Background: The burden of mental disorders in post-conflict areas is higher than in countries where there is no conflict. Post-conflict areas lack the resources to respond to such high burden, resulting in a treatment gap. This study explored the potential for mental health reform in Gaza. Design: Mixed methods study. Methods: The WHO-AIMS questionnaire was used to assess mental health services in Gaza and documentary analysis was conducted to evaluate the Mental Health Policy and Plan. Healthcare professionals‟ mental health training needs were identified and policy makers, healthcare professionals, service users and carers took part in focus groups to elicit their perspectives on mental health reform. Framework analysis was used to identify recurrent themes. Results: Psychotherapy, recovery, family intervention and crisis management were rated priority training areas. Poor coordination between governmental and non-governmental organisations and short-term funding were identified as main barriers to mental health reform. Service users and carers felt excluded from service delivery and development and suggested possible models of partnership working with service providers to address exclusion. Conclusion: Meaningful mental health reform in post-conflict areas requires inclusive policy development, targeted staff training, improved coordination between different service providers, and partnership working between service providers and service users and carers.

Background: Obesity remains a significant public health priority despite ongoing efforts, with few notable advances made in recent years. Individual behaviour change mechanisms, or 'active ingredients', can only partially explain and predict successful weight loss. In addition, maintenance following a period of initial weight loss is rare and relies upon unique combinations of interrelated and overlapping factors. Whilst the outcome of weight loss and its maintenance has been the focus of much research, the individual weight loss journey as a process has been largely overlooked. By looking through the lens of the lived experience, there lies an opportunity to sequence the temporal and contextual dimensions of the weight journey and gain greater insight into this process. Aims: The current study aimed to examine the temporal and contextual dynamics of the weight loss journey by listening to the personal narratives of people who had attended a psychologically-led weight loss intervention, in this way revealing the barriers and enablers to their initial weight loss and maintenance over time. Methods: The study adopted a qualitative approach, using a combination of focus groups and 1-1 interviews with participants who had previously attended a psychologically-based weight management intervention. Results: The study recruited a total of 46 individuals who took part in either a focus group (n=40) or 1-1 interview (n=6). A conceptual linear framework was devised which highlighted three core superordinate themes; Alienation, Connectedness and The Future (Abandonment or Autonomy), representing distinct stages of the weight journey. In exploring the conditions under which individuals migrate across stages results indicated a role for the development of a self-identity which assumes personal responsibility for meeting psychological and emotional needs beyond the physical realm of weight loss. Although most personal narratives reflected a sense of abandonment post intervention and associated weight relapse, a small minority engendered a sense of autonomy and a focus upon psychological and emotional capacities as a metric for their weight loss journey. Conclusions: Bringing into view temporal and contextual dimensions involved in managing weight over time, the findings have implications for addressing the issue of weight as a symptom rather than as a cause and centralise the importance of meeting psychological and emotional needs over and above a unilateral focus on weight loss.

Diabetes has been described as an epidemic with a significant global burden of illness. This burden is associated with poorer engagement with services and the cost of managing avoidable complications. One outcome measure of engagement in the national health service (NHS) in the United Kingdom (UK) is attendance at appointments. The cost implications (direct and indirect) of non-attendance are significant, with empirical evidence consistently demonstrating higher than average non-attendance rates for out-patient appointments and education sessions by minority ethnic and socio-economically deprived individuals. A gap was identified whereby a comprehensive understanding of non-attendance which moves beyond clinical and technical aspects such as capacity and demand is still required. This thesis provides a fresh approach and granular understanding of patient engagement which can influence clinical care, service delivery and policy. The main research questions in this thesis were: 1. What are the predictors of out-patient attendance? 2. What are the barriers and enablers to attendance? To answer these questions, a retrospective geo-demographic trend analysis, critical narrative literature review of Community Health Worker (CHW) and peer support interventions and a research study were conducted. The case study is based on a dataset which comprised of 35,597 appointments. Its findings highlighted that factors such as age, gender, ethnicity, local geography and deprivation were significant predictors of out-patient attendance. A critical review of CHW and peer support interventions demonstrated that despite the heterogeneity of programme designs, duration of interventions, follow up and healthcare systems in which they were used, they were assessed to be both clinically and cost effective. There was limited evidence on the sustainability of these interventions due to a lack of longitudinal studies. The research element was conducted in two stages and utilised multi methods (focus groups, semi-structured interviews and questionnaires) to evaluate the barriers and facilitators to attendance. Key findings included the need for effective and on-going education, better alignment of health and social care due to the impact of the wider determinants of health but more interestingly, the influence of family on the concept of ownership for one's health by some individuals whose self-determination is limited by language and health literacy. The relationship between patient activation (knowledge, skills and confidence) and attendance was also evaluated. This evaluation demonstrated that the more activated individuals are, they are significantly more likely to attend appointments. However, to maximise care planning and operational effectiveness, activation should not be assessed in isolation. The findings of this thesis highlighted the influence of individual, organisational and structural factors on patients' engagement with out-patient services and the need for a synergistic approach involving service users, clinicians, organisations and policy makers to minimise patient dis-engagement with healthcare services.

