This qualitative study focuses on the intersection of Organizational Studies and Public Health. Through the use of cross-sector work, the Public Health field coordinates work across multiple organizations to diagnose and prevent health issues. Interviewing several administrators from organizations who partake in the Healthy Ontario Initiative allowed me to examine how organizations of different types and sectors interact and connect around this project. This study will predominantly focus on the challenges they face, how they overcome them, and how they are evaluated. Highlighting the intersection of Public Health and Organizational Studies and the way a current Public Health initiative organizes and delivers services may impact the way in which the field evolves in the future.

Leptospirosis is an important but neglected zoonotic disease that is often overlooked in Africa. Although comprehensive data on the incidence of human disease are lacking, robust evidence of infection has been demonstrated in people and animals from all regions of the continent. However, to date, there are few examples of direct epidemiological linkages between human disease and animal infection. In East Africa, awareness of the importance of human leptospirosis as a cause of non-malarial febrile illness is growing. In northern Tanzania, acute leptospirosis has been diagnosed in 9% of patients with severe febrile illness compared to only 2% with malaria. However, little is known about the relative importance of different potential animal hosts as sources of human infection in this area. This project was established to investigate the roles of rodents and ruminant livestock, important hosts of Leptospira in other settings, in the epidemiology of leptospirosis in northern Tanzania. A cross-sectional survey of rodents living in and around human settlements was performed alongside an abattoir survey of ruminant livestock. Unusual patterns of animal infection were detected by real-time PCR detection. Renal Leptospira infection was absent from rodents but was detected in cattle from several geographic areas. Infection was demonstrated for the first time in small ruminants sub-Saharan Africa. Two major Leptospira species and a novel Leptospira genotype were detected in livestock. L. borgpetersenii was seen only in cattle but L. kirschneri infection was detected in multiple livestock species (cattle, sheep and goats), suggesting that at least two distinct patterns of Leptospira infection occur in livestock in northern Tanzania. Analysis of samples from acute leptospirosis in febrile human patients could not detect Leptospira DNA by real-time PCR but identified social and behavioural factors that may limit the utility of acute-phase diagnostic tests in this community. Analysis of serological data revealed considerable overlap between serogroups detected in cattle and human leptospirosis cases. Human disease was most commonly attributed to the serogroups Mini and Australis, which were also predominant reactive serogroups in cattle. Collectively, the results of this study led to the hypothesis that livestock are an important reservoir of Leptospira infection for people in northern Tanzania. These results also challenge our understanding of the relationship between Leptospira and common invasive rodent species, which do not appear to maintain infection in this setting. Livestock Leptospira infection has substantial potential to affect the well-being of people in East Africa, through direct transmission of infection or through indirect effects on food production and economic security. Further research is needed to quantify the impact of livestock leptospirosis in Africa and to develop effective interventions for the control of human and animal disease.

Kuwait is subject to fast urbanization and industrialization. This development has increased traffic and other anthropogenic activities resulting in air pollution. Such activities are linked to increasing levels of emitted VOCs. Exposure to VOCs may result in both acute and chronic health effects. VOCs are a major factor in the production of low level ozone which itself has serious effects on health. Air pollution monitoring stations established by Kuwait EPA measure total hydrocarbon vapours, not individual compounds. The practical part of this study was done to assess the levels of identified VOCs in different areas in Kuwait, to identify the health risks associated with observed levels and to manage human health risks associated with VOC emissions. Air sampling was by grab sampling, taking 130 ambient air samples from areas representing residential, commercial and industrial areas. Gas samples were analyzed within 24 hours using EPA method TO15. The results showed mean concentration of TVOCs less than 399 mg/m3 in 78% of the studied sites, however, the remainder were much higher than a mean concentration ten times this in the city centre. Published data established that the measured concentrations of VOCs had known health effects on general populations. Attention was therefore focused upon the sources and points of release of named VOCs enabling practical and pragmatic action. Links were identified between affluence and the species and quantity of VOCs. Vehicles dominate affluent areas and workshop emissions dominate poorer areas. The petroleum industry was less important than expected as a source of VOCs, but work is required on emissions which drift seawards. Recommendations include developing an air emission inventory, an environmental reporting system, and a risk management plan as well as a series of local studies to identify sources and take local action.

