Hypertension is a leading cause of death and disability worldwide. Despite effective treatment regimens the mortality among hypertensive subjects are much higher than that of normal individuals. Several studies have been carried out to identify prognostic factors that have predictive value for mortality in the general population. New biomarkers that are readily available and cost-effective are important in risk stratification and management of hypertension. While important prognostic information can be learned from routine blood tests that are often conducted in hypertension clinics, the usefulness of these markers in predicting survival are not studied in detail. The thesis aims to explain the relationship between such inexpensive and commonly available markers and survival in a hypertensive population. The thesis is divided into five main results chapters (chapters 3 to 7) based on studies conducted to assess the independent role of blood pressure variability (BPV), haematocrit, serum phosphate, serum electrolytes and indices of liver dysfunction or injury in predicting mortality in hypertensive patients. The study settings (Glasgow Blood Pressure Clinic) provided an opportunity to examine these relationships in a treated hypertensive cohort of more than 15,000, predominantly white population, from the West of Scotland. The hypertension clinic database was linked with the electronic records of General Register Office for Scotland. This electronic linking allowed extraction of primary cause of death data (if patients died during the course of follow-up) according to the International Classification of Diseases, 10th Revision, Version for 2007 (ICD-10), codes. The type of mortality was ascertained (namely; ischaemic heart disease, stroke, cardiovascular, non-cardiovascular and all-cause) from the ICD-10 codes. The independent relationships between predictor variables of interests and mortality were estimated after employing appropriate survival models. The main study findings are summarised below. Blood pressure variability and mortality: Long term average BPV is an independent predictor of mortality. Longitudinal changes in BPV also predict mortality independent of underlying mean BP. While sustained high variability increases mortality, sustained low variability decreases mortality in this hypertensive cohort. The findings indicate that BPV is likely a fundamental physiologic trait and it is a marker of early mortality. Visit-to-visit BPV is an important prognostic indicator of long-term mortality, and physicians should be made aware that long term clinic BPV should not be disregarded as random fluctuation between visits. Haematocrit and mortality: Haematocrit (Hct) is the proportion of blood volume occupied by red blood cells. It is associated with follow-up BP and is an independent predictor of mortality in the hypertensive population. There are distinct differences both in terms of the strength and magnitude of the association of Hct and mortality between men and women that have not previously been known. While Hct is associated with CV mortality in men ('U' shaped, non-linear), it is more closely associated with non-CV mortality in women ('U' shaped, non-linear). In the assessment and management of newly diagnosed hypertensive patients, Hct levels should be taken into consideration as an important risk predictor. Serum phosphate and mortality: Inorganic phosphate is an important mineral that is directly linked to energy metabolism, bone mineralisation, signal transduction, storage and translation of genetic information and maintenance of lipid membrane structure. A positive linear association between serum phosphate and mortality is reported in the present study. Deprivation status, serum calcium and serum alkaline phosphatase levels do not attenuate the mortality risk associated with serum phosphate in men and women. While serum phosphate is associated with CV mortality in men, it is more closely associated with non-CV mortality in women. Serum electrolytes and mortality: Electrolytes, especially sodium, chloride, potassium and bicarbonates, play a vital role in maintaining homeostasis within the human body. While the relationship with all-cause mortality is non-linear across the entire range of serum chloride, there is a linear increase in mortality with decrease in serum chloride level below 100 mEq/L. The relationship between serum chloride and mortality is independent of serum sodium and bicarbonate levels. While serum potassium shows a non-linear "U" shaped relationship with mortality, serum bicarbonate shows a positive linear association. Indices of liver dysfunction or liver injury and mortality: Serum albumin, bilirubin, alanine transaminase (ALT), aspartate transaminase (AST), gamma-glutamyl transferase (GGT) and alakaline phosphatase (ALP) are widely used markers of liver function or injury to liver cells. These markers of liver function or injury to liver cells independently predict mortality outcomes in the hypertensive population. While there is a linear association of both GGT and ALP with mortality outcomes, it is a more complex, non-linear and ‘U’ shaped association for AST. Both ALT and bilirubin show inverse linear association with mortality. Age and body mass index significantly influence the relationship between ALT and mortality. Strengths and limitations: The strengths of the studies conducted as part of this thesis include; a large cohort of nearly 15,000 hypertensive adults, a real life clinical setting, 35 years of follow-up with median survival time of 32 years, the ability to link predictor variables with differing causes of mortality outcomes, and adjustment for several potential confounding factors. Exclusion of individuals without predictor variables assessed at baseline and the bias introduced by the missing covariates in the adjusted Cox-proportional hazard models are the major weaknesses. Future recommendations: Although the above mentioned inexpensive markers predict mortality in hypertensive population, the mechanism involved in their association with mortality is not clear. Future studies are required to explain the missing links. Usefulness of inclusion of these markers in predicting mortality should be tested in an independent population.

