The central theme of this thesis is the place of a report provided by the trainer on the performance of the trainee as part of a process of regulating entry to independent general medical practice in the United Kingdom (summative assessment). The thesis aims both to analyse the place of a such a report within a process of summative assessment and to consider whether it is possible to develop a report form for this purpose that enables aspects of the general practitioner trainee's skills, knowledge, attitudes and practice to be assessed by the trainer in a feasible, valid and reliable way. It is argued that the certification process for entry to independent general practice in the United Kingdom needs review and that tests of performance, such as a trainer's report, have a particular role in such a process; that such tests should be criterion-referenced; and that a number of properties are of particular importance in the development and testing of a trainer's report in the context of the assessment of doctors completing general practitioner training in the United Kingdom. A set of research objectives are delineated for a sequential series of five research studies. Using a variety of methods (semi-structured group interviews, postal questionnaire surveys, consensus conference, and pitot testing), these studies demonstrate: that there is a specific place for a trainer's report; that valid contents can be selected and minimum standards set; that the report form that has been developed is reliable and feasible and allows discrimination; and that, should it be widely adopted, there is a strong need for further testing, a continuing quality assurance system and further developmental work. It is concluded that summative assessment does have a role in providing an initial step in assuring the public of the quality of doctors entering independent general practice and that the report form developed here is suitable for wide application within such a process. It is also reasoned that a number of lessons about the application of such a process, and the inclusion of such a report, in other settings can be learnt. In particular it is suggested that a report provided by a trainer may have a particular role in assessment when the requirement is the assessment of performance of complex attributes within the context of training designed to enable the trainee to carry out a particular purpose but that it should rarely be used as the sole instrument.

This dissertation examines the 'implementation gap' and reports evidence on progress in implementing closure of health services at micro-implementation level. Specifically, the research develops an historically bound, processual and contextual account of the development and fate of permanent closures of General Practitioner Maternity Units (GPMU) in four neighbouring Oxford DHAs. The major objectives of this study are to illustrate and analyse the process by which the 'implementation gap' is closed and to identify. some of the potentially important factors which help to explain the pace and rate of change differential across health districts. The key questions, guiding the research include: What affects the pace of implementation? Why do districts fail or succeed in implementing change? What affects the 'implementability' of the GPMU closure proposals? To make further progress towards an understanding of implementation, this research adopts a new, eclectic, and integrative approach: the Contextualist Approach. One major theme underlying most of the results and ideas presented here, is that the outcome of implementation can be explained by the interplay between the content, the context and the process of implementation itself. The research is essentially qualitative. The data collection process comprises three main activities: documentary search, in-depth interviews, and ethnographic material. The strategy of data presentation and analysis was to develop a descriptive framework for organising the data (Yin, 1989). A set of three interacting groups of factors is found to affect implementability and rate and pace of change at micro-implementation level - the nature of the locale, leadership, and the quality of the proposal itself. Although other authors have studied health service policy, this research is unique in offering an extensive treatment of the changing policy context under investigation. It is also the first to investigate partial, as opposed to total, closure of hospitals within the context of the NHS, with particular emphasis on the GPMU.

While health promotion is ostensibly concerned with the full range of processes through which people might control and improve their health, this thesis shows that existing approaches and the literature are limited by Eurocentrism, focusing primarily on the health concerns of Western people and obscuring those of others. Following literature review, the thesis examines the historical process of the formation of health promotion as a hegemonic discourse within the West. A worldsystem approach is then used to situate health promotion in a transnational structure, and to analyse health data from Trinidad and Tobago regarding the relevance of health promotion in the Third World. Fieldwork among non-governmental organisations (NG0s) in Trinidad examines interpretations of health promotion, drawing attention to areas of difference from hegemonic discourse and the symbolic identities invoked. Health problems in Trinidad and Tobago were found to be related to patterns and fluctuations in capital accumulation on a transnational scale, with problems usually associated with "modernisation" coexisting with diseases associated with "poverty". Health promotion strategies need to take account of how both production and consumption are structured globally. In their health promotion work, most NGOs blended elements of non- Western understandings, particularly in the area of spirituality, with hegemonic concepts grounded in biomedical science. The postcolonial concept of hybridity is used to analyse responses and resistance to Western discourse. Respondents maintained that spirituality enabled people to transcend racism and to enhance subjective well-being and control over health. The results highlight that to devise appropriate health promotion strategies means to respect difference, not by adopting a position of cultural relativism but by understanding how transnational relationships of power pervade relationships between cultures and affect health. Strategies should nurture the creative expression of local views, contesting the centralisation of knowledge and material resources for health within the West.

