Colorectal cancer is the third most common cancer and the second most common cause of cancer death in the UK. Outcome is directly related to stage at diagnosis with over 90% of patients with Stage I disease surviving their disease to 5 years compared to less than 10% of those with Stage IV disease. Symptoms for colorectal cancer can be non-specific, particularly when the disease is at its early stage, and hence screening has been introduced. Population screening in the UK, using faecal occult blood testing (FOBt) has been introduced over the past 10 years following several major randomized control trials and a Cochrane review that has shown improved cancer specific mortality in the region of 15% in those individuals invited. This has been attributed to the detection of early stage disease with around 50% of all tumours detected through screening being Stage I. However, it has previously been shown that there are additional tumour and host prognostic factors outside of stage that can determine outcome. For example, the presence of venous invasion and the presence of an elevated host systemic inflammatory response have been associated with poorer cancer specific survival. These additional factors have not previously been studied within the context of a population screening programme or indeed within early stage disease. Moreover, the FOBt screening programme itself is not without its pitfalls. Uptake of the test is below that of other established cancer screening programmes and it is recognised that repeated screening rounds are required to achieve an acceptable sensitivity of the test. This thesis sought to examine the first round of the Scottish Bowel Screening Programme within the West of Scotland and assess its effect on tumour and host determinants of outcome. In Chapter 1 an overview of colorectal cancer and current determinants of outcome is provided. In addition, colorectal cancer screening is explored in detail including the evidence behind the current screening programme. Chapter 2 presents original data, utilising population databases, examining the changes in mode, site and stage of presentation across the West of Scotland that have accompanied the introduction of the national screening programme. It identifies that within non-metastatic disease there has been a shift towards a higher proportion of Stage I disease being present following screening introduction. Chapter 3 presents a detailed examination of the first round of screening in NHS Greater Glasgow & Clyde (NHS GG&C) emphasising the importance of the impact of deprivation throughout the screening programme. For example, deprived patients were less likely to take part, more likely to test positive, less likely to proceed to colonscopy following a positive test and less likely to have cancer detected at colonoscopy following a positive test. Chapters 4, 5 and 6 utilise an original dataset of over 4000 patients who underwent colonoscopy following a positive test in the first round of screening in NHS GG&C generated through work from Chapter 3. Firstly, in Chapter 4, a theoretical model proposing a flexible sigmoidoscopy as a first line test, rather than a colonoscopy, is examined. It found a missed cancer rate of 17% and that around a third would require a completion colonoscopy, concluding that this would not be a desirable change to the current screening algorithm. Chapter 5 then examines the importance of potentially chemopreventative medications such as statins and aspirin, on the risk of neoplasia at colonoscopy, determining that patients on such medications did indeed have lower rates of neoplasia, significant neoplasia and cancer than those not on them. Chapter 6 then looks at symptoms in this population, identifying that around 40% had at least one bowel symptom however that these correlated poorly with the risk of significant neoplasia at colonoscopy. Chapter 7 explores outcomes in those who were invited but did not have a screen-detected cancer in order to examine the incidence of interval cancers (colorectal cancer within 2 years of a negative FOBt) and cancers in non-responders. Overall it identified a 30% interval cancer rate. The chapter then explores differences in tumour and host factors between screen-detected and non screen-detected disease reporting that stage for stage, patients with non screen-detected disease had higher rates of systemic inflammation. Furthermore it characterises the similarity between interval and non-responder tumours suggesting that rather than representing biologically more aggressive tumours, interval cancers arise due to limitations of the test itself. Chapter 8 presents long-term outcomes in patients who have undergone a resection for Stage I disease prior to the introduction of screening. The results report an excellent 5-year cancer specific survival of 95% however an overall survival of 76%. It identifies the presence of an elevated pre-operative host inflammatory response as being associated with a worse overall outcome. Tissue work exploring the local immune-cell microenvironment of both early stage and pre-malignant disease is the focus for Chapters 9 and 10. This characterisation of immune cell infiltrate identifies similar rates of peritumoural inflammation between T1 and T2 disease and validates a previously published automated scoring system. When exploring local inflammation within premalignant polyps there appears to be a change from low-grade to high-grade dysplasia signifying a specific response to early disease progression suggesting host immunosurveillance. Chapter 11 summarises the main findings of the thesis and presents future directions.

