HIV testing uptake as well as ART v initiation. This reinforces the need for community participation in integrated TB and HIV interventions to combat the two diseases. However, for these providers to be effective in promoting TB treatment initiation, the number of sites offering TB testing and treatment initiation in rural areas should be increased to make them more accessible to the population.

Até a Ilustração, em decorrência da grande influência da religião no imaginário popular, das enormes limitações do saber médico e da ausência de serviço público de saúde, o êxito do processo de cura dos enfermos era predominantemente concebido antes de tudo como uma graça de Deus, concedida aos que fossem dignos de merecê-la. Por essa razão, a maior parte da população ficava entregue à sua própria sorte quando se via ameaçada pelas doenças. A partir de então, com o impulso dado à ciência, que já vinha sendo estimulada desde a Renascença, a elite médica começou a reformular as bases da medicina. Em meio a isso, foi mostrando a possibilidade de os problemas de saúde serem combatidos, inclusive preventivamente, por meio da combinação entre as técnicas de tal campo de conhecimento e ações governamentais. Assim, ela mobilizou-se para, por um lado, aprimorar os seus recursos contra as enfermidades com novas descobertas, por outro, elaborar propostas destinadas à melhora das condições da saúde pública, uma vez que essa melhora estava sendo cada vez mais compreendida como um pré-requisito do avanço da civilização e como uma necessidade humanitária. No Brasil, a elite médica que aqui atuou no século XIX, em sintonia com a reformulação do seu saber que estava ocorrendo na Europa e com alguns ideais da Ilustração, sobretudo o de progresso, empenhou-se para apresentar meios que pudessem superar a péssima situação sanitária do país. Dessa forma, seguindo a tendência de seus pares europeus, ela buscou promover a institucionalização da medicina, criando instituições de pesquisa e divulgação de conhecimento, para defender seus interesses corporativos e combater as causas que muito comprometiam a saúde dos indivíduos em geral, inclusive dos escravos. Entre elas, dedicou especial atenção àquelas que poderiam ser superadas com a mudança de costumes, tanto em relação ao corpo das cidades, quanto aos corpos dos seus habitantes. Com esse objetivo, os médicos que integravam a elite do seu campo de conhecimento no Brasil defenderam a intervenção governamental na vida social para impor novos hábitos condizentes com os preceitos da higiene à população, bem como a necessidade de a saúde ser transformada em objeto de interesse público, de acordo com o que estava ocorrendo na Europa desde a Ilustração, o que, com efeito, aos poucos foi aproximando o seu saber ao poder do Estado. Desse modo, eles acabaram, por meio dessa aproximação e do seu esforço destinado a promover uma reforma dos costumes prejudiciais à saúde, sendo convertidos na sociedade brasileira em um dos seus principais agentes reformadores a partir do século XIX. / Until the Enlightenment, due to the large influence of religion in peoples lives, the great limitations of medical knowledge and the absence of a decent public health service, the success of the healing processes was mainly conceived as Holy Grace, presented to those who were found worthy of it. Thus people were forced to rely on their own luck when threatened by diseases. From then on, with the throttle in science, which had already been encouraged ever since the Renaissance, the medical elite began to reformulate the basis of medicine. Meanwhile, it began to show a possibility of effective treatment for health problems, including preventive medicine through by combining its techniques along with governmental action. Hence it was mobilized so that on one hand it could develop its resources against diseases with new discoveries while on the other hand elaborating propositions to improve public health conditions, since it became clear that this was a requirement for the advancements in society and a human necessity. In Brazil, the medical elite had its major influence during the XIX century, in synchrony with the reformulating of its knowledge, the same went on in Europe enforced by Enlightenment ideals, particularly that of progress, working its way to change the decadent sanitary system of the country. Hence, following a European tendency, it struggled to promote the institutionalizing of medicine, creating research institutions and means to spread knowledge, to defend its corporative interests and fight the cause of health problems among the general public, including the slaves. Among which special focus was dedicated to those that could be overcome by the change of habits, in terms of city prospects, as well as its inhabitants. With this in mind, physicians who were part of the elite in their field of work in Brazil defended government intervention within social aspects to impose habits condescend with the hygienic precepts of the population, as well as the need of making health an object of public interest, accordingly to what had been happening in Europe since the Enlightenment, which, as a result, little by little approximated its knowledge to State power. Thus it was accomplished through this approximation and struggle destined to promote change in the habits which were prejudicial to health, having thus been converted in Brazilian society in one of its main reforming agents since the 19th century.