This work aims to demonstrate the use of oral-fluid methods in evaluating the effectiveness of a vaccination programme at the individual (vaccine conversion) and population levels (herd immunity and virus transmission and origin) within a developing country context. The setting for this work was Ethiopia- a country beset with huge economic, social and logistical difficulties in vaccine programme implementation. The study comprises the following: First, the development and evaluation of highly sensitive measles specific IgG/IgM ELISAs using oral-fluid, second, the application of these assays to evaluate routine and campaign measles vaccination programmes, and third genotyping of measles virus strains circulating in the country, again using oral-fluid samples. Paired blood and oral fluid samples were obtained from787 individuals of all ages from rural Ethiopia for evaluation of the measles enhanced IgG antibody capture (GAC) enzyme linked immunosorbent assay (ELISA). Relative to serum, oral fluid assay sensitivity and specificity were: 97.4% and 91.1% for measles IgG. This work is the development and evaluation of a new method that has contributed scientifically to vaccination programme evaluation and refinement. Pre- and post-vaccine antibody determined in 296 children attending for routine measles immunization in Addis Ababa suggested the average vaccination age at which 92.6% (200/216) seroconversion rate attained was about nine and half months. Oral-fluid based testing show 87.3% (185/212) seroconversion rate for IgM antibody compared to the 92.6% serconversion rate for serum. This work included the development and use of an oral-fluid enhanced MACELISA as a useful substitute to serum in evaluating vaccine seroconversion. RT-PCR was performed for oral-fluid and serum samples collected from outbreaks and sporadic measles cases across the country to study the molecular genotype characteristics of the strains. Sequence analysis of outbreaks and sporadic case samples revealed that the viruses of the D4, D8 and B3 genotypes were found in the country. This study also demonstrates the practicality of integrating oral-fluid based genotyping into measles surveillance efforts. Pre-campaign survey work carried out in Assella town by collecting oral-fluid samples from 1928 children aged 9-59 months visiting vaccination stations, and post-campaign survey work undertaken by cluster-based random sampling of 750 oral fluid samples from eligible individuals aged between 9 months to <20 years clearly show (i) a shortfall in measles 'immunity 'in the target age group (9-59 months), and (ii) a significant deficit in 'immunity' in those too old to have received the vaccine. This work demonstrates for the first time the merit of oral-fluid sampling in evaluating a measles vaccine campaign. The main achievements summarized above, give weight towards the practicality of using oral fluid in evaluating and refining immunization programmes in the developing country setting. It waits to be seen if the non-invasive technology will gain wider support in the measles control activities.

This is a study of the experiences and perspectives of the users and providers of primary health care. The study analyses the users and the providers' experiences and perspectives with regards to the decentralization policy and its impact on the quality of primary health care delivery in the rural district of Pallisa in Uganda since its implementation in 1990s-2005. This is mainly a qualitative study in which both users and providers were interviewed although quantitative data was applied to add meaning where necessary. The study has shown that decentralization in Uganda is a new form and means of service delivery. The planners aim at getting every segment of the population to participate in all aspects of service delivery. There is evidence to show that the policy has had a positive impact on the structure of the health sector as a whole. However, the systematic processes of cost containment measures has resulted in the general economic hardship in the operationalization of the decentralization policy in Uganda and has resulted in varied experiences and the way decentralization is viewed in Pallisa. The study noted that hardships have resulted from increasing responsibilities given to lower level of government amidst declining state support in terms of funding and manpower development. The study notes that the apparent changes brought by the overall restructuring of health services have resulted in the 'commercialization of social relations which has changed the way people live and view public goods which also contributes to hardships in service utilization. This study shows that although health service delivery and its quality in rural Pallisa is an old problem, there are feelings among the users and providers that these problems have worsened in the recent past transforming health care consumers and providers into a new category of social actors who have taken different approaches to survive a midst poverty, exclusion and the declining state support system. Although this study does not recommend a return to a centralization system of service delivery in the health sector, it does however, find implementation problems which will have to be addressed if the intended benefits are to be realized.