Introduction: Although the health of military personnel who have taken part in specific conflicts has been studied throughout the 20th century, there is a paucity of evidence on the long-term overall impact of military service on health. This thesis describes the establishment of and findings from the Scottish Veterans Health Study, a retrospective cohort study comparing the health outcomes of veterans with those of people with no record of service, in order to determine whether the long-term health of military veterans living in Scotland differed from that of people who had never served in the armed forces. Methods: The study population comprised all 57,000 military veterans born between 1945 and 1985 who were resident in Scotland both before and after military service, together with a 3:1 comparison group of 173,000 people with no record of service, matched for age, sex and postcode sector of residence. The demographic data were extracted from the National Health Service Central Registry database and were linked electronically to the National Health Service Scottish Morbidity Record and national vital records data for acute and psychiatric hospital admissions, psychiatric day-case admissions, cancer registrations and death certificate data. Survival analysis was used to determine hazard ratios for those health conditions and outcomes considered to be of a priori interest, overall, by sex, by birth cohort and by length and period of service, both univariately and after adjusting for deprivation. Results: Veterans were at significantly increased risk of cardiovascular disease compared to non-veterans overall, and of acute myocardial infarction, stroke and peripheral arterial disease specifically. Subgroup analysis showed the increased risk to be confined to veterans born between 1945 and 1959, reducing in more recent birth cohorts. The risk was highest in veterans who left after only a short period of service (Early Service Leavers), whilst those who served for longest exhibited a similar risk of cardiovascular disease to all non-veterans. Veterans were at no higher overall risk of cancer than non-veterans, although there were major differences in the risk of specific cancers, which changed over time. The oldest veterans had an increased risk of cancer of the lung, oropharynx and larynx, oesophagus and stomach; the risks of these cancers reduced in more recent birth cohorts. The 1960-1964 birth cohort showed an increased risk of both bladder cancer and pancreatic cancer in comparison with non-veterans. There were increased risks of ovarian cancer in veteran women compared with non-veterans, and of breast cancer in longer-serving women. The risk of cervical cancer decreased in more recent birth cohorts. There were no differences in the risk of colorectal cancer or prostate cancer in veterans, overall or in any subgroup. There was no clear evidence of increased risk of lymphohaematopoietic cancer in veterans. Veterans were at increased risk of motor neuron disease, but not of multiple sclerosis. Veterans were at increased risk of peptic ulcer disease for all birth cohorts up to the mid-1960s but not thereafter; the risk was highest in those with the shortest service. Hepatitis C was less common in veterans than in non-veterans, in all subgroups. Analysis of mental health outcomes showed that the greatest burden of ill-health was among Early Service Leavers, whilst veterans who completed at least a minimum length of engagement were not at increased risk compared with non-veterans, except for post-traumatic stress disorder. The results for post-traumatic stress disorder, in both veterans and non-veterans, demonstrated a complexity which could not be reconciled with any operational exposure or conventional clinical pattern, but which may have reflected a ‘hidden iceberg’ of unmet need in the late 1990s which was uncovered by increasing awareness of the condition. Longer service was generally associated with better mental health. Veterans were at no greater risk of suicide than non-veterans; the risk was independent of length of service. Veteran women exhibited a risk profile for mental health outcomes which more closely resembled that of veteran men; this was especially marked for suicide. Veterans were not at increased risk of alcoholic liver disease overall; the only subgroup to show an increase in risk was Early Service Leavers who had completed training, and there was also evidence of increased risk of some alcohol-related cancers in trained Early Service Leavers. Interpretation: Older veterans demonstrated an increased risk of smoking-related ill-health, including cardiovascular and respiratory disease and the smoking-related cancers, which is consistent with reported high rates of military smoking in the 1960s and early 1970s. Overall, there has been an improvement in health of veterans compared with the non-serving population in more recent generations, suggesting that the increased emphasis on health promotion and physical fitness in the armed forces since the late 1970s has been effective. Major alcohol problems were no more common in veterans than in the wider community, and were most likely to affect those who left earliest, although not those who left whilst still in training. Longer service was generally associated with better long-term health. Early Service Leavers had poorer health outcomes than longer-serving veterans, but the ability to stratify by length of service demonstrated that the poorest outcomes were in those who did not complete initial training. It is likely that their long-term health outcomes have been predominantly influenced by pre-service and post-service health and behavioural factors which, at a pre-service level, may have also contributed to their failure to complete the minimum military engagement, rather than by their short period of military service. The early period of service appears to act as an extension to the screening process for entry to service, filtering out those who prove least suited to service. The Early Service Leavers therefore form a ‘less healthy leaver’ group which is the counterpart to the longer-serving ‘healthy worker effect’; their status as veterans means that they can be identified within the community, unlike most other occupational leaver groups, but their poorer long-term health is unlikely to be due to military occupational factors. Improved understanding of the determinants of veterans’ health will inform the provision of appropriate health and community services to meet their needs.

