Rates of suicide amongst young people with a first episode of psychosis are significantly higher than those of the general population. Psychological theory demonstrates that protective and moderating factors that buffer risk against suicidality are important for understanding why people think about, attempt and are successful at killing themselves. A literature review was conducted to identify the factors that reduce the risk of suicidality specific to people experiencing psychosis. Positive self­ appraisals, social support, daily activities, coping, negative symptoms of psychosis, and low IQ were found to protect against suicide amongst people with psychosis. An empirical study was then conducted to investigate whether the moderators (i.e. thwarted belongingness, perceived burdensomeness and acquired capability) outlined in the Interpersonal-Psychological Theory can distinguish between young people with a first episode of psychosis who think about suicide and those who attempt suicide (N=45) using self-report measures. The concepts of the Interpersonal­ Psychological Theory appear to resonate with the experience of psychosis, regardless of suicidality. This may explain why this study was unable to distinguish between those who just think about suicide and those who attempt in a psychosis population. Future research could assess specific features of psychosis and their influence on suicidality.

This thesis has two aims: First, to demonstrate that there is in the current medical model of transsexuality conceptual incoherence. Second, to establish an alternative model for understanding transsexuality: the model of authenticity. The current medical model is based on an assumption that the sexed body and gender identity are distinct, so that gender is different to sex, which forms the basis of transsexuality. The tension in transsexuality between sex and gender gives rise to suffering. Surgery unifies sex and gender and is offered as the humane response. It is this move from separation to unification of sex and gender that constitutes the conceptual incoherence in the current medical model. Suffering is then explored as a potential justification for surgery. It is argued that it is not obvious that suffering must be alleviated. Indeed, suffering may be valuable, and where this is the case there is no moral imperative to remove it. So, whilst there is a serious moral duty to respond to suffering there is no absolute duty to alleviate it. An alternative model is then explored. A model of authenticity, which can replace the medical model, better enables the freely chosen identity and goals of the transsexual to be respected, without compromising the ends of medicine.

This PhD by Publication has investigated contemporary management of change practice in health and social care. Through eight case studies it explores change within different sectors, roles and organisations within national, regional and local systems. More successful change programmes are better able to understand their contexts, to design change theories that will work within these contexts, to fully implement the activities planned on the basis of these theories, and to have the resources and autonomy to complete the programme to its conclusion. Despite the relative success of some programmes, there are common opportunities for change management practice to be improved. These include -the meaningful engagement of service users throughout the process; setting of intermediary and final outcomes that provide opportunity for formative and summative evaluation, and in the use of relevant data to enable reflective change practice. It would also appear that despite the considerable body of knowledge regarding management of change this rarely explicitly influences change programmes and therefore stronger collaboration between academia and practice is still required. A pragmatic approach in which different academic fields collaborate to directly respond to the problems faced in practice would be beneficial.

This research empirically examines and compares the adoption of health technologies through case studies. The health technologies under review are assisted reproductive technologies, cochlear implants, haematopoietic stem cell transplantations, caesarean section deliveries, Gamma knife units and kidney transplants in four countries: Japan, Korea, the UK and the US. The interactions between the micro factors of health technologies and the macro environment in the adoption of health technologies are examined on the basis of a literature review and analysis of data. The micro factors were evaluated in terms of economic, clinical and technical aspects. In assessing the macro factors, payment systems and regulations related to the selected health technologies were taken into account. To examine the micro factors, the results of health technology assessments in earlier studies were reviewed. In order to explore the macro factors, historical changes in the payment systems affecting the selected health technologies and legal regulations, including legislation, directives, guidelines and court orders related to the technologies, were investigated. The adoption level of health technologies was evaluated in time-series and cross-sectional terms, measuring the trend of technology adoption and comparing the experience of the four countries under review. This research suggests clustering health technologies into “welfare oriented technology” and “private benefit oriented technology” by considering the economic incentives of adopters, individual desires of consumers and public concern over the technology. Private benefit oriented technologies are those which adopters expect to increase income from the providers or which meet the personal desires of the consumers. For welfare oriented technology, the decision is dominated by the aims of public welfare. As the model predicted, the adoption of welfare oriented technologies was higher in the health systems under national planning, while that of private benefit oriented technologies was higher in the systems whose health provisions accept market conditions.

