Obesity has been identified epidemiologically as a risk factor for development of chronic venous disease. To examine whether abdominal adiposity obstructs venous outflow from the legs, 26 females aged 34-49 years with no clinical venous disease and body mass index (BMI) between 20.9 – 46.7 kg/m\(^2\) were studied. A novel measurement of the extent of abdominal fat along the legs when seated correlated well with BMI and other measures of central fat (sagittal-abdominal diameter, ultrasound fat thickness, % truncal fat by DEXA scan). On sitting, inguinal tissue pressure recorded by needle manometry increased more in obese (BMI > 30) than normal weight (BMI 20-25) subjects (8.2 vs 1.5 mmHg, p<0.01) as did the femoral vein cross-sectional area (129 vs 60%, p<0.05). Both measures correlated with increasing abdominal fat but were not associated with each other. In the lower leg, saphenous vein distensibility and compliance correlated positively with abdominal fat and BMI, but there was no such association for the popliteal vein. Female sex hormones, physical activity levels and insulin status did not affect venous haemodynamics. Thus, increased abdominal fat can potentially hinder venous return when sitting, leading to distension and changes in vein biomechanics, which could over time contribute to venous disease.

Introduction: Day surgery has many benefits for patients and the NHS, but progress in this area of healthcare has been slow. A high volume procedure, laparoscopic cholecystectomy, was chosen to explore this. The aim of this study was to explore and explain the factors that influence the uptake of day case laparoscopic cholecystectomy at three trusts and the impact of service redesign programmes on day case rates. Methods: A mixed methods collective case study was conducted across three trusts. 34 semi-structured interviews were undertaken and 5 years of hospital activity data was analysed. Results: Day case laparoscopic cholecystectomy rates did increase over a 5 year period at all trusts but to varying degrees. Factors that influenced activity according to qualitative data analysed were grouped into two themes: context and mechanisms. Conclusion: Participants did not believe that the service redesign programmes had any direct impact on their practice. New ambulatory care facilities alone did not lead to increased day case laparoscopic cholecystectomy rates because the trust that performed the most did not have any change to their infrastructure. Clinical attitudes towards performing day case laparoscopic cholecystectomy were variable and may explain the difference in day case rates.

The purpose of this study was to assess the possibility of developing a population based cancer registry in the United Arab Emirates. As this was retrospective and explorative in nature, the study was performed in two stages, the initial stage where the researcher examined critically routinely collected data that is needed to support a cancer registry as well as assessed data on cancer that were obtained from Al Mafraq Hospital records. The final stage took place in Al Ain Medical District where detailed study of the existing practice with respect to cancer registration were undertaken in respond to a request form Ministry of Health, data on cancer were obtained from health care services and cancer registry records. Other information was obtained from key officials and health professionals in the district using qualitative methods. The initial stage showed that this was the first study of this kind in the United Arab Emirates and that cancer data production and recording is a complex intervention, where health and health related professionals and patients are involved. It also revealed that the key professionals were supportive to the study and showed positive attitude. The initial study indicated that there was deficiency in the data collected routinely as well as there was no cancer registry in Al-Mafraq Hospital. Furthermore, the data collected from medical record witnessed deficiency in their completeness and quality. Lack of education and training related to cancer data handling were observed during the fieldwork. The assessment of the population data sources indicated that there was no single data source that might provide a comprehensive and accurate data regarding Al Ain population. This condition was mainly created due to unique demographic pattern of a highly mobile population dominated by expatriates. The final stage showed that health facilities in Al Ain Medical District are capable of producing cancer data especially clinical data. However deficiencies in item definition, complete recording and storing of data by health professionals within the health facilities were identified.