Statement of problem: The expansion of the novelty sweets market in the UK has major potential public health implications for children and young adults as they may cause dental erosion, dental caries and obesity. Aims and objective: To investigate the potential dental public health implications of novelty sweet consumption in children. The objectives of this study were to determine the available novelty sweets available to UK consumers, to determine the erosive potential of the most available novelty sweets, to establish the sensory thresholds in children and to determine any potential link between high sensory threshold individuals and their consumption of novelty sweets. Methodology: A list of the most commonly available novelty sweets was created by undertaking scoping visits of shops in the Cardiff area. Children’s use and knowledge of the ten most available novelty sweets were undertaken using focus groups, amongst 11-16 year old children. The focus groups informed the design of a questionnaire. The questionnaire was distributed to 46 children aged 11-16 years during a sensory analysis assessment involving sensory taste thresholds for sweet and sour, assessed using the intensity ranking method. The pH of the ten most available novelty sweets was assessed using an electronic pH meter; the neutralisable acidity was measured by titration against 0.1M sodium hydroxide; an erosion test was conducted on human teeth using a surfometer; contact angles were measured using a Dynamic Contact Angle Analyser; the viscosity was measured using a rotational viscometer and sugar content of the sweets was measured using a refractometer. Results: A wide range of novelty sweets were available, accessible to children in 73% of shops with an average price of 96p. The children were all familiar with novelty sweets, they reported buying and consuming them regularly. The majority of children (65%) required higher amounts of sugar and citric acid than the absolute taste threshold to recognise the sweet and sour tastes. There was an inverse relationship between the preference of the novelty sweets and perception of sweet and sour sensory thresholds (p < 0.05). The pH of eight of the ten novelty sweets was significantly lower than the orange juice (p < 0.05). The neutralisable acidity of seven of the sweets was significantly higher than the orange juice (p < 0.05). The erosive potential of six novelty sweets was significantly higher than the erosive potential of the orange juice (p < 0.05). Delayed ultrasonication by 1 h, reduced the amount of subsurface enamel loss by 0.52-1.45μm in presence of saliva. Some of the acidic solutions had low contact angles, lower viscosity and higher sugar content than orange juice. Conclusions: A wide range of acidic and free sugar sweetened novelty sweets were easily accessible and affordable to children. Children reported consuming these sweets regularly. The high sensory taste thresholds perception for sweet and sour in children may potentially affect their consumption of novelty sweets. Those personnel involved in delivering dental and wider health education or health promotion need to be aware of and able to advise on current trends in sweet confectionary. The potential effects of these novelty sweets on both general and dental health require further investigation.