This study seeks to explain major shifts in health policy. It takes as case studies two governmentally-led hospital mergers in the 1990s - one in London and one in Reykjavik - when national governments, as part of broader administrative reforms, decided to merge teaching hospitals in their capitals. The decision to merge, and the implementation of the decision, followed a long history in both cities, in which the mergers had been repeatedly held up as highly desirable but had always been blocked or abandoned. The merger decisions in the 1990s represent “the impossible becoming possible”. And they stand out as defining moments because of the way they shape the successive course of events in the health care systems. By answering the empirical question why it was possible to merge these hospitals in the 1990s but not in the 1980s, the research aims to contribute to a body of literature that seeks to improve theoretical understanding about how health care systems are shaped by national governments. It carries out two sets of analysis: historical analysis of the main explanatory factors within the health care arenas in both cities; and political analysis of the degree of political authority and will for action of the governments of Britain and Iceland in the 1980s and 1990s. The research concludes that in both cases the merger decisions in the 1990s are best understood as resulting from a confluence of three main factors: 1) weakening cohesion inside the health care arenas; 2) national governments with a long-term hold on power providing an opportunity to consolidate political authority and will through which the wider context of the reform agenda was adopted, 3) the prolonged continuity of executive forces in the governments providing specific political actors with scope for action. In bringing these factors together, ideas which had once united and divided groups of actors in the health care arenas and caused fragmentations in the old order, became glue to the new structure. Theoretical interpretations of the findings suggest that public policies “happen”, as opposed to being made. The merger decisions can be seen more as indicative of past development within the health care systems than as directive themselves. Political interventions, however, changed the balance between groups of actors in the system resulting in strengthening of influence of particular groups of actors, who now possess ever greater control over where, how, when, how much and at what price medical services are provided.

No description available.

This study aimed to investigate the effect of incorporating adverse drug reactions in economic analyses of drug therapies. Subsequently, the impact of this information on prescribing in primary care is explored. In order to achieve the aims of the study, three main studies were conducted. In the first study, an economic analysis was conducted to estimate the comparative costs of a large UK population (N = 98 887) given nonsteroidal anti-inflammatory drug (NSAID) therapy alone and in combination of gastrointestinal (GI) protective agents including concomitant prescriptions of H2 blockers, omeprazole and misoprostol. The second study was a pharmacoeconomic analysis, using data from the literature and local expert opinion, of three commonly prescribed classes of drugs in primary care – NSAIDs, selective serotonin reuptake inhibitors (SSRIs) and angiotensin converting enzyme (ACE) inhibitors for the treatment of rheumatoid arthritis, depression and hypertension respectively. Finally, the results from the pharmacoeconomic analysis were disseminated to GPs in a local Health Board to explore the impact on influencing primary care prescribing. Economic analyses based on various data sources have shown that the total cost of drug therapies are often much higher than the purchasing cost alone. There is much value in taking into account the clinical and economic impact of drug-induced ADRs when conducting pharmacoeconomic evaluations. However, this is often restricted by the availability of some of the data that are required to complete the economic model. The necessary data do exist, but linked clinical data for this type of analysis are not readily available for research purposes. General practitioners were generally supportive of economic evaluations and the exploratory study on disseminating pharmacoeconomic information. However, the dissemination exercise had failed to demonstrate a positive relationship. In addition to the barriers highlighted in the literature, it was found that GPs do not feel that there is a role for the implementation of economic information in primary care.