This thesis explores a number of areas related to men who experience distress in mental health or physical care. Chapter one, the literature review, considers research that has examined the impact on masculinity when men experience a debilitating healthcare event, such as chronic illness or a mental health condition. Despite the wide variety of healthcare events considered, this critical review finds many similarities in the experiences of men and proposes a conceptual model for the renegotiation of masculinity. Considerations for further research are suggested. Chapter two, the empirical paper, is a grounded theory study of the experiences of male military personnel with emotional distress. Seven participants reflected on their psychological wellbeing and considerations about accessing mental healthcare within the military. A process model was developed from analysis of the interviews which placed military culture as a key consideration for personnel. Other categories, including a number of conflicting perceptions, are discussed. Considerations for further research and implications of the findings for clinical services are offered. Chapter three, the reflective paper, provides the author’s reflections of the research process with specific attention to the area of conducting sensitive research. Consideration is given to how the research carried out as described in chapter two might be considered sensitive and personal reflections are offered that might be of use to other researchers using qualitative methods or researching similar sensitive topics. The author’s reflections on the research process are considered in relation to key literature on sensitive research.

This thesis explores the relationship between migration and disease in c.1830 – c.1860. Each chapter questions how convicts, emigrants and the surgeons who accompanied them thought about disease and in turn how disease changes how we understand migration historically. It is a study of the creation of medical knowledge across the geographical space of the voyage to Australia and emphasises an understanding of disease as a mental and physical interaction between humans and their environment. The thesis argues that this understanding allowed migrants and colonists to see disease at sea as a test of migrants’ and convicts’ fitness to colonise. The point of departure for this thesis is that the Australian sailing voyage provides a unique and prolonged tension between shipboard confinement and global movements through ever-changing, often extreme, oceanic climates. From this premise, six individual chapters follow the trajectory of the voyage from Britain to Australia. These chapters analyse individual disease such as cholera, fevers, scurvy and consumption, as well as deepening our understanding of the tropics and quarantine by rethinking these histories through a maritime dynamic. Throughout, the thesis analyses evidence in convict and emigrant ship surgeons’ journals, migrants’ diaries and published medical literature as its primary source material, supplemented by government reports and contemporary newspapers. Collectively, the chapters of the thesis connect conventionally separate histories of medicine, convict transportation, colonial emigration, and British welfare and prison reform. By exploiting a uniquely maritime tension between shipboard confinement and global migration, the thesis provides a new way to understand the persistence of ideas about the relationship between people, environment, migration and disease in the modern period.

This thesis addresses how mothers and caregivers take care of sick children in rural north central Nigeria combining secondary analysis of the Nigerian Demographic Health Survey (NDHS) and ethnographic fieldwork in a village in a rural area. Theoretically, the thesis draws on concepts from epidemiology and anthropology in order to analyze and extend understanding of plural health seeking behaviour in a socially disadvantaged setting Methods: Rapid ethnographic assessment of mothers and caregivers in rural village in north central Nigeria was carried out using focus group discussions, household interviews and non participant observation over eight months. Findings: The NDHS analysis showed a social gradient generated by different level exposure to socially patterned risk and protective factors overtime in relation to illness, nutrition and living conditions. These mothers and caregivers were constrained by materialistic and neo materialistic factors shaping their circumstances within their daily lives and within Nigerian society – an example of structural violence. They express human agency in their decisions concerning caring for their children in a way that is shaped by cultural behavioural understandings of social and medical diagnostics of health and illness which is manifested in plural health seeking behaviour.

The purpose of this thesis is to explore the theory, practice and application of costing with specific reference to cancer. In part it reviews the theory and guidelines related to costing methods including the recent focus on the analytical techniques used with cost data. In addition it examines how these theories and guidelines are applied in practice, by reviewing the literature on costs and cancer. The empirical research in this thesis applies costing methods to three specific cancer sites; breast, cervix and lung. This analysis provides information on the total burden of these specified cancers in terms of cost to a typical health authority (Trent). It also explores the hypothesis highlighted in previous studies that the cost of cancer increases with the stage of the disease. The final area of contribution for the thesis is in the application of recently suggested analytical techniques for cost data to the breast, cervical and lung cancer data sets; it investigates a number of proposed techniques for the analysis of skewed cost data and methods for data with incomplete patient follow up.

