The purpose of this study was to explore how cancer and palliative care services developed in one place and changed in the course of time. Research on how local cancer and palliative care services have developed is limited. A small number of researchers have provided accounts of hospice developments nationally, but they did not explore individual experiences and the micro context in detail. Other studies have examined accounts of developing local cancer support services, but not hospice developments. This research addresses the question - how were cancer and palliative care services developed in Lancaster 1976 ? 2000? Oral history and documentary sources were used to generate data, which was analysed using thematic analysis/constant comparison. Social constructionism offered a fruitful theoretical basis that increased understandings of oral history accounts. A snowball sample recruited a broad group of participants that had been involved with the local cancer and palliative care services in the relevant period. Thirty five interviews were conducted. The study revealed that services developed in the absence of national planning; participants worked to make them respectable, but there was tension at times. Progress was shaped by a combination of individual and social factors. Services evolved outside the National Health Service, yet alongside oncology and were therefore tripartite in character. Elsewhere developments were often fragmented. Many participants were involved in all the local services; they created networks and collaborated to form comprehensive facilities, which were available from diagnosis to the terminal stage of illness. The approaches complemented each other to reveal that at the macro level services were initially flexible. In time they became more structured, as social, historical, economic, professional and political mechanisms in the broader context impacted to shape them; this created some challenges. The study also uncovered aspects of the meaning of compassion. It revealed that compassionate practices challenged the rationality of conventional approaches and shared relativist perspectives because participants found different ways of providing care. All of these findings contributed to new knowledge about the development of local cancer and palliative care services. The study was limited by the historical period, perhaps by the place and because the reconstruction was one interpretation. It is possible there are others.

