Point-of-choice prompts consistently increase stair climbing in public access settings. Comparison of message content, however, is rare. Chapter two reports that, after controlling for the effects of traffic, similar effects on stair climbing were evident for a more specific and a simpler heart-health message. Chapters three to five demonstrate that specific, calorific expenditure messages were associated with significantly increased stair climbing in public access and workplace settings, with greater increases in overweight than normal weight individuals (chapter four). Chapter three investigated the single and combined effects of volitional and motivational intervention components, in a tram station, to test the theory underpinning the success of point-of-choice prompts. Both components positioned simultaneously were required to increase stair climbing where choosing the stairs resulted in a time delay for pedestrians due to the site layout. Similarly, a motivational intervention alone did not increase stair climbing in the workplace (chapter five). When supplemented with a volitional, point-of-choice prompt at the time the choice of ascent method is made, a significant increase in stair climbing occurred. Analysis should adjust for potential moderating effects of pedestrian traffic, time of day, demographics and building characteristics; failure to do so may mask the true impact of the intervention.

The self-care management of chronic disease patients is complicated by various everyday decisions that range from routine ill-structured problems, e.g., “What to eat?” to uncertain symptoms-related decisions, e.g., “Why do I feel tired?” Such decisions can have significant consequences on a patient’s health, treatment, care, and associated medical costs. Due to the complexity involved in understanding and analysing everyday decision making, there is a lack of empirical research to guide the development of self-care decision aids. This thesis aims to address this problem by formulating and illustrating the Critical Illness Self-care Decision Aid (CISDA) process through a coherent, structured, integrated design and development process using a case study. Following a literature review, the problems in current approaches and the criteria needed for the development were derived from evidence-based frameworks such as chronic disease management, decision aids standards and complex interventions development process for future designs. Mixed methods were used including: focus groups, interviews, questionnaire, Cognitive Work Analysis and case scenarios for not only constructing an account of self-care needs and decisions but also to evaluate the development process and the decision support provided involving patients, doctors, caregivers, non-medical experts like psychologists and IT/Systems engineers. The CISDA process consists of: (i) needs assessment, (ii) theory formation, (iii) modelling, (iv) integration, (v) interface design and development, and (vi) evaluation for addressing the relevant intersection of human factors, systems engineering, and software engineering. This thesis should prove useful to not only systems engineers but also to a range of practitioners concerned about decision making, maintaining a user's cognitive perspective during specification and analysis of a complex system.

This thesis investigated the effects of daily changes in exposure (delta) and short-term exposure patterns on the relationship between air pollution and health in time series studies. Using data from London and Hong Kong, delta was defined as the difference in particulate matter (PM10) concentration between successive days. Short-term exposure pattern series were defined based on number of peaks in PM10 within rolling weekly blocks. The mathematical equivalence of identifiable models for delta with conventional distributed lag model was derived and alternative model specifications were proposed. Measurement error and missing data exhibited more impact on delta than the absolute metrics in simulation studies. Evidence of association for delta PM10 with mortality was found only in Hong Kong which attenuated towards the null with more rigorous adjustment for weather. The pattern analysis approach hypothesized, in addition to amount (dose) and duration of exposure, epidemiological studies ought to take patterns of exposure into account. However, convincing evidence was not found for the effect of short-term exposure patterns on mortality risk estimates both in London and Hong Kong. Refining the definition of exposure patterns and methodological improvements including analysing data from multiple cities are highly recommended in related studies in the future.

Rho GTPases are molecular switches that regulate many aspects of cell physiology. A number of Rho GTPases are essential for the formation of new vessels from pre-existing ones, a process known as angiogenesis. RhoJ/TCL belongs to the Cdc42 subfamily of Rho GTPases. Previous bioinformatic and primary cell line analyses identified RhoJ as being highly expressed in endothelial cells. The aim of this project was to investigate the expression pattern and endothelial function of RhoJ, particularly in the processes necessary for angiogenesis. Silencing RhoJ with siRNA impaired tube formation and migration. On the cellular level, RhoJ knockdown increased focal adhesions, actin stress fibres and collagen gel contraction, suggesting increased actomyosin contractility. Pharmacological inhibition of ROCK and myosin II, two regulators of actomyosin contractility, restored motility and tube formation after RhoJ knockdown. RhoJ localised to blood vessels of developing mice and in various human normal and pathological tissues. In zebrafish embryos RhoJ was not expressed in endothelial cells, instead RhoJ was expressed in the musculature where it was involved in regulating somite formation. This study is the first to describe a role for RhoJ as a negative regulator of focal adhesion numbers and actomyosin contractility and to demonstrate a critical role of this Rho GTPase in endothelial cell migration and tube formation, thus identifying a potential new player in angiogenesis.

Over recent decades health care policy in the English NHS has focused on the role of patient choice of provider as a lever for health care improvement (Mays 2010; Fotaki 2013). The thesis explores the degree to which patient choice policy has been successful in its aim. Specifically, it explores the influence that patient choice policy has on changing and shaping organisation culture in an acute hospital trust. A qualitative case study was undertaken in a teaching hospital Trust involving interviews with 30 interviewees drawn from different levels of the hierarchy in the hospital. The study also reviewed documents to understand where PCP was positioned in the hospitals ambition. The study found that patient choice had not changed organisational behaviour in the hospital and did not have the desired impact as expected by policy makers. The study identified that the PCP programme theory had failed to recognise the impact that the culture of an organisation has on change. The culture of the hospital was still one of ‘knowing what was best for its patients’ and rejecting the notion that patients wanted choice. Also, the incentives of patient choice policy were considered weak in the context of hospitals overrun with demand and competing priorities.