This study explores public attitudes towards healthcare in the Eastern Province of KSA. It employs a sequential mixed-method design. Semi-structured focus group discussions (FGDs) were conducted with fifty-four participants in the Eastern Province. The qualitative arm of the study used a framework thematic analysis. A questionnaire was constructed from evidence-based items from four sources: an international performance assessment framework, literature review, systematic review, and the FGDs. The questionnaire was administered to 813 participants using on-site and online recruitment modes. Two qualitative validity assessments and quantitative construct validity and reliability tests were then carried out for the questionnaire. The FGDs indicate a public sense of pride in the Saudi health system. However, some concerns emerged from the FDGs-most notably, access barriers to the government health sector including the referral system from primary to secondary care and the necessity of personal connections, or 'wasta', to access timely care. Access barriers also emerged in the private health sector, namely the affordability of care and health insurance companies' delays in responding to medical claims. Participants also considered their inability to discuss treatment plans and to be involved in decision-making processes with their doctors as issues in both the public and private sectors. Participants were also concerned about the Ministry of Health (MOH) monitoring and regulating both sectors. This affected participant attitudes towards health service provisions. The questionnaire demonstrated qualitative validity and good psychometric properties in construct validity and internal reliability. Participants perceived doctor-patient communication as the most positive aspect of the Saudi health system while they perceived MOH monitoring of the private sector and affordability of care as the most negative aspects. Socio-demographic characteristics were considered as strong predictors of participants' attitudes towards the health system, and nationality and insurance status were identified as the most frequent predictors of satisfaction. Recommendations include implementing policies that monitor pricing in the private sector, fairer access to government healthcare, and patient involvement in decision-making processes. Future research should investigate the relationship between public attitudes towards the Saudi health system and health-related decisions to ensure better use of healthcare services in KSA.

This thesis concerns investigations into adverse health outcomes among survivors of childhood cancer using the British Childhood Cancer Survivor Study (BCCSS). The BCCSS is a large-scale population-based cohort of 17,981 survivors of childhood cancer who were diagnosed with childhood cancer (age 0-14 years) between 1940 and 1991, in Britain, and had survived for at least five years. The specific aims were to investigate, within the BCCSS cohort; (1) the psychometric properties of the SF-36 health-status questionnaire, (2) the self-reported health-status by using the SF-36, (3) the effect of therapeutic radiation on the offspring sex ratio, (4) the risks of adverse pregnancy outcomes, and (5) the risks of second primary breast cancer. This thesis demonstrates that the SF-36 questionnaire exhibits good validity and reliability when used in long-term survivors of childhood cancer. Survivors rate their physical and mental health similarly to those in the general population, apart from bone and central nervous system tumour survivors who rate their physical health below population norms. Therapeutic irradiation does not alter the sex ratio of offspring. Female survivors exposed to abdominal irradiation are at a three-fold risk of delivering premature and two-fold risk of producing low birth-weight offspring. Lastly, the risk of breast cancer among female survivors is two-fold that of the general population, but is not sustained into ages at which the risk of breast cancer in the general population becomes substantial.

Vitamin D deficiency (VDD) is widespread in England and Wales, affecting both children and adults by increasing their risk of poor bone health. In order to inform public decisions on the prevention of VDD, a decision analytic model was developed to compare four alternatives to prevent population VDD: wheat flour fortification, supplementation of at-risk groups, a combination of wheat flour and supplementation, and no intervention. Methods used to inform the model development stage included literature reviews, expert consultation, and preference-based questionnaires to elicit proxy utility values. An individual-level simulation Markov model was chosen to simulate the costs and benefits of each alternative. A cost-effectiveness and cost-utility analysis were undertaken for the base case analysis, using a 90-year time horizon. A societal perspective was chosen to account for private and public costs of implementing each of the alternatives. Parameter uncertainty was tested through deterministic and probabilistic sensitivity analyses. Moreover, in order to inform decisions under uncertainty, a value of information analysis was undertaken. The model results support the decision to implement interventions to prevent VDD, namely a combined strategy of at-risk groups supplementation and wheat flour fortification. Furthermore, this thesis contributes evidence on methodological considerations for modelling micronutrient interventions.

