Stair climbing is an ideal activity to promote in worksites due to its availability and associated health benefits. To date findings are equivocal regarding stair climbing intervention success in this setting, thus more research is needed. Chapter two of this thesis confirmed that a calorific expenditure message can increase stair climbing in a train station. Based on this finding, chapter three implemented a point-of-choice intervention using a longer calorific expenditure message in four buildings and successfully increased stair climbing. The inability to translate intervention success on public access staircases to the worksite setting is likely to be due the random availability of the lift. Consequently, chapter four examined the effect of lift availability on stair use, concluding that reduced lift availability increases stair use. Lift availability can rarely be modified however, so chapter five assessed whether a point-of-choice intervention using an aspirational climb Mt. Everest message can increase stair climbing. Whilst no increase in stair climbing was recorded during this intervention, the same calorific expenditure message as used in chapter three increased stair climbing in the same building. Collectively, these findings demonstrate the effectiveness of point-of-choice prompts using calorific expenditure messages in increasing stair climbing in the worksite setting.

This thesis describes studies of the requirements, applications and benefits of external quality assessment (EQA) of clinical chemistry laboratories. The involvement of EQA in assessing the analytical quality of results from clinical chemistry laboratories is well-established. This thesis addresses the contribution of EQA in improving clinical chemistry practice and therefore patient care rather than as a method of 'policing' laboratory performance which is the objective of many national EQA schemes. The use of EQA in the assessment of interlaboratory agreement, of analytical methods, of individual laboratory performance, and of quality control and calibration materials is discussed. Surveys are examined as a means to assess the prevailing standard of performance and determine priorities for further EQA to improve performance. The contribution of scoring systems to scheme success by making the information more intelligible to participants is described. The importance of reliable target values is shown, and the reproducibility and accuracy of consensus values in such schemes have been studied. EQA data are shown to be invaluable in providing information on the relative performance of analytical procedures, and on factors such as analyte concentration and laboratory workload which affect performance. The stepwise interpretation of the Variance Index scoring system, and the use of graphical presentations in assisting the assessment of laboratory performance are described. Finally, the use of EQA data in the study of the suitability of quality control materials is examined, with particular reference to their commutability, their use in calibration, and the effects of manufacturing procedures upon their properties. This thesis illustrates the importance of EQA to clinical chemistry practice and to patient care.

Syftet med detta arbete är att kartlägga ytjämnheten på stålbanden efter kallvalsning samt hur den erhålla ytjämnheten påverkas av trimvalsningen. Detta för att undersöka om det är möjligt att minska ner användandet av någon valsyta i Tandemverket vid SSAB Borlänge. Genom att mäta ytjämnheten på stålband av olika kallvalsade kvalitéer efter kallvalsning och trimvalsning, mäta ytråheten på texturerade valsar före och efter användning samt genomföra test med nya ytkombinationer har ett antal resultat genererats. Två test där Docol 200 band som skulle levereras med bandyta 23 valsades med en grövre yta i Tandem (valsyta 48 istället för 34) än vad som är brukligt och sedan trimvalsades med ordinarie valsyta visade att det är möjligt att klara kraven på Ra-värde för bandyta 23 även på band som kallvalsats med en grövre valsyta än i vanliga fall. Dock är det inte säkerställt att kraven för yta 23 alltid kan uppnås på band kallvalsade med grövre valsyta. Trimvalsning med valsyta 57 i den kontinuerliga glödgningslinjen har ingen betydande påverkan på ytjämnheten för Docol 600 & 800 DP, dock påverkar den ytan för Docol 200 eftersom att dessa band har mindre spridning i Ra-värde efter trimvalsning jämfört med innan. Trimvalsning med valsyta 57 höjer toppantalet på bandens yta. Band av en högre hållfasthetsklass får lägre Ra-värde jämfört mot mjukare stålsorter. Band med stor tjockleksreduktion i Tandem får lägre Ra-värde, detta gäller speciellt Docol 200 där trenden är tydligast. Ra-värdet på de texturerade valsarna i Tandem sjunker mycket i början när de används, test har visat att redan under kalibreringen kan Ra-värdet minska med 0,8 µm – 1,3 µm.

