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Previous research had shown that experiences of treatments vary between NHS and private practice. It was unclear whether different treatments might vary in the same or in different ways between healthcare sectors. This thesis explored how experiences of physiotherapy and osteopathy vary between NHS and private settings. Study 1: A systematic review of the literature identified psychosocial factors which are likely to be important within physiotherapy for lower back pain. Study 2: A qualitative interview study explored the experiences and appraisals of 35 patients who had received NHS or private physiotherapy or osteopathy for lower back pain. This study indicated that physiotherapy and osteopathy do not vary in the same ways between healthcare sectors. Study 3 and 4: Mixed methods were used to develop and establish the face validity, internal consistency and structural validity of a new measure of treatment appraisal, the Appraisals of Physical Treatments Questionnaire (APTQ). Study 5: The APTQ and other measures of treatment appraisal were then examined in a cross-sectional questionnaire study (n=91) which explored how and to what extent aspects of treatment appraisal vary between healthcare sectors and treatment types. There were ceiling effects in many of the measures, although some aspects of treatment appraisal varied in ways which were consistent, or partially consistent, with the hypotheses. Study 6: Finally, study 6 looked at practitioners’ (physiotherapists’ and osteopaths’) experiences of treating lower back pain in the NHS and private practice. Practitioners’ reports largely confirmed those of patients, indicating that physiotherapy and osteopathy do not vary in the same ways between healthcare sectors. Factors that might be responsible for the differences in patients’ experiences of NHS and private physiotherapy and osteopathy were also identified and organised into a model. Physiotherapy and osteopathy did not appear to vary in the same ways between healthcare sectors, indicating that the healthcare sector might not have a uniform influence on treatments.

In response to local and national drivers for improvements in quality of hospital nursing care an acute care NHS Trust developed an innovative ward based Clinical Accreditation Scheme (CAS). The scheme aims to assure quality of care and encourage quality improvements. This study aimed to identify changes in the quality and outcomes of care associated with the CAS, to explore the contextual factors and processes by which any effect is achieved and explore how the CAS is embedded into routine clinical practice by examining key participant perspectives on the feasibility and utility of the CAS. A controlled before-and-after study design explored outcomes from three matched pairs of adult general medical and surgical wards over a twelve month period. The Hospital Survey on Patient Safety Culture and Nursing Practice Environment Scale were administered to all study ward staff at study commencement and as follow up at study end. There was no evidence of an association between participation in the CAS and a change in ward culture. Statistical process charts were used to identify changes over time for rates of hospital acquired infections, pressure ulcers and falls but no clear trend emerged. Findings from staff interviews suggest that staff value the assurance and sense of recognition the accreditation process gives. The process of preparing for self-assessment has potential to promote immediate quality improvements but a number of dysfunctional effects and behaviours, and contextual factors such as constant change, were identified as hindering embedding of the process into routine practice. This study provides new knowledge demonstrating how an accreditation scheme is operationalised at the microsystem level. The scheme appears to assure quality of care and promote short term quality improvement but it is a resource intensive scheme and a number of structural changes are required to promote ongoing participation in quality improvement activities.

The intention of this case study research is to explore the factors that facilitate or inhibit effective leadership in Critical Care Settings (CCSs) in a government hospital in Bahrain. The study focuses on Head Nurses (HNs) working in the CCSs, since those positions play a pivotal role in creating and maintaining a Healthy Working Environment (HWE) for nursing practice. In this research the abbreviation ‘Head Nurse (HN)’ will be used and it stands for Charge Nurse/ Ward Sister/ Nurse Supervisor. According to Ministry of Health (MoH) policies, the leadership in Bahrain encounters a variety of challenges including: demands for efficiency, cost cutting and a value for money service; finding alternative ways of funding; ensuring appropriate human resources; supporting improved management practices; developing a proper structure; higher customer expectations; and knowledge armed customers. A qualitative case study design was used. This approach allows the study to explore the important factors that facilitate or hinder leadership effectiveness such as the individual professional factors (e.g. leadership style, communication, the relationship, and the educational factors) and the organizational factors which include for example healthy working environment and the organizational structure. Data were gathered through in-depth semi-structured interviews with key informants (KIs), HNs and Senior Staff Nurses (SSN), as well as through observing HNs in clinical practice and document analysis (e.g. minutes of meetings and department annual reports). The emerging qualitative data have been analysed through coding and grouping according to themes. The findings revealed that effective HN leaders were recruited, and designated to the posts without development plans or without formal presentation. There was a lack of effective HN leaders who have the capabilities that are considered crucial in such a role (e.g. characteristics of emotional intelligence and authenticity). The study findings generated generic issues surrounding leadership in healthcare settings which resonate with the literature. The participants in this study talked about the characteristics of effective leaders in general rather than specifically emphasizing on issues like being in the frontline during a crisis to make quick decision that are required in critical situations. Key messages from the research indicate that effective head nurse leaders play a pivotal role in establishing and sustaining a healthy working environment. Also head nurses working in critical care settings should exhibit specific characteristics such as being: empathetic, open and honest, optimistic, visionary, accessible to be effective leaders.