Purpose: Computerised clinical decision support systems (CDSS) are implemented within healthcare settings as a method to improve clinical decision quality, safety and effectiveness, and ultimately patient outcomes. Though CDSSs tend to improve practitioner performance and clinical outcomes, relatively little is known about specific impact of inaccurate CDSS output on clinicians. Although there is high heterogeneity between CDSS types and studies, reviews of the ability of CDSS to prevent medication errors through incorrect decisions have generally been consistently positive, working by improving clinical judgement and decision making. However, it is known that the occasional incorrect advice given may tempt users to reverse a correct decision, and thus introduce new errors. These systematic errors can stem from Automation Bias (AB), an effect which has had little investigation within the healthcare field, where users have a tendency to use automated advice heuristically. Research is required to assess the rate of AB, identify factors and situations involved in overreliance and propose says to mitigate risk and refine the appropriate usage of CDSS; this can provide information to promote awareness of the effect, and ensure the maximisation of the impact of benefits gained from the implementation of CDSS. Background: A broader literature review was carried out coupled with a systematic review of studies investigating the impact of automated decision support on user decisions over various clinical and non-clinical domains. This aimed to identify gaps in the literature and build an evidence-based model of reliance on Decision Support Systems (DSS), particularly a bias towards over-using automation. The literature review and systematic review revealed a number of postulates - that CDSS are socio-technical systems, and that factors involved in CDSS misuse can vary from overarching social or cultural factors, individual cognitive variables to more specific technology design issues. However, the systematic review revealed there is a paucity of deliberate empirical evidence for this effect. The reviews identified the variables involved in automation bias to develop a conceptual model of overreliance, the initial development of an ontology for AB, and ultimately inform an empirical study to investigate persuasive potential factors involved: task difficulty, time pressure, CDSS trust, decision confidence, CDSS experience and clinical experience. The domain of primary care prescribing was chosen within which to carry out an empirical study, due to the evidence supporting CDSS usefulness in prescribing, and the high rate of prescribing error. Empirical Study Methodology: Twenty simulated prescribing scenarios with associated correct and incorrect answers were developed and validated by prescribing experts. An online Clinical Decision Support Simulator was used to display scenarios to users. NHS General Practitioners (GPs) were contacted via emails through associates of the Centre for Health Informatics, and through a healthcare mailing list company. Twenty-six GPs participated in the empirical study. The study was designed so each participant viewed and gave prescriptions for 20 prescribing scenarios, 10 coded as “hard” and 10 coded as “medium” prescribing scenarios (N = 520 prescribing cases were answered overall). Scenarios were accompanied by correct advice 70% of the time, and incorrect advice 30% of the time (in equal proportions in either task difficulty condition). Both the order of scenario presentation and the correct/incorrect nature of advice were randomised to prevent order effects. The planned time pressure condition was dropped due to low response rate. Results: To compare with previous literature which took overall decisions into account, taking individual cases into account (N=520), the pre advice accuracy rate of the clinicians was 50.4%, which improved to 58.3% post advice. The CDSS improved the decision accuracy in 13.1% of prescribing cases. The rate of AB, as measured by decision switches from correct pre advice, to incorrect post advice was 5.2% of all cases at a CDSS accuracy rate of 70% - leading to a net improvement of 8%. However, the above by-case type of analysis may not enable generalisation of results (but illustrates rates in this specific situation); individual participant differences must be taken into account. By participant (N = 26) when advice was correct, decisions were more likely to be switched to a correct prescription, when advice was incorrect decisions were more likely to be switched to an incorrect prescription. There was a significant correlation between decision switching and AB error. By participant, more immediate factors such as trust in the specific CDSS, decision confidence, and task difficulty influenced rate of decision switching. Lower clinical experience was associated with more decision switching (but not higher AB rate). The rate of AB was somewhat problematic to analyse due to low number of instances – the effect could potentially have been greater. The between subjects effect of time pressure could not be investigated due to low response rate. Age, DSS experience and trust in CDSS generally were not significantly associated with decision switching. Conclusion: There is a gap in the current literature investigating inappropriate CDSS use, but the general literature supports an interactive multi-factorial aetiology for automation misuse. Automation bias is a consistent effect with various potential direct and indirect causal factors. It may be mitigated by altering advice characteristics to aid clinicians’ awareness of advice correctness and support their own informed judgement – this needs further empirical investigation. Users’ own clinical judgement must always be maintained, and systems should not be followed unquestioningly.