Rheumatoid Arthritis (RA) is a chronic autoimmune disease that affects 0,5-1% of the general population worldwide. The disease is a complex genetic disease, meaning that several genes, environmental factors and stochastic factors act as players in the development of the disease. RA causes inflammation in the joints typically in the hands and feet. It also can affect surrounding tissue and organs in the body. RA affects mostly women in their middle age, but the disease can occur at every age and in both genders. New research indicates that early treatment can improve quality of life and living conditions for the patients since medical treatment of the disease can cause remission.   Thermo Fischer Scientific ImmunoDiagnostic Division in Uppsala started the development of a new diagnostic tool, ISAC, to provide early diagnosis for RA patients and consequently enable early treatment.   The report will discuss the costs associated with the disease today and in connection to diagnosis, medication, hospital admissions and sick leave in Sweden. This will lead to a discussion and presentation of a market strategy for the first phase of the introducing the product. The results from the latest study done with ISAC shows that ISAC is “as good as” the present and competitive diagnostic method such as ELISA/CCP2 tests but ISAC has the ability to diagnose 18% more patients. Early diagnosis allows cost savings and during year 4 and with patient base of 3600 patients the savings are 154 million SEK or more for the healthcare system. From the selected group of patients around 900 new patients will be added annually.   The associated cost savings for the healthcare system can be up to 25% for each patient compared to present methods. In addition, there is a great value for each additional year of working life for the patient. However this added value is extremely difficult to predict.

This thesis examines the ways in which a deeply entrenched nursing hierarchy is being reconfigured and challenged, and the status of nurses reshaped, in relation to wider political and social processes in the post-apartheid context. Specifically, it offers an ethnographic analysis of nurses working at Bethesda Hospital, a rural government hospital in northern KwaZulu-Natal. It argues that at this moment of liminal uncertainty characterising the current political and social transformation, nurses’ experiences are made meaningful both through a nostalgic reconstruction of the hospital’s missionary past, as well as through idioms that generate opportunities for – and a sense of control over – the future. These are all manifestations of a contemporary post-apartheid moment, yet they are also extensions of longer historical processes. This thesis, therefore, poses important questions about the nature of ‘transition’ in South Africa, and to what extent this has been marked both by rupture and continuity, in the localised context of a rural government hospital and its surrounding area. The thesis begins with an historical account of Bethesda hospital from its inception in 1937 as a Methodist mission hospital, and its eventual transfer to state control, describing a complex and changing micro-struggle for power in the context of a wider political economy of health care. It goes on to consider the influence of the hospital’s mission past on current practices, exploring the ways in which nostalgic memories feed into contemporary workplace debate. Such debate is framed by a context of severe and widespread ill-health exacerbated by the HIV/Aids epidemic, and the problems of staff shortage, fragmentation and poor pay and working conditions that provide ongoing and critical challenges to the institution and its employees. It considers how the moral concern provoked by this perceived crisis, and the preoccupation with hierarchy that has long been a feature of the South African nursing profession, are played out in relation to the emerging post-apartheid ideologies of ‘accountability’ and ‘rights’. Finally, it explores the ways in which nurses generate a mutual sense of purpose and control, while at the same time engaging in embattled struggles for status and self-recognition, through the practices of Born-again Christianity and international migration, showing how these offer new and powerful forms of status acquisition in the post-apartheid context. Based primarily on ethnographic fieldwork conducted at Bethesda hospital between December 2006 and October 2007, this thesis engages with theoretical discussions about social change and relationships of hierarchy within – and beyond – the workplace. Finally, it contributes to debates about the shifting fields of nursing and health care delivery in the wider South African context of immense political and social transformation.