Background: The elderly account for an increasing proportion of the population and have a high prevalence of coronary artery disease (CAD). Therefore, elderly patients represent an increasing proportion of those presenting for investigation and treatment of CAD. Management of CAD is undertaken to relieve the signs and symptoms of myocardial ischaemia, making quality of life (QoL) a critical consideration in clinical decision making. CAD is associated with both chronological and biological ageing processes. However, conflicting evidence exists as to whether leucocyte telomere length (LTL) is an appropriate biomarker of ageing in CAD. Methods: The thesis comprised four complementary studies. Firstly, secondary data analysis of the Scottish Coronary Revascularisation Register was used to undertake two retrospective cohort studies of patients attending for coronary angiography and percutaneous coronary revascularization. The aim was to compare case mix and outcomes of elderly versus younger patients. A prospective cohort study of 437 patients was then undertaken to assess QoL before, and three months after, PCI and to compare QoL changes in elderly versus younger patients. Finally a cross sectional study was used to investigate the association between LTL (T/S ratio -relative ratio of repeat to single copy number) measured using qPCR and CAD (presence and severity) in 1,846 patients attending a regional cardiovascular centre for coronary angiography. Results: The number and proportion of elderly patients undergoing coronary angiography increased from 669 (8.7%) in 2001 to 1,945 (16.8%) in 2010. Among the elderly (>= 75 years old), symptoms were more severe and disease more extensive compared to patients aged <75 years. Peri-procedural complications were infrequent irrespective of age: 2.0% of elderly patients suffered complications, compared with 1.6% of young patients (p<0.001). Thirty-day MACCE were more common in elderly compared with younger patients (2.0% vs 1.6%, p<0.001). Elderly patients with evidence of stenosis were less likely to proceed to revascularisation (adjusted OR 0.68, 95% CI 0.65–0.71, p<0.001) within one year of angiography, irrespective of disease severity. There was an increase in the number and percentage of PCIs undertaken in elderly patients, from 196 (8.7%) in 2000 to 752 (13.9%) in 2007. Compared with younger patients, the elderly were more likely to have multivessel disease, multiple comorbidity, and a history of myocardial infarction or coronary artery bypass grafting (χ2 tests, all p<0.001). The elderly had a higher risk of MACE within 30 days of PCI (4.5% versus 2.7%, χ2 test p<0.001) Following PCI, mean QoL improved in both elderly and younger patients. Elderly participants had higher baseline mental component score (MCS) but lower physical component score (PCS). After adjusting for baseline differences, QoL (both physical and mental components) in elderly patients improved as much as younger patients, following PCI (SF-12 v2 MCS 50.0(SD 10.4) to 53.0(SD 11.9) vs 46.7(SD 11.1) to 49.7(SD 11.1), p=0.652; and SF-12 v2 PCS 37.6(SD 10.1) to 41.9(SD 10.1) vs 39.7(SD 10.0) to 45.6(SD 10.8), p=0.373). An inverse relationship was found between LTL (T/S ratio) and age. No statistically significant difference was found in mean T/S ratio between those with and without CAD (0.87(SD 0.21) vs 0.89(SD 0.21), p=0.091), even after adjusting for baseline characteristics. In addition, there was no statistically significant difference in relative T/S length by severity of disease in those found to have stenosis on cardiac angiography: 0.875 (SD 0.211) vs 0.875 (SD 0.212) vs 0.860 (SD 0.203) vs 0.867 (SD 0.200), p=0.670. Conclusions: This thesis has demonstrated that, in Scotland, elderly patients account for an increasing number and proportion of diagnostic coronary angiograms and PCIs. However, the threshold for investigation and subsequent intervention appears to be higher among the elderly, even after adjusting for co-morbidities. While elderly patients have a higher risk of early complications than younger patients, their absolute risk is, nonetheless, low. This suggests that coronary angiography and PCI are safe procedures to perform in the elderly. Following PCI, the QoL of elderly patients improves at least as much as in younger patients. A recognized risk factor for CAD is chronological age, and there is increasing interest in whether biological age contributes to the development and progression of disease and can explain socioeconomic inequalities in health. However, the current thesis found no association between LTL and either the occurrence or severity of CAD, or its severity on cross-sectional study. While LTL is considered a useful biomarker of ageing, these findings suggest that LTL may not be as useful in CAD. Although findings suggest that coronary angiography and PCI are safe procedures in the elderly, results of this thesis suggest an age-based inequality in access to coronary artery investigation and intervention that is not explained by differences in demographic trends, levels of need, potential risk or potential benefit. These findings have significant implications for the delivery of cardiovascular clinical services to an increasing elderly population. Further investigation should be undertaken upstream of these studies, on patients referred for investigation rather than just those receiving it to determine the extent to which there are inequalities in referral threshold as well as procedure threshold. Further research is also required to identify those elderly patients who would most benefit from earlier investigation and management. There is also a need for longitudinal studies to assess the usefulness of LTL as a biomarker of ageing in CAD and to investigate whether LTL is associated with adverse outcomes in patients diagnosed with CAD.

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.

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.

The overall objective of the study was to identify factors which play a key role in diet and exercise behaviour for migrant and Danish bus drivers in a workplace setting. The aim was to develop a framework to illustrate how the individual, contextual and cultural influences on health behaviour (diet and physical activity) interplay in an everyday perspective. Data was collected using a qualitative approach. Methods applied consisted of contextual based observations and semi structured interviews with sixteen (n=16) bus drivers. Four interviews were conducted with Danish, four with Somali, four with Turkish and four with participants with a Pakistani ethnic origin. The data was analysed using grounded theory. The core category which emerged from the data was „impact of individual, contextual and cultural influences on health behaviours‟. The core category was supported by five higher order categories. These were as follows: (1) Meanings of health (2) health behaviour and the potential to change, (3) Maintaining Balance (4) Workplace influences on health (5) Positioning in the social context. Each of the higher order categories was further supported with categories and sub-categories. The analysis illustrated findings on different levels. As a result of the impact of individual, contextual and cultural findings, strive for balance through a process of equilibrium was core to well-being and health in an everyday perspective. A collection of factors from the different levels of influence played a key role on diet and physical activity in an everyday work-day context. These have been illustrated through the use of quotes and frameworks. Based on the findings of the study, future research and practice recommendations are outlined.