Background Eliciting health-state utility values (HSUVs) for use in cost-utility analysis (CUA) for some diseases is limited by the variation in the duration of the health-states such as it includes both temporary and chronic health-states. There is no 'gold standard' approach for valuing temporary health states (THS). Conventional time trade-off (TTO) is deemed inappropriate because it presents an unrealistic scenario to respondents and the chained TTO has been proposed to solve this problem. This thesis uses a case study, Chlamydia trachomatis (a sexually transmitted infection) to explore this challenge. The main burden of chlamydia is typically believed to be borne by women, with a paucity of studies describing the psychosocial outcomes for men, hence making it difficult to value outcomes associated with men. Objectives This thesis aimed to: develop approaches for valuing the health-states associated with chlamydia and derive utility values for the chronic and temporary health-states associated with chlamydia. An additional objective was to define the psychosocial impact of chlamydia in men via an exploration of the asymmetric nature of the disease burden. Methods The thesis elicited utilities for seven health-states (five THS and two chronic health-state) depicting the symptoms of chlamydia. The health-states were developed using evidence from the literature and interviews with clinical experts. Chained time trade-off (TTO) was applied to THSs and conventional TTO to CHSs. Ectopic pregnancy was used as a lower anchor for chained TTO. The VAS technique was also employed. The study sampled from three different population groups and the survey was administered face-to-face. A qualitative synthesis was conducted using meta-ethnography, to identify the psychosocial impact of chlamydia in men. Discussion The thesis identified appropriate approaches for valuing chlamydia health-states and showed that chained TTO is feasible. Methodological challenges arising from this study include the development of health-state description, the selection of appropriate anchor states and the duration of the anchor state. The HSUV s could potentially be used in cost-utility analyses examining the cost-effectiveness of screening. The meta-ethnography highlighted the need to broaden the focus of future evaluations.

Objectives: This study linked Scottish education data to a number of administrative health datasets to explore associations between childhood chronic ill health and subsequent educational and health outcomes. Chronic conditions investigated were diabetes, asthma, epilepsy, attention deficit hyperactivity disorder (ADHD) and depression. Educational outcomes were number of days absent from school, number of school exclusions, special educational need (SEN), academic attainment and unemployment. Health outcomes were all-cause and cause-specific hospital admission, total number of hospital admissions, total length of hospital admission and all-cause mortality. Approach: Pupil census data and associated education records for all children attending primary and secondary schools in Scotland between 2009 and 2013 were linked to national prescribing data, hospital admissions, death records and retrospective maternity records enabling outcomes to be studied whilst controlling for socioeconomic, demographic and obstetric factors including birth outcomes and maternal antecedents. Specific medications are prescribed for some particular chronic conditions; therefore, children identified as receiving these medications whilst at school were assumed to have these conditions. Results: Children treated for each of the five conditions had more frequent absenteeism from school and were more likely than their peers to have SEN. However, only children treated for depression, epilepsy or ADHD experienced poorer academic attainment and increased odds of unemployment. Furthermore, children treated for depression or ADHD were significantly more likely to be excluded from school. Children treated for asthma experienced poorer academic attainment but no increased odds of unemployment and the association with attainment disappeared after adjusting for their increased absenteeism. Children treated for each of the five conditions had an increased risk of hospital admission and children treated for depression or epilepsy also had an increased risk of recurrent hospitalisation and longer stays in hospital. All of the chronic conditions, with the exception of ADHD, were associated with increased mortality. Conclusion: All five of the chronic conditions investigated in this thesis were associated with adverse educational and health outcomes. The number of outcomes affected varied by condition. Treated depression, epilepsy and ADHD were associated with the most wide-ranging impacts. Children treated for depression fared worse than their peers across all nine outcomes, and children treated for epilepsy and ADHD across eight and six respectively. In contrast, children treated for asthma and diabetes fared worse than their peers in respect of around half the outcomes investigated. Children with these chronic conditions at school appear to experience significant educational and health disadvantage; therefore further work is required to understand the underlying mechanisms and to develop effective interventions to reduce their risk.