Colorectal cancer is the third most common cancer and the second most common cause of cancer death in the UK. Outcome is directly related to stage at diagnosis with over 90% of patients with Stage I disease surviving their disease to 5 years compared to less than 10% of those with Stage IV disease. Symptoms for colorectal cancer can be non-specific, particularly when the disease is at its early stage, and hence screening has been introduced. Population screening in the UK, using faecal occult blood testing (FOBt) has been introduced over the past 10 years following several major randomized control trials and a Cochrane review that has shown improved cancer specific mortality in the region of 15% in those individuals invited. This has been attributed to the detection of early stage disease with around 50% of all tumours detected through screening being Stage I. However, it has previously been shown that there are additional tumour and host prognostic factors outside of stage that can determine outcome. For example, the presence of venous invasion and the presence of an elevated host systemic inflammatory response have been associated with poorer cancer specific survival. These additional factors have not previously been studied within the context of a population screening programme or indeed within early stage disease. Moreover, the FOBt screening programme itself is not without its pitfalls. Uptake of the test is below that of other established cancer screening programmes and it is recognised that repeated screening rounds are required to achieve an acceptable sensitivity of the test. This thesis sought to examine the first round of the Scottish Bowel Screening Programme within the West of Scotland and assess its effect on tumour and host determinants of outcome. In Chapter 1 an overview of colorectal cancer and current determinants of outcome is provided. In addition, colorectal cancer screening is explored in detail including the evidence behind the current screening programme. Chapter 2 presents original data, utilising population databases, examining the changes in mode, site and stage of presentation across the West of Scotland that have accompanied the introduction of the national screening programme. It identifies that within non-metastatic disease there has been a shift towards a higher proportion of Stage I disease being present following screening introduction. Chapter 3 presents a detailed examination of the first round of screening in NHS Greater Glasgow &amp; Clyde (NHS GG&amp;C) emphasising the importance of the impact of deprivation throughout the screening programme. For example, deprived patients were less likely to take part, more likely to test positive, less likely to proceed to colonscopy following a positive test and less likely to have cancer detected at colonoscopy following a positive test. Chapters 4, 5 and 6 utilise an original dataset of over 4000 patients who underwent colonoscopy following a positive test in the first round of screening in NHS GG&amp;C generated through work from Chapter 3. Firstly, in Chapter 4, a theoretical model proposing a flexible sigmoidoscopy as a first line test, rather than a colonoscopy, is examined. It found a missed cancer rate of 17% and that around a third would require a completion colonoscopy, concluding that this would not be a desirable change to the current screening algorithm. Chapter 5 then examines the importance of potentially chemopreventative medications such as statins and aspirin, on the risk of neoplasia at colonoscopy, determining that patients on such medications did indeed have lower rates of neoplasia, significant neoplasia and cancer than those not on them. Chapter 6 then looks at symptoms in this population, identifying that around 40% had at least one bowel symptom however that these correlated poorly with the risk of significant neoplasia at colonoscopy. Chapter 7 explores outcomes in those who were invited but did not have a screen-detected cancer in order to examine the incidence of interval cancers (colorectal cancer within 2 years of a negative FOBt) and cancers in non-responders. Overall it identified a 30% interval cancer rate. The chapter then explores differences in tumour and host factors between screen-detected and non screen-detected disease reporting that stage for stage, patients with non screen-detected disease had higher rates of systemic inflammation. Furthermore it characterises the similarity between interval and non-responder tumours suggesting that rather than representing biologically more aggressive tumours, interval cancers arise due to limitations of the test itself. Chapter 8 presents long-term outcomes in patients who have undergone a resection for Stage I disease prior to the introduction of screening. The results report an excellent 5-year cancer specific survival of 95% however an overall survival of 76%. It identifies the presence of an elevated pre-operative host inflammatory response as being associated with a worse overall outcome. Tissue work exploring the local immune-cell microenvironment of both early stage and pre-malignant disease is the focus for Chapters 9 and 10. This characterisation of immune cell infiltrate identifies similar rates of peritumoural inflammation between T1 and T2 disease and validates a previously published automated scoring system. When exploring local inflammation within premalignant polyps there appears to be a change from low-grade to high-grade dysplasia signifying a specific response to early disease progression suggesting host immunosurveillance. Chapter 11 summarises the main findings of the thesis and presents future directions.