This thesis looked inside the black box of stroke care, so called because its contents are not clearly defined. This case study of success illustrated how a new inpatient stroke unit (SU) was created in an inner London teaching hospital, transforming treatment for patients with stroke. Whilst it is known that good stroke care results in improved patient outcomes, it is not fully understood how or why. As stroke is the second major cause of death in adults worldwide, and a leading cause of adult disability in the UK, it is essential more is known about how evidence translates into practical knowledge for use in mainstream practice. This action research study, through the systematic documentation and evaluation of the processes and outcomes, has unpacked and illuminated factors that enabled development of success, and provides the first empirical account of its kind. This study adds to the knowledge of knowing how. A variety of qualitative and quantitative methods were used to generate data between January 2001 and November 2002. Findings were analysed using Immersion I Crystallization and descriptive statistics. When the black box of stroke unit care was opened, four key interrelated themes emerged from the process findings: building a multidisciplinary stroke team; developing practice based knowledge and skills in stroke; valuing the central role of the nurse in stroke care and creating an organisational climate for supporting improvement. Analyses of findings suggest the creation of excellence in stroke care was linked to the development of a Community of Practice (CoP), which combines three elements; domain, community and practice, into a conceptual framework of learning that fundamentally places the acquisition of knowledge into a social process of learning. Whilst improvement initiatives have recently been linked in the literature to CoPs, no guidance is available on how this should be done. This thesis makes an original contribution to the body of knowledge by providing the first empirical evidence of not only on how a CoP was created, but shows how it developed into a functional multidisciplinary CoP, a concept identified in the literature as difficult to accomplish. In concluding, issues related to practice, research, education and policy are raised for future considerations.

This action research project aimed to develop inter-professional peer clinical supervision involving nurses and allied health professionals within a community health care organization. The literature revealed limited evidence regarding the development of supervisory relationships in peer group supervision and a deficiency of insider reports of interprofessional peer supervision interactions. Preparedness of practitioners and lack of protected time remain as barriers to sustainable clinical supervision. An inter-professional peer clinical supervision group (IPPCSG) was constituted via a four phase action research process. A qualitative approach was employed using a single case study design. The involvement of participants as co-inquirers reflected the participatory nature of action research. All sessions were audio-recorded and fully transcribed with data analysed using Template Analysis. A theoretical framework was developed to support the interpretation of the findings drawing on concepts of democracy and power. This action research study revealed the part played by structure and rules in securing a safe supervision space, with the incorporation of democratic principles being crucial in equalising power relationships. The study illuminates how trust developed and how supervisory relationships matured and provides detail of the transitions between functional peer supervision group roles. Valuable insights have been gained into how challenge and support are balanced when exploring decision-making and risk. The findings suggest that the different professional identities and perspectives within this group did not impinge on the development of effective supervisory transactions. Substantial common ground was revealed regarding issues brought to supervision, professional beliefs, values and experiences. The analysis suggests that processing work-generated emotion should be a core component of supervision. Learning about each other’s practice and learning how to ‘do’ clinical supervision were identified as important outcomes by co-inquirers. The analysis and interpretation of these data produced the Triple Diamond Model of Interprofessional Peer Group Supervision which may resonate with other practitioners and conveners of group clinical supervision. The evaluation of this action research study identified valuable outcomes for co-inquirers in regard to capacity building and personal development and to a lesser extent for the wider organization in contributing to the development of clinical supervision. The IPPCSG has been maintained since the conclusion of the study.