Cardiovascular disease (CVD) is the leading cause of death worldwide. Vitamin D is important for bones and for other body functions. Whether insufficient vitamin D causes CVD is unclear. Previous trials of vitamin D were unable to evaluate effects on CVD. This thesis will (i) review the literature on vitamin D and CVD; (ii) evaluate the observational associations between plasma 25(OH)D levels and CVD; and (iii) describe the design and results of the BEST-D trial. (i) Associations between baseline 25(OH)D levels and cause-specific mortality were evaluated in the Whitehall Resurvey of survivors undertaken in 1995, and findings included in a meta-analysis of similar studies. (ii) The BEST-D study was a randomised trial in older healthy volunteers of the effects of two doses of vitamin D3 (4000 IU or 2000 IU daily) compared to placebo, on blood 25(OH)D concentrations and CVD risk factors including blood pressure and arterial stiffness. (i) The Whitehall Resurvey of 5409 men with mean age of 77 years, among whom there were 3215 deaths showed an approximately linear (log-log scale) inverse association of plasma 25(OH)D concentrations and both CVD and non-vascular causes of death between 30 to 90 nmol/L. The meta-analysis confirmed the associations of 25(OH)D with CVD mortality. (ii) The BEST-D trial showed marked increases in 25(OH)D blood concentrations but no effects of taking higher doses of vitamin D3 for 12 months on blood pressure or arterial stiffness, compared to placebo. Plasma 25(OH)D is inversely associated with both CVD and non-vascular mortality. No effects were found after oral intake of vitamin D3 on blood pressure or arterial stiffness after 1 year. Randomised trials using adequate doses of vitamin D3 are needed, to evaluate causal effects of taking vitamin D on CVD outcomes.

Background: Human immunodeficiency virus (HIV) remains a global health problem. In sub-Saharan Africa, where the majority of HIV infected individuals live, 1.5 million HIV positive individuals die and 1.2 million become infected every year. Ensuring timely access to anti-retroviral therapy (ART) and efficacious HIV prevention strategies could potentially end the epidemic. To realise these benefits, individuals need access to frequent HIV testing and retesting. Facility-based HIV testing and counselling (HTC) is not popular in the region. HIV self-testing (HIVST), where individuals test in the privacy of their own homes, has been found to potentially achieve the required levels of HIV testing needed to achieve these goals. However no economic analysis of HIVST has been undertaken to inform policy makers whether it is a cost-effective option to scale-up in the region. Objective: To undertake a cost-utility analysis (CUA), from the health provider and societal perspectives, that estimates the incremental cost per quality-adjusted life year (QALY) gained by providing Malawian communities HIVST, in addition to routine provision of facility-based HTC. Methods: A decision-analytical model parameterised using primary cost and health-related quality of life (HRQoL) data collected from three observational studies: (1) a cross-sectional study recruiting individuals (n=1,241) who accessed HIVST and facility-based HTC; (2) a cohort study following up HIV positive individuals (n=330) accessing HIV treatment after HIVST or facility-based HTC; and (3) a cohort study of adults (n=822) admitted to the medical wards at Queen Elizabeth Central Hospital. In addition, evidence from the literature was synthesised to estimate epidemiological parameter inputs. Primary costing was undertaken to estimate health provider costs. Participants were asked about the direct non-medical and indirect costs they incurred, and their HRQoL measured using the EuroQol EQ-5D. Costs were adjusted to 2014 US and INT Dollars, and the primary cost-effectiveness outcome was expressed in terms of incremental cost per QALY gained. Results: The health provider cost per participant tested through HIVST (US$8.78) was comparable to that for facility-based HTC (US$7.53-US$10.57), although the mean societal costs of HTC were US$ 2.38 (95%CI: US$0.87-US$3.89) lower with HIVST. The mean total health provider (US$22.74 v US$28.33) and societal cost (US$25.56 v US$32.22) during the pre-ART period was lower for those who had accessed HIVST to learn their status than for those who accessed facility-based HTC. Mean total health provider and societal costs during the first year of accessing ART were comparable between those who had accessed HIVST and facility-HTC (mean total societal cost: US$251.14 v US$261.57). HIV positive individuals who had more advanced HIV disease, measured by the CD4 