Point-of-choice prompts consistently increase stair climbing in public access settings. Comparison of message content, however, is rare. Chapter two reports that, after controlling for the effects of traffic, similar effects on stair climbing were evident for a more specific and a simpler heart-health message. Chapters three to five demonstrate that specific, calorific expenditure messages were associated with significantly increased stair climbing in public access and workplace settings, with greater increases in overweight than normal weight individuals (chapter four). Chapter three investigated the single and combined effects of volitional and motivational intervention components, in a tram station, to test the theory underpinning the success of point-of-choice prompts. Both components positioned simultaneously were required to increase stair climbing where choosing the stairs resulted in a time delay for pedestrians due to the site layout. Similarly, a motivational intervention alone did not increase stair climbing in the workplace (chapter five). When supplemented with a volitional, point-of-choice prompt at the time the choice of ascent method is made, a significant increase in stair climbing occurred. Analysis should adjust for potential moderating effects of pedestrian traffic, time of day, demographics and building characteristics; failure to do so may mask the true impact of the intervention.

This thesis investigated the effects of daily changes in exposure (delta) and short-term exposure patterns on the relationship between air pollution and health in time series studies. Using data from London and Hong Kong, delta was defined as the difference in particulate matter (PM10) concentration between successive days. Short-term exposure pattern series were defined based on number of peaks in PM10 within rolling weekly blocks. The mathematical equivalence of identifiable models for delta with conventional distributed lag model was derived and alternative model specifications were proposed. Measurement error and missing data exhibited more impact on delta than the absolute metrics in simulation studies. Evidence of association for delta PM10 with mortality was found only in Hong Kong which attenuated towards the null with more rigorous adjustment for weather. The pattern analysis approach hypothesized, in addition to amount (dose) and duration of exposure, epidemiological studies ought to take patterns of exposure into account. However, convincing evidence was not found for the effect of short-term exposure patterns on mortality risk estimates both in London and Hong Kong. Refining the definition of exposure patterns and methodological improvements including analysing data from multiple cities are highly recommended in related studies in the future.

This thesis looks at the subject of old age and retirement in the later years of the Scottish Enlightenment. These subjects are examined in relation to the final years of the physician and natural philosopher, Professor William Cullen (1710–1790). The Cullen Consultation Correspondence digital database (http://cullenproject.ac.uk/) is used to examine letters between the doctor and some of his elderly patients and a study of the botanical materia medica prescribed for this patient group is made. There follows an examination of Cullen’s personal retirement project, his improved farm and designed landscape at Ormiston Hill in West Lothian. The thesis examines the double meaning of the word ‘retirement’, both in its eighteenth-century sense as a retirement from active life, and its modern sense as the concern of old age. Even if Cullen’s notion of old age and retirement represented the concerns of an elite, it carried with it a broader social and moral responsibility. I show how Cullen and his peers sought to develop a programme of improvement which included how to live ‘a good life’.

Universal health coverage (UHC) has been identified as a priority in the sustainable development goals (SDG3), but it is argued here that this is only possible if the health workforce is educated in, and values a public health approach at the primary health care (PHC) level. Encouraging community participation by developing a critical awareness of the social determinants of health and supporting communities to take action is needed. Community health workers (CHWs) have the potential to act as agents for social change to improve the health of rural communities if trained and supported appropriately. This study investigates the optimization of public health skills, knowledge and practices of health workers at the PHC level in rural Cambodia. It is anticipated that this study will afford new insights to inform stakeholders of the factors impacting on the development of public health workforce capacity. The research engaged twenty CHWs over two studies using a participatory action research approach. Over eight participatory workshops and a two-day training session CHWs identified (using photovoice), implemented and reflected on solutions to community health problems. In addition, ten semi-structured interviews were undertaken with key stakeholders from government and non-government organisations (NGOs) to gain an understanding of current methods used to develop the public health capacity of health workers in Cambodia. The public health skills gaps identified at provincial and community levels included planning, communication, community engagement techniques and using initiative to identify and implement solutions. These gaps are intrinsically linked to Cambodian social and political structures, and cultural values which promote a hierarchical working environment. In addition, aid dependency and a lack of ownership has created a new patronage which encourages further disempowerment and an apathetic approach to independently tackling community health issues. Fragmented public health training mainly directed by international agents and a lack of financial support to develop sustainable training, supervision and monitoring negatively impacts public health skill development. Health promotion and prevention training is provided to health facility workers, but there is a ‘know-do’ gap. They view their role as purely curative and removed from the community public health agenda, thus devaluing the application of new public health skills. The implementation of community participation policies in Cambodia is hindered by a reliance on external agencies and cultural norms of respect, obedience and fear of challenging the elite. The capacity for CHWs to act as agents of social change is unlikely given the current policy structure and implementing environment. The health workforce in Cambodia has the potential to contribute significantly to the goal of UHC, however factors affecting their desire and ability to implement a public health approach need addressing. Although many health systems are hierarchical in nature, the degree to which people can innovate, openly analyse processes and procedures and suggest solutions needs to be considered. Identifying ways of supporting CHWs to mobilise and enable communities to be empowered within the contextual environment is required, as is a better understanding of how to close the know-do gap in health facility workers.