The proliferation of health promotion apps along with smartphone's array of features supporting health behaviour change, offers a new and innovative approach to childhood weight management. However, research on the content of current industry led apps reveals they lack a basis in behaviour change theory and evidence. Equally important remains the issue of how to maximise users' engagement with mHealth. Therefore the thesis aimed to address these gaps and design and develop an evidence and theory based, user-centred healthy eating app targeting parents for childhood weight management. The Behaviour Change Wheel framework (BCW), a theoretically-based approach for health behaviour change intervention development, along with a user-centred design philosophy and collaboration with industry, guided the development process. This involved a review of the evidence and conducting a series of nine focus groups (Study one and two), a usability workshop and a 'Think Aloud' study (study three) (N=70) comprised of Change4Life advisors, parents with overweight and healthy weight children aged 5-11 years, university students and staff and consultation with experts to inform the app development. Thematic analysis of focus groups helped to extract information related to relevant theoretical (using the Capability, Opportunity, Motivation, Behaviour Model (COM-B) and Theoretical Domains Framework (TDF)), user-centred and technological components to underpin the design and development of the app. Inputs from parents, case workers and experts working in the area of childhood weight management helped to identify the main target behaviour: to support parents' provision of age appropriate food portion sizes. To achieve this target behaviour, the behavioural analysis revealed the need for eliciting change in parents' Capability, Motivation and Opportunity and twelve associated TDF domains. Therefore, the thesis provides a more comprehensive analysis of the problem compared to previous theoretical accounts, demonstrating that parents' internal processes such as their emotional responses, habits and beliefs, along with social influences such as partners and grandparents and the environmental influences relating to aspects such as schools, the media, and household objects, all interact and impact on their portion behaviours. Theoretical domains were subsequently mapped to five intervention functions and twenty-three behaviour change techniques (BCTs) to bring about change in this target behaviour. BCTs were then translated into engaging app features drawing on parental preferences for healthy eating app features including ease of use, minimal data input, visual aids of food and gamification. Overall parents viewed the prototype app positively. The 'Think Aloud' study highlighted key areas to improve usability in such as navigability. Application of the BCW to the issue of childhood weight management yielded a novel conceptualisation of potential approaches to supporting parents' portion behaviours in the home environment. This thesis is also the first to fully explicate the systematic approach applied in developing a family-oriented mHealth app grounded in the BCW framework and evidence, and balanced with users' preferences to help maximise its potential engagement with the target population. Challenges and adaptations relating to the implementation of the BCW are discussed and suggestions for future research in mHealth development and childhood weight management are provided, along with the implications for public health practice.

Background: In South Africa, 81 per cent of the population are dependent on the public health system. The country faces a complex burden of a combination of chronic infectious illness and non-communicable diseases and high maternal mortality, 310 deaths per 100,000 live births. These and many other systemic health challenges have meant the government is starting to invest in digital solutions to strengthen health services delivery and public health; due to their ease of use, broad reach and wide acceptance. Digital communication systems are an intriguing possibility for delivering healthcare in low-resource settings. This thesis considers how mobile (mHealth) and non-mobile communication technologies are currently and potentially being used by patients and health-workers within the rural South African health system. Health system dimensions are also analysed at the macrolevel to define the enablers and barriers to mHealth. Methods: This qualitative exploratory study was a case study design guided by theory-driven realist methodology. Mixed-methods research triangulated in-depth individual interviews, focus group discussions, prolonged engagement in nonparticipant observations and documentary analysis from a diverse range of participants (community members, patients, health-workers, policy-makers and experts) operating at different tiers within the country (community, facility, district, provincial and national). A realist review of patient mobile monitoring of chronic disease was conducted to determine hypotheses to inform the interpretation of empirical data and refine theory from the Context-Mechanism-Outcome configurations. These were supported by high-level theories of access, normalisation and the capability approach. Results: Supportive government policy combined with patient and health-workers’ informal mHealth use can act as enablers to the uptake of digital communication systems, particularly with improved maintenance and management strategies. Access to health information is a barrier to care, which may be overcome with an evidence-based health website though inequities may still remain. Likewise, digital reminders may support chronic disease management particularly for patients with hypertension. Poor patient referrals and remote diagnosis can be overcome by digital communication as smartphone ownership increases and mobile data prices reduce. Local digital innovation relies on government backing for greater scale. Conclusion: Informal digital communication solutions for health used by patients and health-workers are evident as mobile phone use becomes normalised within society. This is occurring in parallel with the government’s interest in digital health technologies to strengthen the delivery of care. A novel healthcare delivery framework proposes that a foundational electronic health and mHealth ecosystem (Context) can support a health system with multiple challenges. The four health system dimensions of government stewardship, organisational, technological and financial systems are necessary to support mobile health solutions. These dimensions give reinforcement (Mechanisms) to improve communication between patients and health-workers which may increase access to healthcare and continuity of care. Work practices are made more efficient, health service delivery is enhanced and patient outcomes can improve to maximise health gain (Outcomes).