count, had lower EQ-5D utility scores. Health-related quality of life improved once individuals started ART, with the majority of participants reporting perfect health one year after starting ART. The mean cost of hospital admission was high, for example the mean health provider cost of managing Cryptococcal Meningitis and Pulmonary Tuberculosis was US$837.92 and US$473.11, respectively, and was associated with low EQ-5D utility scores. The CUA found the incremental cost-effectiveness ratio (ICER) of providing HIVST in addition routine facility-based HTC to be US$316.18 per QALY gained from the health provider perspective (societal perspective: US$332.05 per QALY gained). The sensitivity analysis found the ICER was comparable if the cost of HIVST was higher, if there were lower rates of linkage into HIV treatment after HIVST and if the HIV prevalence in the population was lower. Conclusion: HIVST was found to be an affordable and cost-effective option for Malawi based on International guidelines (ICER below three times the gross domestic product: US$250 in Malawi). Undertaking primary economic data collection in resource-constrained settings was feasible and provided robust estimates for use in decision-analytic models.

Background: Hypertension is a global public health problem. It is the number one risk factor for mortality and the third leading cause of disability-adjusted life-years (DALYs) worldwide. The burden of the disease is more severe in low- and middle-income countries, where prevalence estimates are projected to increase by 30% over the next decade. This is not surprising owing to the on-going epidemiological transition taking place in these countries, where the interplay between social factors and disease is highly pertinent. However, evidence on the burden of hypertension and its determinants in low- and middle-income countries are limited. The overall aim of this research is to examine the prevalence and status of hypertension in low- and middle-income countries. The definition of hypertension used in this research is blood pressure measurement of ≥140 /90 mmHg (SBP/DBP), the use of antihypertensive medication, or self-reported physician diagnosis of hypertension. Objectives: -To estimate the overall prevalence of hypertension in low- and middle-income countries. -To examine the socio-demographic determinants of hypertension in low- and middle-income settings. -To examine the geographic variation of hypertension prevalence in selected low-and middle-income countries. -To interpret the findings and discuss their implications for practice/policy and future research. Methods: A systematic review and meta-analysis was conducted to provide overall and regional estimates of hypertension prevalence across low- and middle-income countries, and to examine patterns of the disease across different socio-demographic characteristics in these settings. Studies reporting hypertension prevalence in low- and middle-income countries were sought from electronic databases and grey literature. The data from these studies were analyzed using random-effects meta-analyses and sub-group analyses. Secondary data analyses of DHS datasets were also conducted to estimate hypertension prevalence and examine its geographic variation in selected low- and middle-income countries with hypertension data, while accounting for a number socio-demographic characteristics. The secondary data analyses entailed logistic regression and Bayesian geo-additive analyses. Odds ratios with 95% confidence intervals were reported for the logistic regression analyses, whereas posterior odds ratios with 95% credible intervals were reported for the Bayesian geo-additive analyses. Results: The systematic review included 242 studies, comprising 1,494,609 adults from 45 countries. The overall prevalence of hypertension was 32.3% (95% confidence interval [CI] 29.4–35.3) with the Latin America and Caribbean region reporting the highest prevalence (39.1%, 95% CI 33.1–45.2). Prevalence was also highest in upper-middle income countries (37.8%, 95% CI 35.0–40.6) and lowest in low-income countries (23.1%, 95% CI 20.1–26.2). Prevalence among adults ≥65 years was substantially higher than adults < 65 years; however, there was no significant sex-difference overall (31.9% vs 30.8%, p=0.6). Prevalence was generally higher among the non-educated compared to educated people (49.0% vs. 24.9%, p < 0.05), among overweight/obese persons compared to normal weight (46.4% vs. 26.3%, p < 0.05), and among urban settlers compared to rural (32.7% vs 25.2%, p=0.0005). Meta-regression showed that combined overweight/obesity (p < 0.05) and being uneducated (p < 0.05) significantly