This thesis examines the presentation of UK public health policy in the late 1990s and the associated media coverage of health inequalities. It also examines lay perceptions of these inequalities and of government initiatives to reduce them. Such a project is timely for a number of reasons. Inequalities in health were once again on the political agenda with the electron of a Labour government in 1997. Subsequent media coverage of the government's consultant and policy documents, as well as an independent inquiry, put health inequalities in the public domain. In addition, research into health inequalities had been accumulating. One line of enquiry focused on the role psycho-social mechanisms might play in the causation of ill health, yet little empirical work had been carried out on lay perceptions. Two distinct yet interlinking methodologies were employed in the study. Content analysis was carried out on government public health documents, an independent inquiry, their press releases, and of the subsequent press coverage, in order to examine the profile given to inequalities and the manner in which they were presented. Images and headlines from the press coverage were then used to facilitate discussion, in a focus group setting, on inequality, poverty, and relative deprivation. The government's intention to reduce health inequalities was communicated mainly in broadsheet publications. An absence of coverage in the tabloid media suggest that a large section of the population may have been unaware of the government's intentions. The transition from Green Paper to White led to a dilution of the initial fervour of the government to tackle inequalities, and this lack of emphasis was followed through in media coverage of health policy. What had started out as a strong issue faltered in the journey from consultation to policy. Political affiliation of newspapers greatly affected the way in which the inequalities debate was presented. Striking differnces emerged in the reporting of health inequalities by right and left-of-centre newspapers. Right-of-centre newspapers focused on proposals to improve and promote healthy behaviours, whereas left-wing publications focused their reporting on initiatives targeted at the deprived. Researching lay views on health inequalities, and inequality in society at a broader level, elicited often compelling and emotive responses. The government's intention to reduce health inequalities did not appear to register with participants. Inequalities were not discussed in the manner of a public debate churned out by the media. Rather, inequalities were a sensitive issue, affecting people in a very personal and far reaching manner. Those of lower socio-economic status were often painfully aware of their status in relation to other, and a large proportion expressed frustration, anger and helplessness, and linked such feelings to their health and well-being. Views from higher income groups tended to be more disparate and distanced, yet this only reinforced how polarised certain sections of society have become. The social snapshot presented in this thesis conveys a picture of a fundamentally fractured and divided modern Britain with very direct consequences for the future quality of social life.

No description available.

Children looked after by local authorities are considered to be some of the most vulnerable in society, often having experienced histories of abuse, neglect, conflict within their family of origin or other traumas. As a consequence, substitute care e.g. foster care or residential care is often used as a therapeutic intervention. The focus of this thesis is the role that professional caregivers play in supporting children in local authority care. Chapter I provides a critique of the research exploring the efficacy of therapeutic interventions designed to facilitate the attachment relationship between looked after children and their professional caregiver. Due to controversy surrounding the therapeutic application of attachment theory and a number of methodological limitations, a limited evidence-base was found. The clinical implications and directions for future research are discussed. Chapter II investigates Residential Children’s Workers experience of caring for looked after children, from a psychological perspective. Results revealed that their role and relationship with the children in their care, is affected by their emotional and psychological ability to cope with push and pull factors within a complex system. The clinical implications are discussed, and recommendations for future research made. Chapter III explores a reflective account of the author’s experience of both working clinically and carrying out research in this field. As many of the ideas were generated whilst conducting the doctoral research, the author applies the proposed model from the empirical paper to the reflections. Chapter III is written in a first person account.

