This work started from initial questions in the field of transcultural psychiatry concerning the effects of culture and of seclusion on Asian immigrant women's experiences and on their concepts of mental well - and ill-being and their behaviour in face of this. In presenting data concerning the women's views and interactions with health workers, a tripartite framework is used as a way of understanding the logic of behaviours from the actor's perspective. Theoretical conclusions relate to this framework and to the nature of Concepts, in which the influence of structural and cultural factors are drawn out. Context and process are shown to be important in respect of Concepts, health care interactions and social research. The research was a small-scale study involving semistructured discussions with forty-six women, often in a group setting, seventeen of whom were interviewed in depth, and the use (in translation), of two Psychiatric Rating Scales. The women involved were Pathans, currently living in Bradford. This thesis is divided into four Parts, in addition to an overall introduction and conclusion. In each Part, issues concerning social influences on individual experience and behaviour are addressed through the presentation of data from the interviews. These issues concern research methodology (Part 1), social situation and interaction (Part II), the women's role as mothers (Part III) and health and illness experiences, Concepts and behaviours (Part IV). The work contributes to a number of fields of study, illustrating the dynamics of the processes at work in each area. It is, however, in combination that the Parts of the study demonstrate the contribution that can be made to the understanding of illness behaviours by a sociological analysis which is committed to elucidating the logic of these behaviours fram the actor's perspective, in the context of his/her other life experiences.

The thesis examines the formation and evolution of medical provisions in Wakefield and Huddersfield between circa 1780 and 1870. The survey covers 'institutional' facilities, namely hospital and dispensary provisions and Poor Law medical services, friendly society facilities for the sick and the development of 'fringe' or 'peripheral' medical practices. The thesis also discusses the structural, professional and social development of medical communities in the two towns. A wide range of source material was utilised, to include Poor Law material (pre- and post-1834), the records of friendly societies and medical charities census returns, newspapers, trade and medical directories and parliamentary reports and returns. The use of such a combination of material gives a better indication of the range of facilities available and their relative importance. It will be suggested that the emphasis medical historians have put on institutional provisions has been misplaced. The importance of previously neglected options, the friendly society and 'peripheral' forms of treatment, will be stressed. Leading on from this, it is possible to suggest that self-help forms of medical relief (compared with those 'provided' by the wealthy classes for the poor) were of greater significance-than has previously been assumed. An attempt has been made to place the development of medical services against the backdrop of the communities that they evolved in. The growth of institutional provisions and the progress of self-help forms are linked to the organisation of the two communities, their class structure and social, civic and economic developments. The leading role of laymen in creating a demand for, and in the setting up and evolution of, medical provisions has also been stressed. It is hoped an analysis of these factors will lead to a clearer understanding of how and why medical facilities developed-as they did, and to a greater insight into the relationships between medicine and society.

In recent years there has been a great increase in work on epidemiological modelling, driven partly by the increase in the availability and power of computers, but also by the desire to improve standards of public and animal health. Through modelling, understanding of the mechanisms of previous epidemics can be gained, and the lessons learnt applied to make predictions about future epidemics, or emerging diseases. The standard SIR model is in some sense quite a simplistic model, and can lack realism. One solution to this problem is to increase the complexity of the model, or to perform full scale simulation—an experiment in silico. This thesis, however, takes a different approach and makes an in depth analysis of one small improvement to the model: the replacement of a constant birth rate with a birth pulse. This more accurately describes the seasonal birth patterns observed in many animal populations. The combination of the nonlinearities of the SIR model and the strong seasonal forcing provided by the birth pulse necessitate the use of numerical methods. The model shows complex multi annual cycles of epidemics and even chaos for shorter infectious periods. The robustness of these results are proven with respect to a wide range or perturbations: in phase space, in the shape and temporal extent of the birth pulse and in the underlying model to which the pulsing is applied. To complement the numerics, analytic methods are used to gain further understanding of the dynamics in particular areas of the chosen parameter space where the numerics can be challenging. Three approximations are presented, one to investigate very small levels of forcing, and two covering short infectious periods.

No description available.

No description available.