accounted for between-study heterogeneity in hypertension rates The secondary analysis comprised data on 93,247 respondents in 10 selected countries (Albania, Armenia, Azerbaijan, Ukraine, Uzbekistan, Egypt, Morocco, Lesotho, Senegal and Maldives). The prevalence of hypertension was lowest in Morocco (5.4%) and highest in Albania (22.7%). Age was the most consistent predictor of hypertension. Being employed was protective in the Eastern European countries (Albania, Armenia, Azerbaijan, Ukraine and Uzbekistan) (p < 0.05 for each) and in African countries such as Egypt and Senegal (p < 0.05 for each). Education was protective in Egypt, Senegal and Maldives (p < 0.05 for each), but may be a strong determinant in Lesotho given the extremely high literacy rates in the country. Examining the geographic variation of hypertension revealed that Tirana and Elbasan districts had the highest burden of hypertension compared to other districts in Albania; Sharkia and Kalyoubia districts had the highest burden of hypertension compared to other districts in Egypt; while Quthing and Maseru districts had the highest burden of hypertension in Lesotho. Conclusion: Overall, the findings provide contemporary and up-to-date estimates that reflect the significant burden of hypertension in low- and middle-income countries and evidence that hypertension remains a major public health issue in these settings. The findings also suggest that addressing the wider social determinants of hypertension, such as illiteracy and unemployment, may reduce overall prevalence of the disease in low- and middle-income countries.

Carers who look after family members on an unpaid basis often experience negative impacts from their caring role due to the lack of value placed upon care more widely in society. Casework with carers, ‘the individualised support work undertaken by a practitioner with a newly identified carer’, offers a means to support carers. This thesis considers the research question ‘Casework with carers: what works and why?’. The study places an original focus upon the work of third sector carer organisations upon which there has been very little other research. A comparative perspective is taken to consider this together with the casework with carers undertaken by third sector condition specialist organisations and through statutory carer assessment. The study uses the realist evaluation framework, grounded in critical realism, to identify the outcomes of casework, the mechanisms explaining these and the contextual factors influencing this. A longitudinal research design involving thirty seven qualitative case studies of individual carers’ experiences enabled original findings about change in outcomes over time to be identified and provided a unique insight into the long term impacts of casework. Separate carer and practitioner interviews at timed intervals, supported by audio-recording of the first main contact of casework, provided a comprehensive insight into casework. The findings have been used to develop a new and original model of casework with carers. This identifies how outcomes can be achieved through a number of different types of mechanisms consisting of: psychological support to recognise the value of caring and carer needs; expression of feelings; development of knowledge and skills about caring and about resources and how to access these; and carer action including to access secondary services. It also identifies how a range of contextual factors, including carer characteristics and practitioners’ characteristics and approach to casework, influence outcomes. The study illustrated that third sector carer and condition specialist organisations were potentially well placed as relatively accessible and visible services to achieve varied positive outcomes with carers. However, the findings also showed that casework was of limited help to some carers who continued to have serious unmet needs principally because of barriers in terms of the availability of appropriate secondary services or the reluctance of the person receiving care to use such services. Interpreting the findings through the theoretical frameworks of the ethic of care and carer empowerment highlighted how the nature of the casework practised constrained its potential to support carers. The lack of integrated and ongoing support limited the ethic of care achieved, but perhaps the personalisation of services might help towards overcoming this. The mainly administrative approach of casework (rather than a therapeutic or empowerment based approach) limited the achievement of carer empowerment. Substantial changes in casework practice would be required to address this.

