The prevalence of obesity is high and the primary care setting enables treatment to be offered to large numbers of people. This thesis investigates behavioural weight management interventions in primary care. A noninferiority analysis was used to examine whether four behavioural weight management programmes differed in weight loss at three and 12 months. Commercial programmes resulted in similar weight losses and the NHS programme was inferior at three months, with an inconclusive result at 12 months. GPs can refer patients to commercial weight management programmes, however not all people use these types of programmes. There is a need to find simple effective interventions that can be offered in primary care. Self-weighing may be one such strategy for weight loss; a randomised controlled trial investigated this. There were no significant differences in weight loss between baseline and three months. Self-weighing may be more effective for weight loss maintenance as people have developed skills to manage their weight. A quasi randomised controlled trial was used to investigate this and found encouragement to self-weigh prevented 0.7 kg weight regain. A systematic review and meta-analysis investigated the effect of self-weighing. Overall, self-weighing as part a multicomponent weight loss intervention resulted in greater weight loss but isolated there was no evidence of effectiveness. In conclusion commercial weight management programmes result in similar weight losses and patients could be referred to such programmes by primary care. Self-weighing may be an effective strategy that primary care practitioners could advise patients to use combined with other behavioural strategies.

This thesis reports work to develop and score (value) a measure to capture the impact of end of life care (EoLC) on those people close to the dying. This work is conducted in response to the need to capture wider impacts of EoLC for economic evaluation where there is lack of appropriate measures. To develop the measure, twenty seven in-depth interviews were conducted with those who were recently bereaved or close to somebody receiving EoLC. Constant-comparative analysis was used to develop dimensions for the measure. Pictorial tools were used to explore who is close to those at the end-of-life and therefore could legitimately be included within the evaluation of EoLC interventions. The measure was valued using an exploratory deliberative methodology conducted with six focus groups comprising members of the public. The measure contains six dimensions: \(communication\) \(with\) \(those\) \(providing\) \(care\) \(services\), \(practical\) \(support\), \(privacy\) \(and\) \(space\), \(emotional\) \(support\), \(preparing\) \(and\) \(coping\) and \(emotional\) \(distress\). The communication and practical support attributes received the greatest weighting in the valuation process. On average, there were eight individuals close to those at EoL. This work significantly enhances the potential for including close-persons in economic evaluation of interventions at the end of life.

This thesis is submitted as part of the Doctorate in Clinical Psychology at the University of Birmingham and consists of two volumes. Volume I contains the research component of this thesis and consists of a systematic literature review, empirical research paper, and public dissemination document. The systematic review found that content on social networking sites can provide researchers with tentative information about the psychopathology and personality traits of the user. However, research displaying greater internal and external validity is required before this information could reliably inform the development of targeted online public health information or interventions. The research paper presents a study exploring the relationships between drinking identity, alcohol use, mental health symptoms, and alcohol content in social networking site pictures, in a community sample of young females. Drinking identity may be an important factor to consider in alcohol reduction and prevention efforts. The public dissemination document provides an accessible overview of the review and research paper. Volume II consists of five Clinical Practice Reports (CPRs). CPR I presents a Cognitive-Behavioural and Systemic formulation for a 21-year-old female experiencing low mood. CPR II presents a service evaluation of non-attendance to psychological assessment appointments in an adult community mental health setting. CPR III presents a single-case research design to assess the effects of a Positive Behavioural Support intervention with a 40-year-old female displaying behaviour that challenges. CPR IV presents a case study of Acceptance and Commitment Therapy with a 69-year-old female experiencing chronic pain and depression. CPR V presents a presentation abstract for a case study of Cognitive Behavioural Therapy with a 31-year-old female experiencing Bulimia Nervosa.