Obesity has been identified epidemiologically as a risk factor for development of chronic venous disease. To examine whether abdominal adiposity obstructs venous outflow from the legs, 26 females aged 34-49 years with no clinical venous disease and body mass index (BMI) between 20.9 – 46.7 kg/m\(^2\) were studied. A novel measurement of the extent of abdominal fat along the legs when seated correlated well with BMI and other measures of central fat (sagittal-abdominal diameter, ultrasound fat thickness, % truncal fat by DEXA scan). On sitting, inguinal tissue pressure recorded by needle manometry increased more in obese (BMI > 30) than normal weight (BMI 20-25) subjects (8.2 vs 1.5 mmHg, p<0.01) as did the femoral vein cross-sectional area (129 vs 60%, p<0.05). Both measures correlated with increasing abdominal fat but were not associated with each other. In the lower leg, saphenous vein distensibility and compliance correlated positively with abdominal fat and BMI, but there was no such association for the popliteal vein. Female sex hormones, physical activity levels and insulin status did not affect venous haemodynamics. Thus, increased abdominal fat can potentially hinder venous return when sitting, leading to distension and changes in vein biomechanics, which could over time contribute to venous disease.

This thesis examines the presentation of UK public health policy in the late 1990s and the associated media coverage of health inequalities. It also examines lay perceptions of these inequalities and of government initiatives to reduce them. Such a project is timely for a number of reasons. Inequalities in health were once again on the political agenda with the electron of a Labour government in 1997. Subsequent media coverage of the government's consultant and policy documents, as well as an independent inquiry, put health inequalities in the public domain. In addition, research into health inequalities had been accumulating. One line of enquiry focused on the role psycho-social mechanisms might play in the causation of ill health, yet little empirical work had been carried out on lay perceptions. Two distinct yet interlinking methodologies were employed in the study. Content analysis was carried out on government public health documents, an independent inquiry, their press releases, and of the subsequent press coverage, in order to examine the profile given to inequalities and the manner in which they were presented. Images and headlines from the press coverage were then used to facilitate discussion, in a focus group setting, on inequality, poverty, and relative deprivation. The government's intention to reduce health inequalities was communicated mainly in broadsheet publications. An absence of coverage in the tabloid media suggest that a large section of the population may have been unaware of the government's intentions. The transition from Green Paper to White led to a dilution of the initial fervour of the government to tackle inequalities, and this lack of emphasis was followed through in media coverage of health policy. What had started out as a strong issue faltered in the journey from consultation to policy. Political affiliation of newspapers greatly affected the way in which the inequalities debate was presented. Striking differnces emerged in the reporting of health inequalities by right and left-of-centre newspapers. Right-of-centre newspapers focused on proposals to improve and promote healthy behaviours, whereas left-wing publications focused their reporting on initiatives targeted at the deprived. Researching lay views on health inequalities, and inequality in society at a broader level, elicited often compelling and emotive responses. The government's intention to reduce health inequalities did not appear to register with participants. Inequalities were not discussed in the manner of a public debate churned out by the media. Rather, inequalities were a sensitive issue, affecting people in a very personal and far reaching manner. Those of lower socio-economic status were often painfully aware of their status in relation to other, and a large proportion expressed frustration, anger and helplessness, and linked such feelings to their health and well-being. Views from higher income groups tended to be more disparate and distanced, yet this only reinforced how polarised certain sections of society have become. The social snapshot presented in this thesis conveys a picture of a fundamentally fractured and divided modern Britain with very direct consequences for the future quality of social life.