Introduction: Although the health of military personnel who have taken part in specific conflicts has been studied throughout the 20th century, there is a paucity of evidence on the long-term overall impact of military service on health. This thesis describes the establishment of and findings from the Scottish Veterans Health Study, a retrospective cohort study comparing the health outcomes of veterans with those of people with no record of service, in order to determine whether the long-term health of military veterans living in Scotland differed from that of people who had never served in the armed forces. Methods: The study population comprised all 57,000 military veterans born between 1945 and 1985 who were resident in Scotland both before and after military service, together with a 3:1 comparison group of 173,000 people with no record of service, matched for age, sex and postcode sector of residence. The demographic data were extracted from the National Health Service Central Registry database and were linked electronically to the National Health Service Scottish Morbidity Record and national vital records data for acute and psychiatric hospital admissions, psychiatric day-case admissions, cancer registrations and death certificate data. Survival analysis was used to determine hazard ratios for those health conditions and outcomes considered to be of a priori interest, overall, by sex, by birth cohort and by length and period of service, both univariately and after adjusting for deprivation. Results: Veterans were at significantly increased risk of cardiovascular disease compared to non-veterans overall, and of acute myocardial infarction, stroke and peripheral arterial disease specifically. Subgroup analysis showed the increased risk to be confined to veterans born between 1945 and 1959, reducing in more recent birth cohorts. The risk was highest in veterans who left after only a short period of service (Early Service Leavers), whilst those who served for longest exhibited a similar risk of cardiovascular disease to all non-veterans. Veterans were at no higher overall risk of cancer than non-veterans, although there were major differences in the risk of specific cancers, which changed over time. The oldest veterans had an increased risk of cancer of the lung, oropharynx and larynx, oesophagus and stomach; the risks of these cancers reduced in more recent birth cohorts. The 1960-1964 birth cohort showed an increased risk of both bladder cancer and pancreatic cancer in comparison with non-veterans. There were increased risks of ovarian cancer in veteran women compared with non-veterans, and of breast cancer in longer-serving women. The risk of cervical cancer decreased in more recent birth cohorts. There were no differences in the risk of colorectal cancer or prostate cancer in veterans, overall or in any subgroup. There was no clear evidence of increased risk of lymphohaematopoietic cancer in veterans. Veterans were at increased risk of motor neuron disease, but not of multiple sclerosis. Veterans were at increased risk of peptic ulcer disease for all birth cohorts up to the mid-1960s but not thereafter; the risk was highest in those with the shortest service. Hepatitis C was less common in veterans than in non-veterans, in all subgroups. Analysis of mental health outcomes showed that the greatest burden of ill-health was among Early Service Leavers, whilst veterans who completed at least a minimum length of engagement were not at increased risk compared with non-veterans, except for post-traumatic stress disorder. The results for post-traumatic stress disorder, in both veterans and non-veterans, demonstrated a complexity which could not be reconciled with any operational exposure or conventional clinical pattern, but which may have reflected a ‘hidden iceberg’ of unmet need in the late 1990s which was uncovered by increasing awareness of the condition. Longer service was generally associated with better mental health. Veterans were at no greater risk of suicide than non-veterans; the risk was independent of length of service. Veteran women exhibited a risk profile for mental health outcomes which more closely resembled that of veteran men; this was especially marked for suicide. Veterans were not at increased risk of alcoholic liver disease overall; the only subgroup to show an increase in risk was Early Service Leavers who had completed training, and there was also evidence of increased risk of some alcohol-related cancers in trained Early Service Leavers. Interpretation: Older veterans demonstrated an increased risk of smoking-related ill-health, including cardiovascular and respiratory disease and the smoking-related cancers, which is consistent with reported high rates of military smoking in the 1960s and early 1970s. Overall, there has been an improvement in health of veterans compared with the non-serving population in more recent generations, suggesting that the increased emphasis on health promotion and physical fitness in the armed forces since the late 1970s has been effective. Major alcohol problems were no more common in veterans than in the wider community, and were most likely to affect those who left earliest, although not those who left whilst still in training. Longer service was generally associated with better long-term health. Early Service Leavers had poorer health outcomes than longer-serving veterans, but the ability to stratify by length of service demonstrated that the poorest outcomes were in those who did not complete initial training. It is likely that their long-term health outcomes have been predominantly influenced by pre-service and post-service health and behavioural factors which, at a pre-service level, may have also contributed to their failure to complete the minimum military engagement, rather than by their short period of military service. The early period of service appears to act as an extension to the screening process for entry to service, filtering out those who prove least suited to service. The Early Service Leavers therefore form a ‘less healthy leaver’ group which is the counterpart to the longer-serving ‘healthy worker effect’; their status as veterans means that they can be identified within the community, unlike most other occupational leaver groups, but their poorer long-term health is unlikely to be due to military occupational factors. Improved understanding of the determinants of veterans’ health will inform the provision of appropriate health and community services to meet their needs.