No description available.

No description available.

Self-injurious behaviours are associated with long-term negative consequences for social, emotional and physical wellbeing. As such, and in order to inform the development of both treatment plans and preventive approaches, it is necessary to develop a comprehensive understanding of the a etiological factors associated with self-injury. In the first instance, literature assessing the prevalence of self-injury in adolescents was systematically assessed in order to determine the presence of gender differences. This was in response to a lack of clarity within the self-injury field as to whether there are gender differences in the prevalence of self-injurious behaviours. Thirty seven studies were included in the final review and were grouped according to the exclusion of suicidal intent and the assessment method of self-injury. Common methodological limitations across all studies are discussed, including the variation in definition and assessment of self-injury. Results suggested that female adolescents were significantly more likely to report engaging in self-injurious behaviour than males. However, it is unclear whether this finding reflects a gender bias in how self-injury is assessed, or whether there is a true difference in self-injury rates. Gender differences were also reported in both the method and function of self-injury. Recommendations are offered with respect to future research and regarding ‘gold standard’ methods of assessment. In an empirical study, we aimed to improve our understanding of the risk factors and potential functions of self-injurious females and, specifically, whether these differed by gender. Based on previous literature it was hypothesised that an insecure attachment style, either anxious or avoidant, may result in deficits in effective emotion regulation skills. As such, these individuals may become reliant on maladaptive strategies such as self-injury. Three hundred and seventy adults completed measure of attachment style, emotion dysregulation, alexithymia and self-injury. Results suggested a lifetime prevalence of 50.8%, which was notably higher than previous research findings. Furthermore, and contrary to previous research, there were no significant gender differences in prevalence. With respect to the proposed model of mediation, in females there was clear evidence to suggest that emotion dysregulation mediates the relationship between attachment insecurity and self-injurious behaviour. This has important implications for the development of effective preventative and treatment approaches for self-injury in females. In contrast, no such relationship was demonstrated in males. This suggests the need for future research efforts directed at understanding the origins and function of self-injury in males.

The project effects arise from specific projects or programmes that are undertaken in the context of the Games, but which could be implemented in the absence of such an event. The evaluation of these could be improved if either a prospective cohort study (where the participants in the projects can be predicted in advance) or retrospective cohort study (where the participants will only be known after they have taken part) is arranged. This will require to be undertaken in combination with qualitative studies and the creation of a theory of change to understand why any such project effects are (or are not) seen. The direct impacts of the Games, that is the impacts that occur as a direct result of playing host (such as the impact on tourism), require a different approach to achieve a quality evaluation. First, a theory of change to identify the critical pathways in generating impacts should be elucidated. Next, a combination of a cohort study and an ecological study (using routine data and a series of comparison areas identified in advance), should be used to identify the attributable impacts of the Games. Qualitative work alongside these studies will be required to understand why the impacts occur (or not). For the economic impacts specifically, an ecological design or economic modelling should be performed using routine statistical data (rather than estimates) and taking account of the opportunity costs. The catalytic impacts are particularly difficult to evaluate as it is not yet clear what these impacts might be. These potential impacts will require being identified using regular qualitative work with key individuals within the public and private sector in Glasgow, and this information will then need to be used to design quantitative studies to test these hypotheses. The synthesis discussed whether or not the Games could legitimately be described as a health improvement intervention. It found that some of the critical steps in the intervention were very similar to the tried and tested mechanisms used over many decades in the West of Scotland in attempt to improve the health and social conditions (economic growth and improved environment), without success. The ability of the Games to impact on the other critical steps (sports participation, increased volunteering and increased pride) is not supported by the evidence from previous events, and it is difficult to see what is different about the plans for the 2014 Games that might generate