Whilst there is evidence of a range of effective treatments available for people with severe mental health problems (SMHP), people frequently disengage from mental health services (MHS). This thesis investigates experiences of disengagement of people with SMHP and comprises two studies: 1) semi-structured interviews to elicit the experiences of people with SMHP and a history of disengagement from MHS; and 2) building on those findings, focus groups with staff from assertive outreach teams (specialising in providing care for people with SMHP and a history of disengagement). The participants were those perceived as the most disengaged from MHS yet they were willing to engage with the research. Interpretative phenomenological analysis was used to develop themes for individual participants and then across the participants. Disengagement from MHS was part of a wider experience of a limited connection to social structures, including an ambivalent and complex relationship with MHS. There was a sense of sadness in all aspects of the participants’ experience but they had developed strategies to reinforce personal resilience and to reassert personal identity. The findings of this thesis can be employed to better understand the context of disengagement from MHS and consequently better inform future engagement with this client group.

This thesis reports work to develop and score (value) a measure to capture the impact of end of life care (EoLC) on those people close to the dying. This work is conducted in response to the need to capture wider impacts of EoLC for economic evaluation where there is lack of appropriate measures. To develop the measure, twenty seven in-depth interviews were conducted with those who were recently bereaved or close to somebody receiving EoLC. Constant-comparative analysis was used to develop dimensions for the measure. Pictorial tools were used to explore who is close to those at the end-of-life and therefore could legitimately be included within the evaluation of EoLC interventions. The measure was valued using an exploratory deliberative methodology conducted with six focus groups comprising members of the public. The measure contains six dimensions: \(communication\) \(with\) \(those\) \(providing\) \(care\) \(services\), \(practical\) \(support\), \(privacy\) \(and\) \(space\), \(emotional\) \(support\), \(preparing\) \(and\) \(coping\) and \(emotional\) \(distress\). The communication and practical support attributes received the greatest weighting in the valuation process. On average, there were eight individuals close to those at EoL. This work significantly enhances the potential for including close-persons in economic evaluation of interventions at the end of life.

The concept of clinical governance was first introduced to the National Health Service in the White Paper published in 1997 (Department of Health); it has been described as the 'linchpin' of the quality reforms and, as of April 1999, is one of the statutory duties placed on NHS Trust Boards. Clinical governance is defined as: 'A framework through which NHS organisations are accountable for continuously improving the quality if their services and safeguarding high standards of care by creating an environment in which excellence in clinical care will flourish.' (Department of Health, 1998; p33). The research project upon which this thesis is based took place over an 18 month period and has followed one NHS Trust as it implemented this new policy. Implementation may be conceptualised as both a change process and an end state; to capture this duality, two broad research questions are posed namely: what constitutes the local clinical governance agenda (content) and how has clinical governance been implemented (process). Given that the main purpose of these research questions is to explore and describe, an overarching qualitative framework has been adopted and, within this, an action research approach utilised

This thesis examines factors associated with length of hospital stay for mentally disordered offenders, detained within the medium secure psychiatric estate. Following an introduction, Chapter two presents a systematic literature review examining the current literature on factors that predict length of stay for patients detained in medium secure hospitals. Mixed results were found. There was limited convergence across clinical and forensic variables investigated, but greater consensus on what is not associated with length of stay. The limited research available and inconsistencies found indicates the need for further research. Chapter three comprises an empirical research study, investigating which variables within a population of male mentally disordered offenders predict length of stay within a regional, medium secure psychiatric hospital. Preliminary analyses revealed statistically significant relationships between length of stay and nine variables. Effect sizes were small to medium. Logistic regression revealed a statistically significant relationship between length of stay of two years or more and having a diagnosis of schizophrenic disorder. Chapter four presents a critical review of the Historical, Clinical, Risk–20 Violence Risk Assessment (HCR-20) (Version 2), a widely adopted risk assessment framework utilised within forensic psychiatry and the standardised measure used within the empirical study. The review explores the literature on the reliability and validity of the HCR-20, and considers its strengths and limitations. A discussion of the work presented concludes the thesis.

This thesis explored the role of health informatics (decision support systems) in caring for hospitalised patients with diabetes through a systematic review and by analysing data from University Hospital Birmingham, UK. Findings from the thesis: 1) highlight the potential role of computerised physician order entry system in improving guideline based anti-diabetic medication prescription in particular insulin prescription, and their effectiveness in contributing to better glycaemic control; 2) quantify the occurrence of missed discharge diagnostic codes for diabetes using electronic prescription data and suggests 60% of this could be potentially reduced using an algorithm that could be introduced as part of the information system; 3) found that hypoglycaemia and foot disease in hospitalised diabetes patients were independently associated with higher in-hospital mortality rates and longer length of stay; 4) quantify the hypoglycaemia rates in non-diabetic patients and proposes one method of establishing a surveillance system to identify non diabetic hypoglycaemic patients; and 5) introduces a prediction model that may be useful to identify patients with diabetes at risk of poor clinical outcomes during their hospital stay.