Aim: Empathy is widely regarded as an important attribute of healthcare professionals, and has been linked to higher patient satisfaction, enablement, and some health outcomes. The ‘mechanism of action’ of clinical empathy is not well understood. An ‘effect model’ of empathic communication in the clinical encounter has been proposed by Neumann et al (2009). In this model, clinician empathy is seen as having a positive effect in encouraging patients to tell more about their symptoms and concerns (for example, by picking up on emotional cues and responding in an encouraging way). This can result in ‘affective-oriented effects’ (such as the patient feeling listened to and understood) or ‘cognitive/action-oriented effects’ which include the clinician collecting more detailed information (medical and psychosocial), gaining a more accurate perception of the problem (and possible diagnosis) and enhanced understanding and responses to the patients’ individual needs. Such responses may include Self-Management Support of various kinds, which help enable the patients to better manage their condition(s), leading to improved outcomes. Recent Government policy in Scotland has focused on Self-Management Support and Anticipatory Care as key priorities in primary care, in response to the rise in chronic disease and health inequalities. However, the amount and type of Self-Management Support and Anticipatory Care that occurs in routine consultations in primary care is not known, nor their relationship with empathy and patient enablement. Thus the ‘effect model’ of empathy as proposed by Neumann, which postulates a relationship between empathy, Self-Management Support, and outcomes in the consultation remains largely theoretical. The aim of this thesis was to examine the relationships between patients’ perceptions of doctors’ empathy, patient enablement, health outcomes and the amount and the type of Self-Management Support (including Anticipatory Care) in general practice consultations. Due to the wide health inequalities that exist in Scotland, and the continuing operation of the ‘inverse care law’, a comparison was made between consultations in areas of high or low socio-economic deprivation to establish whether the relationships varied by deprivation. The thesis had the following research objectives; • To assess the nature, type and frequency of Self-Management Support (including Anticipatory Care) in general practice consultations in high and low deprivation groups • To determine whether patients’ perceptions of GP empathy is related to Self-Management Support (including Anticipatory Care) in consultations in high and low deprivation groups • To explore the effects of Self-Management Support (including Anticipatory Care) on patient enablement and health outcomes in high and low deprivation groups • To assess patients’ perception of empathy in terms of the nature, type, and frequency of emotional Cues and responses by GPs rated as high or low in empathy by their patients in consultations in high and low deprivation groups Methods: The research objectives were investigated by a secondary analysis of data collected between 2006-2008 by Mercer and colleagues in the Section of General Practice and Primary Care at the University of Glasgow. These data were collected as part of a research project in general practice in areas of high and low deprivation funded by the Chief Scientist Office of the Scottish Government. The research produced database, includes 659 videoed baseline consultations, with patient rated experience measures, including the Consultation and Relational Empathy (CARE) Measure, the Patient Enablement Instrument (PEI) and outcomes (self-reported symptom change and well-being) at 1 month post-consultation available on 499 patients. An observer-rated method of assessing Self-Management Support and Anticipatory Care was sought from the literature to answer objectives 1-3. However, there were a lack of validated observer-rated tools available that were specifically designed to measure these constructs. As such, the Davis Observation Code was identified as a validated system of coding primary care consultations across a broad range of consultation components which included items deemed to relate to Self-Management Support and Anticipatory Care. The process of selecting the Davis coding system, and the rejection of alternative coding systems is discussed in detail in Chapter 5. The Davis coding system was also considered feasible given the large size of the database. Self-Management Support and Anticipatory Care were then measured by using combinations of seven codes deemed relevant to Self-Management Support within the consultation setting. Four additional codes were added to the Davis system, in order to include tasks relevant to UK general practice consultations. These additional codes were not part of Self-Management Support or Anticipatory Care but were added to achieve a complete coding system of activities within the consultations. The Verona coding system measured emotional cues, concerns and health provider responses that were observed within the consultations. As such, this system was used to answer objective 4. The choice of this system reflected a desire to use an observer-rated measure to help ‘validate’ the patient-rated empathy measure (the CARE Measure) in terms of the first part of the Neumann et al (2009) model, i.e. eliciting concerns and symptoms, separate from the cognitive/action oriented effects relating to Self-Management Support. Results: Reliability of the objective coding systems Preliminary work was carried out on both coding systems in order to establish reliability in the application of the codes. This was a lengthy process, involving several cycles of coding by two coders (the author and one of her supervisors) but resulted in acceptably high levels of inter-rater reliability (kappa > 0.7 for the Davis coding system, and > 0.9 for the Verona coding system). Objective 1: The nature, type and frequency of Self-Management Support (including Anticipatory Care) in general practice consultations in high and low deprivation groups In both the high and low deprivation groups, time was predominantly allocated to gaining information about the patient’s complaint, conducting physical examinations and planning treatment. There was no difference observed in the amount of Self-Management Support overall in the consultations between high and low deprivation areas. However, there were significant differences in the nature, type and frequency of certain aspects of Self-Management Support, with significantly more Anticipatory Care in the consultations in the high deprivation areas. The results also showed that patients in the high deprivation group tended to experience a more direct biomedical focused consultation that featured practical tasks such as physical examinations and discussion of substance misuse. In the low deprivation group, a biopsychosocial approach was more common, which involved more time spent within the consultation discussing treatment effects, compliance or discussing how previous interventions had impacted on the patient’s health. For both groups, little time was allocated to gathering family information or counselling, answering patient questions or discussing health knowledge. Objective 2: Patients’ perception of GP empathy and relationship with Self-Management Support (including Anticipatory Care) in consultations in high and low deprivation areas. The relationship between empathy and Self-Management Support was explored using the Consultation and Relational Empathy Measure (CARE) and the Davis observation code respectively. Potential confounding variables were taken into account. Patients' perceptions of their GP's empathy were significantly associated with Self-Management Support in the low deprivation group, but not the high deprivation group.