a different result. It was therefore concluded that the 2014 Games are unlikely to be an effective health improvement, and are unlikely to generate the plethora of social and economic benefits that pepper the bid document and legacy plans. Discussion: There are high expectations from Government that the 2014 Games will deliver a plethora of health and social benefits. The evidence from previous events is of poor quality, and there is an absence of evidence of positive impacts occurring. Given that a publication bias towards positive impacts is expected, it is unlikely that large positive health or socioeconomic benefits have occurred from major multi-sport events in the last 30 years. Health impact assessment can be used as an effective method of engaging the public and can be used to inform policy-making with evidence. Although the HIA did not predict the net overall impact of the Games, it is possible to make evidence-informed recommendations that are likely to maximise the potential for positive impacts and minimise the potential for negative impacts. The quality of evidence on the impacts of major sports events could be improved if a theory of change evaluation framework was applied to the event and if this was used to design a series of qualitative, cohort and ecological studies with appropriate comparison groups. However, it is unlikely that the 2014 Games will have a large positive impact on the health of Glaswegians or on socioeconomic outcomes because there is little evidence that the likely critical pathways have been successfully used in generating positive impacts despite similar attempts in the past. Some critics of major sports events have also made a plausible case for their being important negative consequences from playing host. The strengths of the thesis include the use of robust methodologies for the systematic review and health impact assessment, and the innovative use of a critical pathways approach for estimating whether or not the net impact of the Games will be positive. The weaknesses of the thesis include the reliance on the Government’s published work to discern the theory of change; the 34 studies that could not be obtained for possible inclusion in the systematic review; the limited evidence base upon which to make recommendations in the HIA; and the reliance on an accurate theory of change to predict the net impact of the Games, including the absence of emergent impacts from the complex Glaswegian context. Conclusions: The 2014 Games are unlikely to generate a large positive impact for health or the socioeconomic determinants of health. There is potential for unintended negative consequences to occur. The impacts of the Games are most likely to be optimised if the HIA recommendations are acted upon by decision-makers, and these impacts will only be accurately known if there is work to improve the quality of the evaluation. It is possible that the marketing of the Games as an intervention for health and social improvement might deflect attention from more important determinants of health in the city. In that vein, it may be more reasonable to make few other claims for the Games than that it will provide public entertainment and a festival for the population, and to minimise the opportunity costs that the Games will generate.

Background: Low socioeconomic position throughout the life course is associated with a number of adverse health outcomes in older people. However, whether life course socioeconomic position influences subjective outcomes in early old age, such as quality of life, is not well known. There is a lack of life course research that considers the wider structural determinants of health. In particular, it is not well understood if the association between life course socioeconomic position and quality of life is the same across European societies that have differing welfare state arrangements. This thesis addressed two key aims: (1) Investigate whether, and how, life course socioeconomic position influences the quality of life of Europeans in early old age. (2) Examine differences in this relationship by welfare regime. Methods: Two methodological approaches were taken to address the research objectives: (1) A systematic review of quantitative studies examining the influence of life course socioeconomic position on quality of life was conducted, with a narrative synthesis. (2) An empirical analysis was carried out examining the influence of life course socioeconomic position on the quality of life of individuals in early old age, as measured by CASP-12 and life satisfaction. This used secondary data from 13 European countries (representing Southern, Scandinavian, Post-communist, and Bismarckian welfare regimes) that were part of Wave 2 of the Survey of Health, Ageing, and Retirement in Europe (SHARE) and SHARELIFE, which collected retrospective life histories of respondents. Two statistical techniques were used to analyse the data: multilevel modelling and path analysis. Slope indices of inequality were calculated to enable measures of socioeconomic position to be compared. Results: The systematic review identified 12 relevant studies, which varied in terms of the outcomes examined, study quality, and populations. No studies were identified from Bismarckian or Post-communist