This thesis charts the rising importance of the state in extending the influence of modern medicine, contexualised within the history and political-economic dynamics of the health care reforms in Taiwan, a leading Newly Industrialised Country (NIC) which has a distinguished record of health improvement. It highlights the processes by which health care reforms represented a shift towards medicalisation, particularly as consolidated by the creation of a universal National Health Insurance (NHI) system in 1995. The thesis seeks to analyse these processes by bridging the gap between medical sociology and health policy evaluation. It deploys a range of methods: historical analysis of secondary sources and multiple methods of data collection. These include qualitative in-depth interviews with key actors, a questionnaire survey and relevant policy documents. This thesis employs an overarching framework for analysis, which embraces both the 'political economy' and the 'cultural critique' approaches to health, in ways which seek to integrate discussion of policy issues and developments at the macro, meso, and micro-levels. It starts by locating the NHI reform against longer-term historical processes of modernisation, often as a result of outside influences, and the associated transformation of medical paradigms that occurred in different periods. It charts how particular structural factors have impinged on medicine to enable it to become dominant collegiate profession, with special reference to the role of the state promoting the legitimation of particular modes of medical intervention. The thesis highlights the fact that the NHI has extended the influence of doctors, paradoxically also provides the basis by which medical autonomy has been undermined. On the other hand, it charts the social impacts of modern medical care, and argues that the NHI has played an important role in stimulating the process medicalisation and consequently fostered a culture of dependency and passivity contained in medical technology and in the healing relationship. This thesis is a reminder that the contemporary Taiwanese health care state is arriving at a moment of crisis, and that deep reflection on the strengths and weaknesses of the NHI reform is necessary in order to deal with problems associated with growing medicalisation, public demands for greater social equity, and new threats to health, the latest being SARS.

This research explores how information systems (IS) implementation is accomplished when cultural change of an organisation is attempted and what this accomplishment means for those touched by it. Efforts of this kind are being made in the UK National Health Service (NHS), Where modernisation programmes involving technological rationalisation and change are aiming to make the NHS more responsive to contemporary public demands. This study focuses on the ambulance services and specifically on a history of IS implementation efforts over 20 year at the largest and most appraised of the English services, the London Ambulance Service (LAS). A perceived need for cultural change involving the use of advanced information technologies is pervasive in managerial and ministerial discourses about modernising the health service. Yet the way that ambulance services are regulated and monitored has given rise to a modernisation programme in which cultural change and IS implementation have been conceived largely instrumentally in terms of achieving performance targets. Moreover, goals to which the modernisation efforts aspire are at most partially realised. Organisational change is uneven, and the performance improvements achieved are contradictory, and this is not only true in London but elsewhere in the UK. Drawing from organisational theory and critical social theory, past IS implementation efforts at the LAS are reinterpreted in light of recent developments, with contributions to theory and practice in mind. The theoretical contribution rests in exploring how emotion as well as rationality may be conceptualised to examine historically and culturally constituted working practices. Implications for practice address how IS implementation can give rise to cultural fragmentation, and also how professional identity can constrain IS innovation. Finally, the research contributes to a current debate about the future for ambulance services and the mechanisms used to evaluate their performance.