Aim: Empathy is widely regarded as an important attribute of healthcare professionals, and has been linked to higher patient satisfaction, enablement, and some health outcomes. The ‘mechanism of action’ of clinical empathy is not well understood. An ‘effect model’ of empathic communication in the clinical encounter has been proposed by Neumann et al (2009). In this model, clinician empathy is seen as having a positive effect in encouraging patients to tell more about their symptoms and concerns (for example, by picking up on emotional cues and responding in an encouraging way). This can result in ‘affective-oriented effects’ (such as the patient feeling listened to and understood) or ‘cognitive/action-oriented effects’ which include the clinician collecting more detailed information (medical and psychosocial), gaining a more accurate perception of the problem (and possible diagnosis) and enhanced understanding and responses to the patients’ individual needs. Such responses may include Self-Management Support of various kinds, which help enable the patients to better manage their condition(s), leading to improved outcomes. Recent Government policy in Scotland has focused on Self-Management Support and Anticipatory Care as key priorities in primary care, in response to the rise in chronic disease and health inequalities. However, the amount and type of Self-Management Support and Anticipatory Care that occurs in routine consultations in primary care is not known, nor their relationship with empathy and patient enablement. Thus the ‘effect model’ of empathy as proposed by Neumann, which postulates a relationship between empathy, Self-Management Support, and outcomes in the consultation remains largely theoretical. The aim of this thesis was to examine the relationships between patients’ perceptions of doctors’ empathy, patient enablement, health outcomes and the amount and the type of Self-Management Support (including Anticipatory Care) in general practice consultations. Due to the wide health inequalities that exist in Scotland, and the continuing operation of the ‘inverse care law’, a comparison was made between consultations in areas of high or low socio-economic deprivation to establish whether the relationships varied by deprivation. The thesis had the following research objectives; • To assess the nature, type and frequency of Self-Management Support (including Anticipatory Care) in general practice consultations in high and low deprivation groups • To determine whether patients’ perceptions of GP empathy is related to Self-Management Support (including Anticipatory Care) in consultations in high and low deprivation groups • To explore the effects of Self-Management Support (including Anticipatory Care) on patient enablement and health outcomes in high and low deprivation groups • To assess patients’ perception of empathy in terms of the nature, type, and frequency of emotional Cues and responses by GPs rated as high or low in empathy by their patients in consultations in high and low deprivation groups Methods: The research objectives were investigated by a secondary analysis of data collected between 2006-2008 by Mercer and colleagues in the Section of General Practice and Primary Care at the University of Glasgow. These data were collected as part of a research project in general practice in areas of high and low deprivation funded by the Chief Scientist Office of the Scottish Government. The research produced database, includes 659 videoed baseline consultations, with patient rated experience measures, including the Consultation and Relational Empathy (CARE) Measure, the Patient Enablement Instrument (PEI) and outcomes (self-reported symptom change and well-being) at 1 month post-consultation available on 499 patients. An observer-rated method of assessing Self-Management Support and Anticipatory Care was sought from the literature to answer objectives 1-3. However, there were a lack of validated observer-rated tools available that were specifically designed to measure these constructs. As such, the Davis Observation Code was identified as a validated system of coding primary care consultations across a broad range of consultation components which included items deemed to relate to Self-Management Support and Anticipatory Care. The process of selecting the Davis coding system, and the rejection of alternative coding systems is discussed in detail in Chapter 5. The Davis coding system was also considered feasible given the large size of the database. Self-Management Support and Anticipatory Care were then measured by using combinations of seven codes deemed relevant to Self-Management Support within the consultation setting. Four additional codes were added to the Davis system, in order to include tasks relevant to UK general practice consultations. These additional codes were not part of Self-Management Support or Anticipatory Care but were added to achieve a complete coding system of activities within the consultations. The Verona coding system measured emotional cues, concerns and health provider responses that were observed within the consultations. As such, this system was used to answer objective 4. The choice of this system reflected a desire to use an observer-rated measure to help ‘validate’ the patient-rated empathy measure (the CARE Measure) in terms of the first part of the Neumann et al (2009) model, i.e. eliciting concerns and symptoms, separate from the cognitive/action oriented effects relating to Self-Management Support. Results: Reliability of the objective coding systems Preliminary work was carried out on both coding systems in order to establish reliability in the application of the codes. This was a lengthy process, involving several cycles of coding by two coders (the author and one of her supervisors) but resulted in acceptably high levels of inter-rater reliability (kappa > 0.7 for the Davis coding system, and > 0.9 for the Verona coding system). Objective 1: The nature, type and frequency of Self-Management Support (including Anticipatory Care) in general practice consultations in high and low deprivation groups In both the high and low deprivation groups, time was predominantly allocated to gaining information about the patient’s complaint, conducting physical examinations and planning treatment. There was no difference observed in the amount of Self-Management Support overall in the consultations between high and low deprivation areas. However, there were significant differences in the nature, type and frequency of certain aspects of Self-Management Support, with significantly more Anticipatory Care in the consultations in the high deprivation areas. The results also showed that patients in the high deprivation group tended to experience a more direct biomedical focused consultation that featured practical tasks such as physical examinations and discussion of substance misuse. In the low deprivation group, a biopsychosocial approach was more common, which involved more time spent within the consultation discussing treatment effects, compliance or discussing how previous interventions had impacted on the patient’s health. For both groups, little time was allocated to gathering family information or counselling, answering patient questions or discussing health knowledge. Objective 2: Patients’ perception of GP empathy and relationship with Self-Management Support (including Anticipatory Care) in consultations in high and low deprivation areas. The relationship between empathy and Self-Management Support was explored using the Consultation and Relational Empathy Measure (CARE) and the Davis observation code respectively. Potential confounding variables were taken into account. Patients' perceptions of their GP's empathy were significantly associated with Self-Management Support in the low deprivation group, but not the high deprivation group.