The quality of healthcare is increasingly the subject of scrutiny by a range of stakeholders, including healthcare provider organisations, health professionals and their representative bodies, healthcare purchasers and funders, policy makers and national governments, patients and users of health services. The use of a variety of quality measures has become widespread in the healthcare systems of many developed countries, including the United Kingdom. The twin tasks of measuring and improving the quality of care - often termed quality assurance - have been addressed by new arrangements for professional accountability, new approaches to managing and comparing organisational performance, and new statutory and legal mechanisms. Adverse events in healthcare, which can be loosely defined as instances which indicate or may indicate that a patient has received poor quality care, offer an important opportunity for quality measurement and improvement. There is extensive evidence that adverse events are relatively common, that they can have serious and lasting impacts on patients, and that they represent a considerable cost to healthcare organisations. Equally importantly, evidence in healthcare and experience in other sectors suggests that adverse events offer an important insight into the strengths and weaknesses of healthcare processes, and an invaluable opportunity to bring about improvements in the quality of care. Adverse events have been used quite widely, particularly in the United States of America, as the basis of a number of measures of the quality of healthcare. However, these measures have rarely been developed and tested rigorously before they have entered widespread usage, and there has been considerable debate about their advantages and disadvantages. A series of empirical studies were undertaken, using data collected through the use of adverse-event measures of quality in a British acute hospital, aimed at investigating the validity and reliability of those measures. The results showed that the adverse-event measures being tested had moderate to good face, content and construct validity. Although their validity was capable of improvement, it was still clear that they were measuring meaningful and important dimensions of the quality of healthcare. However, the reliability of the measures being tested was more mixed. While experimental studies of interrater and intrarater reliability indicated that they had moderate to good reliability (though, again, it was capable of improvement) observational studies suggested that the reliability in actual use might be lower than that found during testing. This research concludes that adverse-event measures of quality are important measures of the quality of healthcare, which should be used in healthcare quality assurance with two main provisos. Firstly, the development of measures should be more rigorous, and should pay more attention to both validity and reliability issues. Secondly, the routine use of such measures should incorporate some element of ongoing reliability testing, in order to ensure that good reliability is maintained.

Medical tests are essential for patient care. Evidence-based assessment of the relative accuracy of competing diagnostic tests informs clinical and policy decision making. This thesis addresses questions centred on assessing the reliability and transparency of evidence from systematic reviews and meta-analyses of comparative test accuracy, including validity of meta-analytic methods. Case studies were used to highlight key methodological issues, and provided rationale and context for the thesis. Published systematic reviews of multiple tests were identified and used to provide a descriptive survey of recent practice. Availability of comparative accuracy studies and differences between meta-analyses of direct (head-to-head) and indirect (between-study) comparisons were assessed. Comparative meta-analysis methods were reviewed and those deemed statistically robust were empirically evaluated. Using simulation, performance of hierarchical methods for meta-analysis of a single test was investigated in challenging scenarios (e.g. few studies or sparse data) and implications for test comparisons were considered. Poor statistical methods and incomplete reporting threatens the reliability of comparative reviews. Differences exist between direct and indirect comparisons but direct comparisons were seldom feasible because comparative studies were unavailable. Furthermore, inappropriate use of meta-analytic methods generated misleading results and conclusions. Therefore, recommendations for use of valid methods and a reporting checklist were developed.

This thesis consists of research and clinical components and is submitted as partial fulfilment of a doctorate degree in Clinical Psychology. Volume 1, the research component, comprises of a literature review, an empirical paper and a public domain paper. The systematic literature review looks at evidence linking attachment and caregiving in adult couples. The empirical paper explores the experiences of individuals with a partners diagnosed with Motor Neurone Disease (MND). Lastly, a public domain provides a summary of the empirical paper. Volume II, the clinical component, contains clinical practice reports conducted within placements from adult, child, learning disability older adult specialities. The first report contains a behavioural and systemic formulation of a 3 year-old who was referred as her mother was having difficulties managing her behaviour. The second report describes an evaluation of the Experiences of practitioners interpreting and delivering Triple P (Positive Parenting Programme) groups in South Asian Community languages. The third report presents a single case experimental design concerning a behavioural approach to challenging behaviour displayed by a 7-year old boy with learning disabilities and autism. The fourth report is a case study of a Cognitive Behavioural approach used with a man diagnosed with Persistent Paranoid Delusional Disorder. Finally, the fifth report is an abstract of an oral case presentation of a small-scale service related project around a multiple family therapy group for adolescents with anorexia nervosa.