No description available.

Background (Kenya) Sub-Saharan Africa (SSA) is in the midst of experiencing an unprecedented increase in non-communicable diseases (NCD), specifically diabetes and hypertension. This shift has required public sector health systems, which have historically focused on managing acute diseases, to redesign their services to appropriately serve chronic disease needs. Issue Addressed In order to provide a description of our efforts to bring up comprehensive services for NCDs in rural Kenya within this thesis, I have specifically selected publications which target different aspects of the healthcare system. This includes our efforts related to clinical training for pharmacists, screening for NCDs, medication supply chains, remote phone-based care services, and care delivery based in the community. Prior to the implementation of the programs mentioned in these domains, access to these services was largely not available in western Kenya. Furthermore, the publication of our research from this western Kenyan cohort is designed to supplant the relatively limited research which emanates from rural sub-Saharan Africa. Research Questions For each of these selected publications, we defined a set of primary and, in some cases, secondary research questions focused on identifying the contextualized attributes of service delivery in this setting while also assessing the impact. For the first publication on training for clinical pharmacists, we assessed the impact of Kenyan Bachelor of Pharmacy interns and North American Doctor of Pharmacy interns while providing clinical care in an inpatient setting in Kenya. Our primary research question assessed whether there was a significant difference in the number of clinical interventions documented by interns from the two countries. In the second paper, we shifted our focus to outpatient care and wanted to address the uptake of different strategies of screening for diabetes and hypertension. Our primary research question assessed whether there were any significant differences in follow-up at the public sector clinic after screening positive via home-based screening (community health volunteer provides screening at your home) versus community-based screening (a community wide event is established where people voluntarily show up to receive screening) in a rural setting. In the third paper, we sought to continue to improve aspects of outpatient care by describing our model for improving access to medications. Our primary research question focused on descriptively assessing the change in availability of essential medications before and after implementation of this model. In the fourth paper, we described and assessed our model for providing intensive diabetes follow-up remotely. Our primary research question focused on whether patients experienced statistically significant improvements in blood glucose control after participating in this service for six months. In the fifth paper, we brought together various elements of our prior activities to design and evaluate the community-based model of care called BIGPIC - Bridging Income Generation through grouP Integrated Care. The primary research question for this investigation was to identify the frequency with which patients who screened positive for diabetes or hypertension linked to care. Secondary research questions compared the linkage frequency observed with this model compared to a historical control, along with a descriptive assessment of the loss to follow up, and an assessment of whether this model led to statistically significant reductions in blood pressure after 1 year of implementation. Short Summary of the Individual Papers with Results Linking Them Together Within our assessment of pharmacy training, we found that the Kenyan pharmacy interns provided statistically significantly more clinical interventions per day than their North American counterparts. This result highlighted the potential for Kenyan pharmacy providers to provide clinical services which were largely unavailable in western Kenya prior to this research. Despite the lack of the clinically focused Doctor of Pharmacy curriculum in Kenya, Kenyan pharmacy interns within the Bachelors in Pharmacy program were able to make an average of 16.7 consultations per day with the medical team compared to 12.0 per day for the North Americans. In the second paper we shifted our focus to the outpatient setting and were surprised to find that there weren’t any statistically significant differences in follow-up between home-based versus community-based screening for NCDs. This highlighted the reluctance of rural patients to travel to public sector facilities for care regardless of the screening method utilized. This realization led us to simultaneously focus on improving the reliability of services available in public sector while also trying to implement solutions to facilitate the provision of remote services for care. Within our efforts to improve medication access in paper 3, we were able to demonstrate how our revolving fund pharmacy model was able to improve access to medications from < 40% to > 90%. In paper 4, we were able to implement a self-monitored blood glucose program and demonstrate a dramatic improvement in the blood sugars of patients enrolled in the self-monitored blood glucose program with a statistically significant 31.6% absolute decline in HbA1c. The culmination of these efforts and learnings is described in paper 5, where we implemented the BIGPIC care delivery model which resulted in a statistically significant improvement in linkage to care for screened patients, a retention in care frequency of 70.3%, and a statistically significant mean decline in the systolic blood pressure of 21mmHg (95% CI 13.9-28.4, P < 0.01).