This thesis looked inside the black box of stroke care, so called because its contents are not clearly defined. This case study of success illustrated how a new inpatient stroke unit (SU) was created in an inner London teaching hospital, transforming treatment for patients with stroke. Whilst it is known that good stroke care results in improved patient outcomes, it is not fully understood how or why. As stroke is the second major cause of death in adults worldwide, and a leading cause of adult disability in the UK, it is essential more is known about how evidence translates into practical knowledge for use in mainstream practice. This action research study, through the systematic documentation and evaluation of the processes and outcomes, has unpacked and illuminated factors that enabled development of success, and provides the first empirical account of its kind. This study adds to the knowledge of knowing how. A variety of qualitative and quantitative methods were used to generate data between January 2001 and November 2002. Findings were analysed using Immersion I Crystallization and descriptive statistics. When the black box of stroke unit care was opened, four key interrelated themes emerged from the process findings: building a multidisciplinary stroke team; developing practice based knowledge and skills in stroke; valuing the central role of the nurse in stroke care and creating an organisational climate for supporting improvement. Analyses of findings suggest the creation of excellence in stroke care was linked to the development of a Community of Practice (CoP), which combines three elements; domain, community and practice, into a conceptual framework of learning that fundamentally places the acquisition of knowledge into a social process of learning. Whilst improvement initiatives have recently been linked in the literature to CoPs, no guidance is available on how this should be done. This thesis makes an original contribution to the body of knowledge by providing the first empirical evidence of not only on how a CoP was created, but shows how it developed into a functional multidisciplinary CoP, a concept identified in the literature as difficult to accomplish. In concluding, issues related to practice, research, education and policy are raised for future considerations.

This action research project aimed to develop inter-professional peer clinical supervision involving nurses and allied health professionals within a community health care organization. The literature revealed limited evidence regarding the development of supervisory relationships in peer group supervision and a deficiency of insider reports of interprofessional peer supervision interactions. Preparedness of practitioners and lack of protected time remain as barriers to sustainable clinical supervision. An inter-professional peer clinical supervision group (IPPCSG) was constituted via a four phase action research process. A qualitative approach was employed using a single case study design. The involvement of participants as co-inquirers reflected the participatory nature of action research. All sessions were audio-recorded and fully transcribed with data analysed using Template Analysis. A theoretical framework was developed to support the interpretation of the findings drawing on concepts of democracy and power. This action research study revealed the part played by structure and rules in securing a safe supervision space, with the incorporation of democratic principles being crucial in equalising power relationships. The study illuminates how trust developed and how supervisory relationships matured and provides detail of the transitions between functional peer supervision group roles. Valuable insights have been gained into how challenge and support are balanced when exploring decision-making and risk. The findings suggest that the different professional identities and perspectives within this group did not impinge on the development of effective supervisory transactions. Substantial common ground was revealed regarding issues brought to supervision, professional beliefs, values and experiences. The analysis suggests that processing work-generated emotion should be a core component of supervision. Learning about each other’s practice and learning how to ‘do’ clinical supervision were identified as important outcomes by co-inquirers. The analysis and interpretation of these data produced the Triple Diamond Model of Interprofessional Peer Group Supervision which may resonate with other practitioners and conveners of group clinical supervision. The evaluation of this action research study identified valuable outcomes for co-inquirers in regard to capacity building and personal development and to a lesser extent for the wider organization in contributing to the development of clinical supervision. The IPPCSG has been maintained since the conclusion of the study.

No description available.

China is currently facing unprecedented health challenges; non-communicable diseases (NCD) now account for 80 percent of its 10.3 million deaths annually. China’s growing health challenges arise, at least in part, due to its rapidly aging population and are compounded by its inadequate social security provision and rapid urbanization. This dissertation examines the extent to the health and well-being of the elderly in China are affected in the presence of these demographic and social changes. It uses data from a rich but relatively underutilized data source, the China Health and Retirement Longitudinal Study (CHARLS). CHARLS is the first Health and Retirement Study (HRS) of its kind in China, and as such represents a rich source of data on health and well-being for the country. A two-province sample was piloted in 2008 and followed up in 2012, while a national wave was surveyed in 2011. This dissertation is a collection of three self-contained empirical studies on the health and well-being of the elderly in China. The first study examines the effect that chronic diseases have on different dimensions of health in a structural equation framework. The second study examines the extent to which elderly households are able to continue to finance their consumption in the presence of ill-health and the extent to which health insurance and family support from children play a role. In the last study, we further investigate the effect that adult children’s migration decisions have on the physical and subjective well-being of their elderly parents.