In modern society, blood donor motivation and recruitment is a fundamental part of health care delivery. Well defined and documented programmes exist throughout the world but new ideas are always welcome. The situation in the Sudan is different and much remains to be done by way of comparison with elsewhere. This thesis outlines the objectives of a study, how it was supported, sponsored and achieved. It describes briefly the geography of the Sudan, the source of Sudanese economy, climate, culture and historical backgrounds. The problems of existing services in the Sudan are reviewed and a brief account of the demographic characteristics of the Sudanese population is given. Two surveys done in West of Scotland and in the Sudan are described in detail. This work discloses and compares the positive motives that enhances giving of blood and the negative motives that hinders its donation. The comparison is between an Eastern Society with a voluntary motivation not fully activated because of lack of understanding and awareness of the need to give blood voluntarily for strangers and Western Society with a well established voluntary system of donation. An addition to this research was the investigation into the immunity to tetanus and hepatitis in the Sudanese population. An estimate of the percentage of individuals with detectable levels of hepatitis A and B antibodies and tetanus antibodies is included since there is a need to establish a plasmapheresis programme as part of a good Blood Transfusion Service for the procurement of specific immunoglobulin's. This work has revealed major differences between the West of Scotland and the Sudan and suggestions are made for their resolution. The main conclusion and comparison are summarised in Chapter 7. It is hoped that many of the suggestions in this thesis can be introduced in the Sudan at an early date.

The purpose of this thesis is to examine the impact of financial incentives to promote health behaviour change. Financial incentives include tangible rewards as cash, vouchers and lotteries that are offered to individuals conditional to the fulfilment of health guidelines. Despite the growing use of such patient incentives in practice, some fundamental questions are yet to be answered: (1) Are financial incentives effective? (2) What type and size of incentive is more effective? (3) Do patient income and past health behaviour moderate the impact of incentives? These questions are analysed in the context of (a) blood donation and (b) compliance with health care including adherence to treatment, disease screening, immunisation and appointment keeping. Behavioural economics, in particular prospect theory, provide the theoretical foundations for this work and substantiate my hypotheses about the effect of financial incentives. I perform the first meta-analyses in the literature to quantify the impact of patient financial incentives to promote blood donation (chapter 3) and compliance (chapter 4). These results show that financial incentives do not promote blood donation but increase compliance with health care, particularly for low income patients. Two large field studies were developed to further examine the effect of incentives in compliance - testing pioneer incentive schemes. I test the impact of a certain (£5 voucher) versus uncertain (£200 lottery) incentive framed either as a gain or loss to promote Chlamydia screening (chapter 5). I also develop the first study ever testing preferences for sequences of events in the field – using the naturalistic setting of colorectal cancer. This study compared the effect of a €10 incentive offered at the end of screening versus two €5 incentives offered at the beginning and end of screening (chapter 6). The former showed the voucher framed as a gain was the most effective incentive and the latter showed that smaller two €5 incentives increase screening more than a single €10 incentive (which had a detrimental effect compared to no incentive). I fundamentally contribute to the literature by showing that (i) patient financial incentives do not increase the quantity of blood donations and may have an adverse effect on quality, providing empirical evidence to a long-standing policy debate. Furthermore (ii) small certain rewards around £5 are likely to be the optimal incentive for compliance with health care, (iii) higher incentives may be more effective if offered as smaller segregated incentives of the same amount and (iv) incentives have over twice the impact on low income patients than on more affluent patients.

This thesis focuses on the care of older people, both those with and without dementia, by family caregivers and one group of health professionals (trainee clinical psychologists). This thesis considers and explores a number of factors which are important to those providing care. These factors have been defined specifically as Religion / Spirituality in the literature review, which focuses on family caregivers of people with dementia. However, in the empirical paper those factors important to providing care were not pre-defined by the research team but emerged from the data. It is hoped that, in conjunction, these papers will contribute to understanding the perspectives of those caring for older people. Chapter 1 is a systematic literature review investigating the association between religion/spirituality and the psychological wellbeing/role adjustment among Black and Minority Ethnic (BME) family (informal) dementia caregivers. It focuses on one specific factor ‘religion/spirituality’ in order to understand one aspect of the dementia caregiving experience. Chapter 2 is an empirical study exploring trainee clinical psychologists’ experiences of working with older people, including people with and without dementia. Interpretative phenomenological analysis (IPA) was used to analyse the transcript data from eight interviews with participants. Three superordinate themes and nine subordinate themes emerged following the data analysis. The themes are explored, including implications for research, clinical practice and clinical psychology doctoral training. Chapter 3 is a reflective account, which includes the experience of carrying out the research and the insights it provided. Adopting the theme of ‘story’ allowed a connection to be made between hearing the stories of older people, and hearing the stories of participants in IPA research. The theme of ‘story’ then also allowed further exploration of this topic in books, research and media articles.