The formal management of risk was an idea in its early stages of introduction into the National Health Service when this research started. In this thesis I document the development of my thinking as an acute hospital risk manager over the last five years as I developed the Trust's risk management system. Using Action Learning as the research approach, I explored theories and concepts and tested them in the fire of real world action and reflective questioning of experiences. The definition of risk is explored in relation to health care, as are the approaches used to manage these risks. A key finding is that risk management decision making does not generally fit into either programmed or non-programmed decision making models but neither do decision makers guess. Decision makers tend to use heuristics, which are simple rules of thumb, which generally help them make the right decision with minimum mental effort. However, heuristics also tend to be applied inappropriately and can result in an organisation being exposed to unacceptable levels of serious risk. A number of key heuristics are identified and they appear to fall into two general types, B-heuristics and E-heuristics. The B-heuristics are 'basic' in form and can be summarised as a simple sentence while, E-heuristics have an 'extended' form which can be summarised as a list of related simple sentences. Knowledge of heuristics helped in the design of the Trust's risk management which has been implemented and its effectiveness tested in the field. This field testing has demonstrated that the worst effects of heuristics can be mitigated by effective soft-system design.

This thesis explores the phenomenon of workforce modernisation through the reconfiguration of professional roles, which represents a policy priority in healthcare systems in the United Kingdom (UK) and globally. Heavily informed by conflict or power accounts of professionalism, the literature presents attempts to reconfigure professional roles as opportunities for the reallocation of professional knowledge and expertise and therefore power and status. Existing work emphasises the strategic, competitive activity of professionals to establish, extend and defend jurisdiction in the face of such change. Utilising an organisational neoinstitutional approach this thesis provides a novel theoretical interpretation of the opportunities and threats that the renegotiation of roles presents to the professional groups involved, adding complexity to the accounts that dominate the literature. The thesis draws upon work that describes the evolving nature and function of professionalism to demonstrate that in the contemporary organisational environment, focussed on accountability and risk management, attempts to reconfigure professional roles are understood not only in terms of the transfer of professional knowledge and expertise but the concurrent transfer of accountability for the management of risk. This represents a more complex commodity potentially associated with professional risk in the event of untoward incidents. Using the case of changes to the roles of consultant psychiatrists in the UK National Health Service (NHS) that propose the redistribution of clinical activity and responsibility from psychiatrists across the wider mental health workforce, the thesis demonstrates that rather than competing for jurisdiction associated with the management of significant risk, professionals carefully renegotiate their roles in a manner that ensures the protection, not just of their clients, but of the professionals involved. In this case, despite institutional work from professionals and managers to create change in established practice, concern with accountability for the management of risk drove adherence to traditional, readily accepted and organisationally sanctioned interprofessional boundaries, limiting the degree of change enacted. These findings have important practical implications for those involved in the management of change as well as theoretical implications for our understandings of professional role reconfiguration attempts and the nature of contemporary professionalism more broadly.

The aim of these studies was to improve laboratory methods for the detection of virus-specific antibody to mumps and rubella. The presence of virus-specific antibody is indicative of immunity to disease so simple and effective antibody detection allows for the planning and monitoring of immunisation programmes. In facilitating antibody surveillance, oral fluid has advantages as a sample compared with blood. It is simple, safe and cheap to collect and being non-invasive encourages subject recruitment. In this study, an ‘IgG’ antibody capture enzyme-linked immunosorbent assay (GACELISA) was developed and evaluated for the detection of mump-specific IgG in oral fluid. Compared to an indirect commercial ELISA for the detection of mumps-specific IgG in serum, the oral fluid GACELISA was 100% sensitive and specific. The GACELISA should therefore be useful for future antibody prevalence studies. The limitation of oral fluid samples compared with blood are that they contain lower antibody concentrations. Immuno-polymerase chain reaction (I-PCR) is an ultrasensitive method and in this study was adapted to detect antibodies to mumps virus. Though the method was shown to be feasible for antibody detection and quantification, its sensitivity and specificity did not exceed that of a conventional ELISA. Sensitivity was limited by non-specific binding of human IgG to the solid phase. In this study, the PinPointTM Xa-1 T-Vector system was used to produce recombinant rubella virus (RV) E1 fusion proteins in Escherichia coli. Their antigenicity was assessed by Western blotting and ELISA. One of these antigens may be a suitable reagent for immunity studies as it reacted with RV E1-specific monoclonal antibodies (MAb’s) and a high percentage (80%) of RV antibody positive sera.