How may the mental health of socially deprived HIV/AIDS affected communities be supported in an era of ‘global mental health’? To date, ‘community’ efforts have been informed by a largely biomedical and epidemiological body of evidence, distracting attention from lived realities, local contexts and their abilities to frame understandings of mental distress and treatment. This thesis seeks to contribute a productive critique of the Global Mental Health field, by expanding on some of the missing dimensions in their conceptualisations of health and healing. Through a focus on social psychological processes of community, knowledge and social change, it formulates a series of suggestions for how the Movement for Global Mental Health (MGMH) and other policy actors can build on their existing efforts, through establish health enabling contexts where communities actively participate in addressing mental distress, and tackling the contexts that constitute distress in locally relevant ways. The thesis reports on a case study of KwaNagase (Manguzi), an HIV-affected rural community in KwaZulu-Natal, South Africa. It takes interest in the intersection of three respective groups, exploring how they understand, cope with, and work together in efforts to support mental well-being: 1) poor HIV/AIDS affected women experiencing mental distress; 2) community level supports (local NGOs and traditional healers); and 3) public health services (primary health sector). Data was collected over a three month period using multiple methods. In-depth individual interviews (n = 43) were triangulated by a motivated ethnography (Duveen and Lloyd, 1999) that explored local cultural, structural and symbolic contexts of community that frame understandings of mental health and delivery of care. Grounded thematic analyses identified that women’s understandings of mental distress were shaped by experiences of poverty, violence and HIV, which in turn, limited their ability to meet normative expectations linked to gender roles of ‘mother’ and ‘wife’. Indigenous psychosocial coping strategies employed by women to tackle the aforementioned drivers of distress were underpinned by the presence or absence of social psychological resources that optimise health and well-being: agency, partnerships, critical thinking and solidarity. Primary mental health care actors’ (NGOs and formal health service actors) understandings of women’s distress were informed by an awareness of the structural and symbolic issues facing women in everyday life, aligning with the women’s own understandings. Their best practices highlighted efforts to establish receptive social spaces – a critical dimension of health enabling contexts but were limited by symbolic and structural barriers such as stigma among providers, and general under-resourcing of the sector. To overcome the limits facing community mental health services in Manguzi and similar contexts, the thesis concludes by highlighting a series of suggested actions to bolster identified community mental health competencies, and provides a tool kit of recommended strategies to support existing public sector efforts to promote mentally healthy communities.

This thesis examines the literary response to the AIDS crisis. It concentrates on literature produced between 1988 and 1995, published in English, and available in Britain and the United States. The AIDS texts investigated here are representative of other AIDS literature produced during this time period in the way that they both enact and construct the identities of those affected by AIDS. Mourning and melancholia are the operative responses revealed in the literature, and revealed as the formative components of changing identities in response to AIDS and its manifestations. The thesis is structured in six chapters: a theoretical introductory chapter that proposes mourning and loss as pre-existing concerns in gay men's literature, followed by a chapter addressing gay AIDS fiction and its narrative response to mourning. The next two chapters examine hybrid texts, that is, AIDS texts that do not conform to a conventional narrative form, and that are connected more firmly to a queer sensibility than to a gay identity. These texts, the thesis claims, are engaged with the processes (and resistances) of melancholia rather than with the work of mourning. The subsequent chapter addresses fictions of caretaking and witnessing, that is, novels written from the point of view of one who is caring for an other ill with AIDS. These are identified as more mainstream texts as they involve representations that are not connected to declared sexual identities and therefore mean to address a wider audience and to work out a more public discourse of grief around AIDS. In conclusion, the thesis suggests that although AIDS literature is involved in an effort to resist loss through narrative form, in fact it is the literature that in some instrumental ways makes the work of mourning and melancholia in response to AIDS productive rather than debilitating.