This thesis explores the experiences of informal carers of people with dementia. Undertaking a caregiving role can have a wide range of implications for the carer from negative outcomes such as increased physical and psychological stress to positive experiences such as a sense of pride or mastery in the role. Through further exploration of these differing experiences, this thesis informs understanding of the caregiving role and suggests new directions for carer support and research. The first paper is a critical review of the qualitative research exploring the positive aspects of caregiving in dementia. After database and manual searches were conducted, fourteen studies met the inclusion criteria and were reviewed. Carers across the studies consistently described a variety of positive aspects of caregiving. They also highlighted a number of factors that were important in supporting their positive caregiving experiences. Clinical implications relating to the inclusion of positive aspects in the holistic assessment and support of caregivers are discussed. The second paper reports on a quantitative study that explored the relationship between self-compassion, dysfunctional and emotion-focused coping strategies and carer burden. Survey data was collected from 73 informal caregivers of people with dementia. Carers with higher levels of self-compassion reported lower levels of carer burden. The use of less dysfunctional coping strategies was found to mediate this relationship. Emotion-focused coping strategies were not found to be a mediator. Clinically, compassion-based interventions represent a potentially useful intervention for carers. The final paper reflects on the differing contributions of qualitative and quantitative methodologies to research in psychology. The impact of the different methods on participants is considered along with the challenges to conducting diverse research in clinical settings. The scientist-practitioner nature of clinical psychologist role is noted as key in both respectfully representing participants and valuing the use of varied, clinically relevant research.

This dissertation examines the evolution of British diabetes management over the over the course of the twentieth century. It argues that through a series of technological, political, institutional and epistemological changes, British diabetes management came to centre on the bureaucratic discipline of professional medical labour by the early 1990s. That is to say that, by the end of the period discussed here, medical professionals and state bodies united in heralding care protocol, guidelines and audit systems as the best means to improve the quality of medical care, and, through improved risk management, to improve national health outcomes by extension. In undertaking such a study, however, this thesis looks to do more than simply add a new perspective to the growing literature on the history of diabetes. Instead, it both expands current understandings of the history of twentieth-century chronic disease control strategies in Britain, and historicises and reformulates existing literature on the emergence of clinical governance-style mechanisms for managing British medicine. In bringing these literatures and perspectives together, therefore, it is able to gain new insight onto the multiplicity of approaches taken to public health in the twentieth century, and to see structured and reviewed medical care as a framework that gradually emerged out of changing professional and political activities during the previous century. As a condition seen from the mid-century onwards as a model chronic disease, diabetes mellitus provides an excellent lens through which to read these histories. The history of its management and prevention, moreover, will only grow in importance over the coming decades as prevalence rates for the condition itself continue to rise into the twenty-first century.

This study critically engages with the concept of ‘recovery’ which has become a dominant discursive feature in the UK mental health policies. It asks ‘what people recover from’ through a case study of Chinese mental health service users in the UK. The dominant recovery approach under the dominant neo-liberal context tends to promote individualistic recovery strategies. It fails to address the structural inequalities that give rise to distress and mental ill health or place sufficient emphasis on the diversity of intersectional inequalities among service users that shape recovery journeys. To make visible what recovery means for ethnic minorities, Chinese mental health service users were chosen as the case study to explore how structural factors such as class, gender and ethnicity, contribute to their diverse recovery journeys. A synthesis of the Capabilities Approach and Intersectionality Analysis was developed as an alternative framework to shed light on the complex interplay of structure and agency in shaping recovery journeys. They were adapted as evaluation and analytic tools to reveal the social conditions that facilitate or hinder a meaningful recovery for Chinese mental health service users. Repeat in-depth life history interviews were carried out with twenty two Chinese people having received a psychiatric diagnosis, recruited from three cities in the England. Their recovery journeys were analysed thematically. Findings showed how the participants strove, sometimes cautiously, to retain and exercise agency to move from patienthood to personhood. Their journeys were shaped by social inequalities demonstrating that targeting social inequalities is essential for facilitating and nurturing meaningful recovery. Class, gender, ethnicity, ageism, and other forms of discrimination contributed to the diminishment or deprivation of capabilities, resulting in distress and mental ill health among the Chinese mental health service users in this study. The different ways that these inequalities intersected gave rise to the variations in what they needed to recover from and hence also the directions of their recovery journeys. The process of becoming a psychiatric patient can help develop capabilities for some but it could also result in a diminishment of other capabilities. While striving to rebuild a life they value, ableism and sanism intersect with other inequalities to constrain their life chances. While the way ‘hope’ was ‘adapted’ to limited perceived life chances and dominant ideologies of class, gender, and ethnicity could be capability diminishing and detrimental to nurturing their aspirations.