Advanced capitalist societies are currently experiencing a series of widespread global public health challenges. The purpose of this research has been to explore the role of ‘fitness professionals’ in this landscape and to understand whether and how they are able to make the contribution to public health that is claimed. The research was conducted over three iterative phases of research: (1) a comprehensive literature review; (2) five complex case studies of fitness professionals in practice; and (3) interviews with twenty key stakeholders/policymakers in the health, fitness and leisure sectors. The findings show that fitness professionals are an important, complex, undervalued and precarious health-related occupational group. Based on the research evidence, it is clear that there is a gap between the health- and fitness-related needs of society and the capacity of the health, fitness and leisure sectors to serve those needs effectively. Using ‘neoliberalism’ as a framework, it is argued that the occupational group of fitness professionals appears to highlight critical gaps in the neoliberal ideology concerning whether, how and under what circumstances the state should intervene in a health-related market. Recommendations are made for improving the practice and/or the development of practice for fitness professionals in the future.

This work is an endeavour on the subject of the Critical Success Factors imposed by Human Resources, in the process of reforms, under the context of New Public Management, particularly, as this applies in the Greek Public Sector and more specifically in the cases of ISO implementation. The fundamental issues it attempts to elucidate are the Human Resources policies that must be applied, so that employees become an integral element for the successful implementation of any introduced reforms. Many scholars have pointed out the gap in literature regarding the effect of New Public Management (NPM) reforms on the human factor. Moreover, in the current Greek reality, in the context of the economic recession and the debt crisis, where public administration reforms are mandatory, the thorough examination of the vital issues, pertaining to Human Resources, consists a major priority. The qualitative research method applied with the employees of the reformed organisations has further aspired to ponder and determine what really matters during the transformational process from the employees’ point of view. The conclusions we have reached underpin the importance of Human Resources motivational factors in the reform process, taking into consideration that the employee is the catalyst for any change effort. Some of those factors were found to be also part of the ISO concept per se, thus, their implementation would boost the employees’ morale, while others must be carefully analysed, planned and implemented by all the stakeholders to further facilitate the change process. We have to bear in mind that, especially under the current dire economic environment, quality reforms could be a challenge, as they combine fiscal discipline and at the same time aspire to increase the employees’ and citizens’ satisfaction. This study goes further to suggest that, the implementation of ISO reforms could help all the participants, provided that the decision makers take into serious consideration the Critical Success Factors outlined herewith, that have been extracted from a survey conducted pertinent to our research. This study focused on the reforms/ISO process as implemented by the Intermediate Managing Authority of the Ionian Islands. Further research on the implications from the implementation of NMP doctrines on Human Resources should be conducted in other Greek governmental organisations, in order to reaffirm the results and possibly enhance the suggested model. Conclusively, our ultimate target is to assist decision makers and encourage them to utilise the arguments depicted, towards the successful implementation of NPM doctrines.

Over 275,000 women died of pregnancy related causes in 2015. Most occur in resource-poor settings and are preventable. This study aimed to improve the working lives of maternity healthcare workers in Malawi to enable delivery of higher quality care, using Appreciative Inquiry (AI); a positive-focused, participatory action cycle. Following a systematic review and narrative synthesis of AI, an ethnographic study and Interpretative Phenomenological perspective were utilised to understand working lives. Before the intervention was implemented, working lives were assessed through validated questionnaires for staff and patient satisfaction surveys. AI has been used in healthcare, but little empirical evidence for its effectiveness exists. Staff wanted to do a good job, but were confined by a lack of resources, knowledge and support. The longitudinal survey of staff showed significant improvements in general wellbeing and home-work interface, and patient satisfaction improved. AI also improved staff relationships and made work easier and happier. Qualitative work suggested this was because staff were working better together, underpinned by everyone meeting together. From these findings a theory of change was developed. AI showed great promise. However, further research, in the form of a large-scale trial, is needed to empirically demonstrate the effectiveness of AI in healthcare.

Patient chronic illness and disability impacts the health of family members and household members who experience psychological distress and care burden. These impacts, known as ‘health spillovers’, are typically ignored in economic evaluations, despite being relevant to ensuring maximum health benefits from scarce resources. This thesis explores methods for including health spillovers in economic evaluation. Three empirical studies were carried out. The first study generated evidence supporting the validity of the EQ-5D-5L and SF-6D for measuring health spillovers. The second study examined the health spillover from a behavioural intervention on related household members’ outcomes. Further trials are warranted which measure household member outcomes for patient health interventions. The third study demonstrated and applied a methodology which could be used to include health spillovers in a cost-utility analysis. The general conclusion is that family member costs/outcomes should be systematically accounted for in extra-welfarist economic evaluations, and though there remains uncertainty about the best way to achieve this, the findings from this thesis show that this is possible and advance the methods forward.