The Scottish Executive (SE) commissioned the first phase of a National Coronary Heart Disease (CHD) Demonstration Project, Have a Heart Paisley (HaHP), in 2000. HaHP was a complex community-based partnership intervention. An independent evaluation of HaHP (phase one) was commissioned by the SE in 2001. This thesis presents the learning from the evaluation. The first aim is to identify the key implementation, evaluation and policy lessons to result from the evaluation. The second is to contribute to learning about how best to evaluate complex community-based interventions. The evaluation consisted of four approaches: a theory-based approach (the Theories of Change); the mapping of the context; a quasi-experimental survey; and, a range of integrated case studies. This thesis uses the programme logic (the intervention’s Theories of Change) articulated by the HaHP stakeholders to integrate the results from each of the evaluation approaches. HaHP (phase one) did not achieve significant changes in population level CHD risk factors, behaviours, morbidity or mortality. Like many previous community-based CHD interventions HaHP did not fully implement its intended Theories of Change. HaHP’s activities were not consistently based on best practice. It did not articulate or implement clear strategies for addressing health inequalities. The project delivered mainly individually focussed, ‘downstream’ interventions and struggled to achieve wide-scale local service, policy and agenda changes. It did, however, make progress with regard to improving partnerships and jointly delivering interventions. The findings from HaHP add to existing evidence that large-scale behaviour and cultural change will only be achieved through national action and the increasing use of ‘upstream’, legislative, or policy solutions, or changes in mainstream services and organisations. Activity in localised demonstration projects can add to such change rather than create it. The Theories of Change approach claims to improve planning and implementation, enhance evaluation, and address attribution. The approach (as applied within this evaluation) provided substantial amounts of formative feedback that was of use for improving programme implementation. This learning, however, was not always acted upon.

Tackling health inequalities is a policy priority. Research on cancer and particularly oral cancer aetiology has somewhat overlooked this area, in favour of pursuing genetic and 'lifestyle' risk factors. The over-arching aim of this thesis was to investigate the epidemiology of oral cancer in relation to individual socioeconomic status (SES), area-based socioeconomic circumstances, and socioeconomic inequalities. Descriptive epidemiology studies undertaken demonstrated that the burden of oral cancer was increasing across the UK, especially in Scotland, and a socioeconomic gap was widening with those from more deprived communities having significantly greater and increasing incidence of the disease. A systematic review and meta-analysis of the world literature showed that low compared to high SES was associated with significantly elevated risk of oral cancer independent of behavioural factors. A local case-control study provided unclear findings when individual- and area-based socioeconomic factors were explored together; however, a framework for future analyses was developed. In totality, this thesis suggests that public health policy to address the overall rising incidence and widening inequalities of oral cancer needs to acknowledge the complexity of the risk factors; in addition, the findings provide evidence to steer policy, which focus on lifestyles factors towards an integrated approach incorporating measures designed to tackle the root causes of disadvantage.