UK ethnic minority patients are reported to be under-represented in clinical trials. Under-representation of any patient group within an Randomised Clinical Trial can bias trial results and subsequent extrapolation into the general population. However, the true extent of ethnic minority representation in RCTs is masked by the poor quality of ethnicity data. This thesis investigates ethnicity data collection in healthcare and the representation of ethnic minority patients in RCTs in the UK. A systematic literature review of ethnicity data collection identified a paucity of published evidence. Self-reported ethnicity was recognised as the optimal method of data collection but training is needed to raise awareness of the importance of such data. Reasons for the gaps in ethnicity data were explored through a healthcare professional survey and focus groups with lay South Asian volunteers. The majority of healthcare professionals agreed it was important to collect ethnicity and emphasised the need for training. The focus groups revealed a willingness to provide these data, subject to being given information regarding their use. A second systematic literature review of interventions to improve recruitment and retention of ethnic minorities to RCTs found a dearth of literature from the UK. US studies reported financial incentives, government grants and the involvement of community representatives to be effective. Census data, hospital episode statistics data, clinical trials recruitment and reasons for non-participation, collected in one cancer research network, were used to assess the local representation of ethnic minorities within RCTs. The results did not show ethnic minorities to be under-represented, but there was insufficient evidence to rule out under-representation as a problem. Reducing inequalities in participation in clinical trials is dependent upon having accurate and complete ethnicity data. A change in policy to mandate the collection of ethnicity data in primary care and linked through to other healthcare service providers is required.

My substantial, original contribution to mental health research, education and practice spans 17 years, from the mid 1990s to the present day. It is a journey on which I consider I am still travelling, during which the landscape of mental health services and the workforce that delivers them has changed in an unprecedented fashion. It has been a privilege to have contributed to this metamorphosis which began with my research into diversion schemes for mentally disordered offenders (MDOs) moving onto interdisciplinary mental health education/training and workforce redesign. Latterly, my to contribution promoting service user-led research has revisited the care and treatment for MDOs, focusing on the effectiveness of participatory action research (PAR) for effecting improvements in care delivery for individuals with complex mental health needs.

This Health Services Research PhD, funded by the Chief Scientist Office (CSO), investigated the psychosocial aspects of obesity in a community sample of men and women aged 30-60 living in deprived and affluent areas of Greater Glasgow. The study incorporated a mixed method design and combined a community health survey and semi-structured interviews with a purposively selected sub-sample of questionnaire respondents. 52% of the participants who completed the questionnaire were either overweight or obese and 16% were defined as obese. Obesity and body image were not significant predictors of poor psychological health. Furthermore, low self-esteem was the most significant predictor of poor psychological health for both men and women. The quantitative and qualitative findings demonstrate that obese individuals are aware of their current weight status and express a desire to lose weight. Potential motivating factors for weight loss included health concerns, appearance, special occasions and psychological factors such as increased self-esteem and self-confidence. Participants were knowledgeable about the causes of obesity and had absorbed and understood health promotion messages regarding healthy eating and physical activity. However, they identified a number of barriers, which prevented them from fully implementing health promotion advice. The qualitative findings suggest the possibility of a cyclical relationship between dieting depression and emotional eating. In addition, the findings demonstrate that weight cycling – losing and regaining weight – was a common experience for the interviewees. As weight cycling is a potentially damaging health problem, it might be more appropriate to encourage obese individuals to maintain a stable weight and improve their health by re-focusing the issue on fitness rather than fatness.

This thesis sought a greater understanding of the social variables that influence diet and dietary change using a repertoire of research methods. The studies of the present thesis, like all studies, have methodological limitations and possible biases. However, after considering the problems of each study, it seems reasonable to make the following conclusions; 1) the poor were spending a greater proportion of their income on food, than people living on higher incomes; 2) providing food (and therefore health) for the family was the main responsibility of a woman in the household; 3) that all the individuals in the Income Charge study were meeting their basic food needs; 4) there was a strong desire to maintain 'mainstream' or 'normal' social eating practices following an involuntary decrease in household income; 5) there is an 'inverted V' relationship between income and variety with £20,000 as a turning point; 6) lower income families focus on meals rather than on the individual value of individual foods and on cost and taste of the food rather than its nutritional content; 7) the impact of a change in income on meal patterns, although variable from one individual to the next, was significant in most cases; 8) income was associated with dietary variety per se; 9) food changes evidence from the Income Change Study may support the view that less healthy eating in low-income groups may be a consequence of less healthy eating when a household income decreases involuntarily and 10) different subtle calculations of measures of income were found to have little notable impact on results and it was assumed that these measures could be used interchangeably in future studies as equivalence was good. For future research into the area of income and 'healthy' eating practices, the following recommendations were made: 1) studies need to have a fully comprehensive list of income and outgoings; 2) dietary interventions and health promotion activities need to consider advocating variety at each mealtime wherever possible; and 3) studies need to examine the possibilities that a change in income affects weight management in greater depth using objective tools where possible.