This thesis consists of three chapters. Chapter one is a systematic review of the qualitative literature examining the experiences of clinicians working in mental health services with forensic service users (FSU). Following systematic searches and a process of quality assessment, a total of 14 articles were included and their findings were systematically compared. Staff members experienced both positive and negative emotional responses to their work, there are conflicting aspects to their role and additional challenges within the organisational context. Implications for clinical practice and further research are discussed. Chapter two uses Interpretative Phenomenological Analysis (IPA) to consider the experiences of FSUs diagnosed with Personality Disorder (PD) in Forensic Services and the meaning given to recovery within their accounts. The findings discuss the disempowered position of FSU participants and suggest that feeling safe within relationships in their environment is important for those with this diagnosis. There was evidence in their accounts of attempts to establish new identities but there also appeared to be multiple barriers to this. Chapter three offers a reflective account of the researcher’s experience of carrying out this study. It demonstrates the reflexive strategies used that allowed the competing subjective roles alongside that of ‘researcher’, to be examined and their influence on the research process explored.

This thesis contributes to a national evaluation of a Dental Health Support Worker (DHSW) intervention in Scotland. The DHSW intervention is a targeted component of Childsmile; an oral health improvement programme which aims to improve the oral health of children and reduce oral health inequalities. DHSWs facilitate families in registering with, and attending, a dental practice, support oral health behaviour change at home, and signpost families to wider community initiatives. In programme development, elements proposed to be critical to the success of the DHSW intervention were: effective targeting of ‘the right children’ and ensuring the intervention is ‘tailored to families’ needs’. When the programme was rolled out across Scotland, there was a lack of consensus about how these elements should be implemented. Furthermore, some aspects of the programme were adapted to suit the characteristics of the local Scottish health boards. This thesis aims to explore how ‘targeting’ and ‘tailoring’ were being implemented in the DHSW intervention, how they should be implemented in order to be optimally effective, and the effect of the DHSW intervention on dental participation at the early phase of implementation. A systematic review and mixed methods study were conducted. The systematic review synthesised evidence on the implementation of tailoring in effective lay health worker interventions. The mixed methods study looked at how targeting and tailoring were implemented within the Childsmile DHSW intervention and its impact on child dental participation. The mixed methods study involved quantitative analysis of linked administrative health datasets and qualitative analysis of focus groups and interviews with Childsmile stakeholders, synthesising the findings from a pragmatic stance. Findings show that ‘the right children’ were defined by stakeholders as any child in a family identified as vulnerable (for whatever reason) whose family must be ready to engage with the intervention. The right child is not every child or children in families facing acute health or social issues that may inhibit engagement. In the early stage of implementation of the intervention, there was some evidence of targeting of the right children from a socio-economic and oral health risk position. Nonetheless, there were differences between health boards in the extent to which this targeted approach was adopted and the extent to which the Childsmile referral pathway was being utilised. ‘Tailoring to families’ needs’ should involve assessing individual families’ needs and then providing differential support matched to those specific needs. There was some evidence that DHSWs were tailoring the intervention in line with some of the features of tailoring found to be effective in other LHW programmes; however, there were many barriers that restricted DHSWs’ freedom to tailor to families’ needs. Barriers included: health visitors not providing background information with the referral; DHSWs having responsibilities outside of Childsmile Practice; dental practices not notifying DHSWs of children who fail to attend appointments; a lack of consensus within the programme on whether DHSWs should deliver a brief intervention or whether it can be more intensive support where necessary; and, communication difficulties across language barriers. Despite this, there was clear evidence that the DHSW intervention had been effective at this early stage of implementation. Moderate effects on dental participation were observed across Scotland in all risk groups. Across Scotland, there was a 17% difference in dental participation between groups who did and did not receive the intervention, and children were more likely to participate sooner if they had received an intervention. Recommendations for the Childsmile programme follow three key themes: (1) reform the referral pathway; (2) develop working policies to help reduce organisational barriers to DHSWs delivering an effective intervention; and, (3) although challenging within the health service system, improve selection criteria of DHSWs and enhance subsequent training to highlight the unique benefits lay people bring to these roles.