Background: The increase in the number of people living with HIV (PLHIV), especially in sub-Saharan Africa, is a major public health concern. To date, most attention has been paid to prevention strategies and clinical trials of therapy. In comparison, there have been very few studies of care and support programmes. The ‘HOPE’ programme is a major community-based care and support programme in Ghana. ‘HOPE’ provides nutritional support, skills training for employment, health education and psychological support for PLHIV and for those orphaned through AIDS. Therefore, it was seen by policy makers in the country as desirable that it should be evaluated. A PhD scholarship was funded and the researcher presenting this thesis was appointed. Broad Aims The overall aim was to carry out an evaluation of the ‘HOPE’ programme in Ghana in order to make wider recommendations for evaluation of community-based interventions (CBIs) in Ghana and Africa generally. The timing was less than ideal as many of the major decisions about the intervention had already been made and baseline data had been collected. Therefore, the preliminary aim was to explore a range of possible evaluation methods so that the most suitable approach could be selected. Thereafter, a range of more specific aims, objectives and research questions was identified. Methods: A ‘mixed methods’ approach was adopted. The first component was a desk-based analysis of the literature on the various evaluation approaches that might, at least in theory, be applied to an HIV/AIDS intervention like ‘HOPE’. From this, a decision was made to evaluate ‘HOPE’ in terms of structure, process and outcome. The second component operationalised this decision by reviewing HOPE’s working documents and conducting two pieces of field work: a quantitative and a qualitative study. The quantitative study was a structured questionnaire administered to 200 PLHIV on the ‘HOPE’ programme. The qualitative study consisted of 14 interviews with stakeholders directly involved in the programme implementation and 8 focus group discussions with the programme beneficiaries. Results: The desk-based analysis achieved three main outcomes. First, it set out in a systematic manner the different approaches to evaluation that could in theory have been applied to ‘HOPE’. It identified strengths and weaknesses and the perspectives behind each approach. Second, it set out and then summarised a detailed description of the ‘HOPE’ programme and the national context in which it operated. Third, it set the above within the context of global literature on HIV, community-based interventions and nutritional support programmes. The analysis of the quantitative data showed that beneficiaries were being provided with soy-fortified wheat and vegetable fortified oil at the time of the evaluation. On average, beneficiaries gained weight (Mean difference in weight was 2kg with 95% CI (1.1, 2.9), p-value < 0.001) and increased Body Mass Index (BMI) (Mean difference in BMI was 0.8units with 95% CI (0.4, 1.2), P-value < 0.001). Over a third of the beneficiaries (37.5%) was currently unemployed and only one in five of the beneficiaries had been trained in a skill that might have been useful to find employment: this, despite skills training for all being a programme goal. Multivariate analysis showed that the support group to which the beneficiary belonged was the most important determinant of a positive outcome. Qualitative components demonstrated perceived successes and challenges. Beneficiaries indicated that the anti-retroviral drugs were making them hungry and the food helped to alleviate that effect. They further indicated that the food was nutritious and contributed to their weight gain. Support groups have been sustained and membership increased. Some indicated that food should be more varied and some mentioned selling food to earn money to pay for their medications. Most of the beneficiaries indicated they were unemployed having lost their jobs as a result of stigmatisation. Only a few benefited from skills training leading to employment because of inadequate budgeting. Some who had been trained could not use their newly acquired skills because of lack of capital to start a business. To compound these weaknesses, most reported that they preferred petty trading to the skills offered. The monthly education and the training workshops generated hope, and improved knowledge of HIV/AIDS, promoted drug adherence and helped to reduce stigmatisation. The training of the PLHIV as peer educators is an effective method for HIV education and counselling since PLHIV listen to their peers more than health workers. Respondees predicted dissolution of the support groups when the programme ends. This is because they were not adequately involved in the decision making. Beneficiaries identified participation and cooperation as key prerequisites for sustainability but they also identified important weaknesses in ‘HOPE’ with respect to these criteria. Discussion: Despite the challenges presented by the timing and context of this study, it has been possible to carry out an evaluation that provides important learning. A mixed methods approach was appropriate and is likely to be useful in many similar evaluations. Beneficial outcomes were identified but these cannot be attributed, without qualification, to the intervention. Nonetheless, the findings indicated that participants were highly satisfied with the food support and monthly education. They were dissatisfied with the numbers trained in new skills and in other aspects of the skills training components. Also, the sustainability of the food component when the funding stops was a concern. However, the educational component could be sustained because peer educators could continue at very low cost. Most importantly, community involvement, using locally available resources, inter-sectoral collaboration and harnessing the motivation of local people were seen as key but underutilised ingredients. So, the results of the evaluation are encouraging but not conclusive. Nonetheless, care for people living with HIV is such an important problem that the desirability of conducting a cluster randomised controlled trial among a large number of support groups to assess the programme effectiveness on health, nutrition and economic status should be seriously considered despite the practical and ethical challenges implicit in such a recommendation.