welfare regimes, with most containing populations from the Scandinavian or Liberal regime types. Some supportive evidence was found for a latent effect of low childhood socioeconomic position on quality of life among women. Social mobility models were generally not supported. High quality studies addressing inter-generational mobility were lacking and few studies examined cumulative and pathway effects. Results from the analysis using SHARE suggested that the most proximal measures of socioeconomic position were the strongest predictors of quality of life. In most welfare regimes, inequalities in quality of life were largest by current wealth, but among women in the Southern and Post-communist regimes inequalities by education level were particularly large. In the Scandinavian regime there were very small differences in quality of life between the least and most educated. Generally, there was little difference in the magnitude of socioeconomic inequalities in quality of life between Scandinavian and Bismarckian regimes. Support for a latent effect on quality of life was lacking, using most measures of childhood socioeconomic position. The findings from both the multilevel models and path analysis supported the pathway theory whereby childhood socioeconomic position chiefly influenced quality of life through later socioeconomic experiences. However, the number of books in childhood exhibited a weak association with quality of life even when taking into account current measures of socioeconomic position, suggesting a small latent effect for this measure. When stratifying by welfare regime, the potential direct effect from the number of books in childhood was specific to particular welfare regimes and genders. A greater number of socioeconomically advantaged positions over the life course was associated with higher quality of life in early old age, but the results suggested this was mainly due to the influence of socioeconomic advantage during adulthood. The association between life course socioeconomic position (as measured by a cumulative socioeconomic advantage score) and quality of life was weaker in the Scandinavian regime and stronger in Southern and Post-communist regimes. Including a measure of current financial distress greatly attenuated these associations. There was generally a lack of supportive evidence for an effect of social mobility on quality of life. Conclusions: Socioeconomic inequalities in quality of life were apparent in all welfare regimes and were largest by more proximal measures of socioeconomic position. Overall, Scandinavian and Bismarckian welfare regimes exhibited both higher quality of life and narrower inequalities in quality of life, compared to Southern and Post-communist regimes. Interventions to reduce socioeconomic inequalities across the life course are needed, but those which buffer the effect of financial distress in early old age may be particularly beneficial for improving quality of life and producing a more equitable distribution.

Literature suggests that the public sector has a unique responsibility to promote sustainable practice from within. Food systems impact on planetary, social, economic and human health, and Ecological Public Health (EPH) is making these holistic connections explicit. This study developed a new methodological approach based on the principles of EPH, which for the first time are used to empirically investigate a complex foodservice system, the hospital foodservice system. In addition, Street Level Bureaucrat theory is used at the ward level for the first time deepening understanding of workers’ practices, particularly on the theme of choice. Using a case study based within one Welsh Health Board, this research considered the translation of a new Welsh policy into practice through an exploration of two key elements within the foodservice system: menu planning and food service at ward level. Following the systemic and interdisciplinary thinking promoted by EPH, a multi-methods approach was taken using documents and formal interviews with 28 key stakeholders in the case study Health Board. Ward based studies took place in three Health Board hospitals: lunch service on a total of nine wards was explored through observation, 33 informal interviews, 104 patient experience questionnaires, waste data and an in-depth study of one meal (lasagne) with 48 participants. The study showed mixed findings in the translation of policy into practice: aspirations to improve sustainability through procurement and waste reduction did not materialise in practice, and the individualised approaches of workers led to high levels of food waste and inconsistent approaches to choice. Patient satisfaction with choice increased under new menus, but a drop in satisfaction around menu changeability was found, particularly for longer stay patients. Finally, the lasagne study showed that patients had diverse responses to the same dish, and that liking the dish did not mean enough was eaten to meet nutritional needs. Such findings, in drawing the fields of nutrition and sustainability together, have multi-disciplinary impact, particularly for nutrition, environmental and hospitality management studies. In turn the findings demonstrate the value of research that draws on the principles of EPH.