Various aspects of impulsivity, including risk-taking, were investigated by comparing the responses of control groups with those of three populations that were believed to exhibit problems with impulse regulation: those with eating disorders, attention deficit hyperactivity disorder (ADHD) and recreational drug users. Impulsivity was regarded as a multi-dimensional construct, tests were selected or developed to tap into various aspects of impulsivity, including self-report questionnaires, a novel discrete trials delayed reinforcement operant choice paradigm, a novel measure of financial risk-taking, and the continuous performance test which provides measures of both inattention and impulsivity. These tests varied in their ability to discriminate between groups, and the correlations between measures, as in previous studies, were typically low and mostly non-significant. Findings supported the proposal that impulsivity is a multidimensional construct that must be assessed using a wide range of measures including self-report questionnaires and more objective behavioural measures. The profile of effects found in the three targeted groups supported the proposal that impulsivity manifests itself differently in different populations. Women with anorexia nervosa scored low on impulsiveness and venturesomeness, and demonstrated behavioural impulsivity. Recreational drug users scored high on impulsiveness, venturesomeness and risk-taking, whereas ADHD individuals were inattentive and scored high on impulsiveness and risk-taking taking, but not venturesomeness. Overall the findings highlight the complexity of the impulsivity concept and demonstrate the need to acknowledge its multi-dimensional nature by using a variety of tests to capture its variable expression. Whether impulsivity in particular groups reflects state or trait remains to be determined.

Acute infective conjunctivitis (AlC) is a common self-limiting condition presenting to general practice. However, evidence is limited on GPs current management of AlC, patients' understanding of conjunctivitis or the most appropriate management strategy for AlC in general practice. The aims of this thesis where to: 1) To determine GPs' current management strategies for AlC 2) To gain an understanding of patients concerns and beliefs about AlC and develop a patient information leaflet (PIL). 3) To assess the effect of common management strategies for AlC on symptom resolution and patients belief in antibiotics. Three complementary studies were used: 1) A postal survey of 300 GPs regarding their diagnosis and management of AlC. 2) A qualitative study involving interviews with 25 patients to explore conjunctivitis from the patients' perspective. 3) An open randomised controlled tria~ with 307 recruits, to assess the effect of different management strategies (immediate, delayed or no offer of antibiotics; a patient information leaflet and an eye swab) for AlC in general practice. The results were: 1) Survey: 95% of responding GPs usually prescribe topical antibiotics for AlC despite 58% stating that they thought at least half of the cases they see are viral in origin. Only 36% of GPs believed they could discriminate between viral and bacterial infection 2) Qualitative study: patients regarded conjunctivitis as a minor illness although some considered it might become more serious if not treated. They stated a preference not to take medication but believed that conjunctivitis would not clear without treatment. However, they were open to alternative management approaches (e.g. delayed prescription approach) because they trusted their GPs judgement. Once aware of the selflimiting nature of conjunctivitis, patients felt they would prefer to wait a few days to see if it improved before seeking medical advice even if this resulted in a few more days of symptoms. 3) Randomised trial: different prescribing strategies did not affect symptom severity in the ftrst 3 days, but duration of moderately bad symptoms was less with antibiotics (control 4.83 days, immediate 3.26 days (p=O.OOl), delayed 3.86 days (p=O.002)). Compared with no initial offer of antibiotics, antibiotic use was higher in the immediate group (control 30%, immediate 99% (p=0.001), delayed 53% (p=O.004)) as was belief in the effectiveness of antibiotics (control 47%, immediate 67% (p=0.03); delayed 55% (p=0.35)) and intention to re-consult (control 40%, immediate 68% (p=0.001), delayed 41 % (p=0.98)). A patient information leaflet or an eye swab had no affect on the main outcomes, but an eye swab seemed to increase patient worry about AlC and a PIL seemed to increase satisfaction with the consultation and the amount of information received. Re-attendance in the next two weeks was less in the delayed group (delayed OR 0.33 (0.11;0.98); immediate OR 0.65 (0.26; 1.63)). In conclusion: Most general practitioners prescribe topical antibiotics for most cases of acute infective conjunctivitis -a self-limiting condition. Most patients are unaware of the self-limiting nature of AlC. A delayed prescribing approach is probably the most appropriate strategy to use for the management of acute conjunctivitis in primary care - it reduces antibiotic use by nearly 50%, shows no evidence of 'medicalisation', provides similar symptom duration and severity to immediate prescribing and reduces re-attendance in the short term compared with no offer of antibiotics.