Introduction: Day surgery has many benefits for patients and the NHS, but progress in this area of healthcare has been slow. A high volume procedure, laparoscopic cholecystectomy, was chosen to explore this. The aim of this study was to explore and explain the factors that influence the uptake of day case laparoscopic cholecystectomy at three trusts and the impact of service redesign programmes on day case rates. Methods: A mixed methods collective case study was conducted across three trusts. 34 semi-structured interviews were undertaken and 5 years of hospital activity data was analysed. Results: Day case laparoscopic cholecystectomy rates did increase over a 5 year period at all trusts but to varying degrees. Factors that influenced activity according to qualitative data analysed were grouped into two themes: context and mechanisms. Conclusion: Participants did not believe that the service redesign programmes had any direct impact on their practice. New ambulatory care facilities alone did not lead to increased day case laparoscopic cholecystectomy rates because the trust that performed the most did not have any change to their infrastructure. Clinical attitudes towards performing day case laparoscopic cholecystectomy were variable and may explain the difference in day case rates.

No description available.

An Army training program was evaluated in order to present recommendations for program refinement. The training program, developed as part of two larger Army combat development (CD) studies (DuBois & Smith, 1989a, 1989b), represents an attempt to define program design requirements for training tank commanders to use the Intervehicular Information System (IVIS). IVIS is a computer-based command, control, and communications system proposed for future M1A1 tank upgrades. Twenty-four Army tank commanders (TCs) participated in the research effort. TCs were of various rank and age. Training and testing were conducted over a 4 day period. Training lasted 1-1/2 days followed by 2-1/2 days of testing. The Biographical Questionnaire, the IVIS Knowledge Test, the IVIS Performance Test, the SIMNET Knowledge Test, the IVIS Survey, and the IVIS Training Reactions Questionnaire were administered to each TC. TC biographical data, reactions to training, post-training performance, and post-operational performance were evaluated. Scale reliability was evaluated for each IVIS instrument. Descriptive statistics were calculated for the soldier reaction and performance measures. Regression analyses were performed to assess the impact of TC background characteristics on commander performance. Results of the above analyses indicate: (a) the IVIS Performance and Knowledge tests are reliable, (b) the soldiers learn during training and the learning transfers to the operational setting (performance measured after two days of testing shows soldiers performance significantly increased from that of post-training performance), and (c) soldier biographical characteristics do not predict IVIS proficiency. The results call for more training time allotted to teaching IVIS skills with some IVIS functions deserving more attention. Additionally, it appears personnel requirements may not be an issue for selecting IVIS system users as the study found no correlation between biographical characteristics and IVIS proficiency. And finally, it is recommended that observational raters receive greater rater training as interrater reliability estimates were low.

The architectural and spatial design and two public housing projects, Brownsville and Van Dyke, located in the Brownsville section of Brooklyn, New York, were tested to determine their effects upon the crime rates and mental illness. While keeping the socio-economic factors under limited control, a data comparison approach was used to illuminate any difference in the crime and mental illness rates between the two projects. A significant difference in the crime rates was noticed between them with the Van Dyke Houses having a higher crime rate. Since Van Dyke also had a significantly higher percentage of mental illness than compared to Brownsville Houses, a correlation between the sense of residential security and mental health was drawn. In conclusion, the architectural and spatial design was found to be an important influence in crime deterrence in public housing as well as the cultivation of mental health of the project's occupants.

A study was conducted to develop a written tank knowledge test for United States Army armor trainees. Such a test may be employed as a tool for training program evaluation and as a criterion measure for assessing trainees. The Tank Knowledge Test (TKT) was developed from items written by subject matter experts familiar with the armor training program. After pilot testing, a revised version of the TKT had an internal consistency reliability of .79. Item difficulty levels ranged from .16 to .92 with a mean of .57. A factor analysis performed to examine the possibility of deriving subscales from four clusters of topically related items revealed no support for a four factor solution.

Following the 1992 LA Riots, the LAPD underwent institutional reform, with Community-Policing as a lead programmatic effort to bridge tensions between the community and the LAPD. Conceptually, Community-Policing was designed to improve community relations and create shared responsibility. Following the early 90’s, several programming efforts were made to support the Community-Policing approach. Following the reform period, one must wonder whether Community-Policing proves effective. In order to assess the effects of community-policing, this paper is formatted as a Case Study, conducted in Watts, California. The Watts Case Study analyzes the effectiveness of Community-Policing, and how Community-Policing has shaped community-police relations over time.