Cardiovascular disease is one of the leading causes of death around the world. Resting heart rate has been shown to be a strong and independent risk marker for adverse cardiovascular events and mortality, and yet its role as a predictor of risk is somewhat overlooked in clinical practice. With the aim of highlighting its prognostic value, the role of resting heart rate as a risk marker for death and other adverse outcomes was further examined in a number of different patient populations. A systematic review of studies that previously assessed the prognostic value of resting heart rate for mortality and other adverse cardiovascular outcomes was presented. New analyses of nine clinical trials were carried out. Both the original and extended Cox model that allows for analysis of time-dependent covariates were used to evaluate and compare the predictive value of baseline and time-updated heart rate measurements for adverse outcomes in the CAPRICORN, EUROPA, PROSPER, PERFORM, BEAUTIFUL and SHIFT populations. Pooled individual patient meta-analyses of the CAPRICORN, EPHESUS, OPTIMAAL and VALIANT trials, and the BEAUTIFUL and SHIFT trials, were also performed. The discrimination and calibration of the models applied were evaluated using Harrell’s C-statistic and likelihood ratio tests, respectively. Finally, following on from the systematic review, meta-analyses of the relation between baseline and time-updated heart rate, and the risk of death from any cause and from cardiovascular causes, were conducted. Both elevated baseline and time-updated resting heart rates were found to be associated with an increase in the risk of mortality and other adverse cardiovascular events in all of the populations analysed. In some cases, elevated time-updated heart rate was associated with risk of events where baseline heart rate was not. Time-updated heart rate also contributed additional information about the risk of certain events despite knowledge of baseline heart rate or previous heart rate measurements. The addition of resting heart rate to the models where resting heart rate was found to be associated with risk of outcome improved both discrimination and calibration, and in general, the models including time-updated heart rate along with baseline or the previous heart rate measurement had the highest and similar C-statistics, and thus the greatest discriminative ability. The meta-analyses demonstrated that a 5bpm higher baseline heart rate was associated with a 7.9% and an 8.0% increase in the risk of all-cause and cardiovascular death, respectively (both p less than 0.001). Additionally, a 5bpm higher time-updated heart rate (adjusted for baseline heart rate in eight of the ten studies included in the analyses) was associated with a 12.8% (p less than 0.001) and a 10.9% (p less than 0.001) increase in the risk of all-cause and cardiovascular death, respectively. These findings may motivate health care professionals to routinely assess resting heart rate in order to identify individuals at a higher risk of adverse events. The fact that the addition of time-updated resting heart rate improved the discrimination and calibration of models for certain outcomes, even if only modestly, strengthens the case that it be added to traditional risk models. The findings, however, are of particular importance, and have greater implications for the clinical management of patients with pre-existing disease. An elevated, or increasing heart rate over time could be used as a tool, potentially alongside other established risk scores, to help doctors identify patient deterioration or those at higher risk, who might benefit from more intensive monitoring or treatment re-evaluation. Further exploration of the role of continuous recording of resting heart rate, say, when patients are at home, would be informative. In addition, investigation into the cost-effectiveness and optimal frequency of resting heart rate measurement is required. One of the most vital areas for future research is the definition of an objective cut-off value for the definition of a high resting heart rate.

The non-registered assistant workforce in the National Health Service Scotland (NHSS) has recently been afforded increased attention due, in part, to forecast changes in demographics and the NHSS workforce and reorganisation in delivery of healthcare. Government health papers pursue the strategic aims of developing the workforce to meet the changing needs of the Health Service. This thesis reports on research into workplace learning in the NHSS. It examines the NHSS in relation to the concepts of ‘The Learning Organisation', ‘Expansive/Restrictive Learning Environments' and the learning initiative of the Scottish Vocational Qualification (SVQ) route, adopted by the NHSS for its nonregistered clinical employees. Participants in the research included non-registered clinical assistants to registered nurses and allied health professionals and learning facilitators and managers. A critical realist methodology was adopted and through an embedded case study, data collection methods included one-to-one semistructured interviews and secondary data from the NHS staff survey. This produced a rich source of data for analysis around the perceptions of the participants. Findings show that the NHSS has introduced the concept of a learning organisation to its strategic plans with no real rigour. Some elements of an expansive learning environment exist but these are evident in only some clinical areas. This means that for the assistant workforce, personal development and learning opportunities are dependent on the place of work and the profession they are employed by. The SVQ is embraced by those who are given the opportunity to undertake this initiative but disparities exist throughout the NHSS. Furthermore, the SVQ is perceived as validation of existing knowledge only that does not provide any new learning. This further curtails development opportunities for the assistant group of staff. This thesis has provided the NHSS with a basis to reconsider their strategic direction around learning and development opportunities at work for their nonregistered clinical staff.

In this thesis, I argue that the practice of visiting patients on the more general acute medical and surgical wards in National Health Service hospitals in England has been underresearched and is frequently overlooked by policy. This is despite the large number of written complaints received annually about NHS acute hospital care services in England. The thesis commences with an extensive examination of the contextual influences on hospital visitors’ experiences and expectations. This is followed by a detailed account of the qualitative research, using semi-structured interviews, with participants who had been hospital visitors. Visiting experiences were described as a journey through the patient’s admission, hospital stay and discharge or death. This journey was identified as a time of liminality (van Gennep 1960) with the visitors’ everyday routines and structures suspended and transitions to be made. Liminality and its core features identified by Turner (1974) therefore provided a theoretical framework through which to explore the data. The analysis resulted in the identification of extensions to the understandings of liminality when applied to the hospital-visiting scenario. In turn, the use of liminality, as central to the theoretical framework, provided richer interpretations of hospital visitors’ experiences and so adds to the knowledge about the practice of hospital visiting. Evidence is therefore provided to support future policy, training and professional education improvements and to suggest measures to improve hospital visiting experiences. These improvements, especially in terms of hospital hospitality, effective communication and improved discharge management, could increase hospital visitors’ satisfaction and reduce the costs to the NHS incurred by responding to the high volume of written complaints.