Infancy is a time of rapid physiological (e.g. anthropometric, immunological and neurological) development. Hence, during this period of life nutritional requirements are at their highest in relation to body mass. There is a paucity of data with respect to the nutritional quality of complementary foods manufactured in the UK for infants and young children. The primary objective of this study was to examine the nutritional value of ‘ready to feed‘ complementary infant foods on the UK market in order to ascertain their suitability, relative to dietary guidelines, for the target group. Quantitative analysis was conducted on eight different products representing four popular commercial brands (meat and vegetable based) currently on sale in the UK for infants aged between 6-12 months. The chemical analyses conducted included Kjeldhal for protein, acid hydrolysis and extraction for fat, phenol sulphuric acid for carbohydrate and AOAC 985.29 for fibre. The results of these studies were referenced to the Recommended Nutrient Intake (RNI) values for 6 to 9 months old children, and a listing of the entire daily intake of nutrients was composed taking into consideration the nutrient and energy intake from milk consumption in order to (1) accurately estimate the daily intake of these nutrients derived from commercial infant food consumption, and (2) ascertain their nutritional suitability relative to dietary guidelines for the 6-9 month age group. The only significant difference found between different product varieties (meat and vegetable-based) was with respect to the protein content (p = 0.04) per 100 g of food. The experimentally determined concentrations of macronutrients (g/100 kcal) were compared to the declared values provided by the manufacturers on the product labels and, despite some variations, the values obtained comply with regulatory requirements (Commission Directive 2006/125/EC). The total daily intake of fat (27.0 g/day), based on the menu composed from commercial complementary food, is suggested to exceed the Dietary Reference Values (DRVs) for fat (31%), if the intake of snacks and desserts are incorporated. The aforementioned results imply that the formulations of the recipes, based on a standard commercial menu, are of significant importance in relation to the nutritional quality of the diet of infants. In terms of elemental analysis, the concentrations of up to twenty (essential and non-essential) elements in a selected range of sixteen different products representing meat, poultry, fish and vegetable base varieties were established by ICP-OES and ICP-MS. Six major essential elements, namely: calcium, iron, magnesium, potassium, sodium and zinc were measured by ICP-OES. The concentrations of six essential trace elements (selenium, molybdenum, cobalt, copper, chromium, manganese) and eight non-essential, potentially toxic, elements (arsenic, barium, nickel, cadmium, antimony, lead, mercury, aluminium) in chicken and fish-based varieties were determined by ICP-MS due to the higher sensitivity required. Based on the results of elemental analysis, there was also some evidence of a lack of attention to micro-nutrient interactions in food. With reference to the guidelines, the RNI values for 6 to 9 month olds, all samples provided less than 20% of RNI values except for potassium (20%). In terms of the risk of exposure to toxicity, the concentration of non-essential elements in ready to feed products analysed were not considered to be of concern. With regard to the analyses of vitamins, a novel assay for the simultaneous quantitative determination of riboflavin (B2) and pyridoxine (B6) has been developed. The method involves a mild hydrolysis step, extraction of the supernatant by centrifugation followed by quantitative analysis using UHPLC. Separation of the two water soluble vitamins achieved is excellent and rapid - within one minute whilst the resultant sample is also LC-MS compatible. With respect to vitamin B analyses, despite wide individual differences between brands (p = 6.5e-12), no significant differences were observed in the levels of vitamin B6 between the meat and vegetable-based varieties (p = 0.7) per 100 g of commercial infant food. Vitamin B2 was not detected in any of the samples, where the detection limit was below 0.07μg/mL. In terms of the RNI of vitamin B6 for 6 - 9 month old infants, the complementary infant meal products analysed herein provided less than 15% of the RNI values with mean (SD) values of 12.87 (±4.46) % and 13.88 (±4.97) % for the meat- and vegetable-based recipes, respectively. The estimated total daily intake of vitamins B2 and B6 from the consumption of commercial complementary food was found to be satisfactory and in accordance with the DRVs. The intake of both vitamin B2 and B6 was estimated to be mainly derived from the consumption of formula milk which could be a cause of concern if the quality of an infant‘s milk diet is compromised by an inadequate or lack of supplemented milk intake. All the foregoing results suggest that commercial complementary infant foods on the UK market may not contain minimum levels of micronutrients required for labelling declaration of micronutrient content (Commission Directive 2006/125/EC). An attempt, therefore, was made to optimise the formulated version of the meat based infant food as a baseline and measure the post-process retention of its nutrient content after being subjected to different processing condition in terms of a combination of temperature and time. This was achieved by quantitative analysis of the post-process values of the nutrients in the optimised formula using the aforementioned analytical techniques. The results of this study indicates that careful formulation of the recipes, in the context of new product development, is important; the selection of high quality ingredients and the ratios in which they are used have a direct effect on the nutrient content of the final product. It also indicates that a carefully controlled temperature-time combination, pH, pressure and macroscopic conditions of processing (e.g. controlled leaching) are very important in reducing heat loss and improving the nutritional quality of the food product. This provides opportunities and scope for product optimisation, of ready to eat to eat infant foods, in order to improve their nutritional value.

Chronic illnesses are the leading cause of death worldwide and are also expected to be the leading cause of disability by 2020 (World Health Organization [WHO], 2003). They are changing the experience of healthcare for both patients and healthcare professionals. In particular, they are changing the roles of patients and doctors, with patients expected to be more involved in their disease management and doctors shifting their focus away from curing pathology to regulating and palliating symptoms (May, 2005). Chapter one presents a systematic review of the role of patients' relationship styles on healthcare outcomes in diabetes. Outcomes of the review highlight the impact of attachment styles that are characterised by having a 'negative model of other' on health outcomes. Despite methodological limitations, the review finds evidence to support the use of attachment theory for understanding healthcare outcomes in the diabetes population and describes the clinical utility of using attachment theory in the development of interventions with this patient group. Chapter two examines the experiences of healthcare professionals in chronic illness in an empirical study investigating the lived experiences of the long term doctor-patient relationship in male Consultant Nephrologists. The experiences of seven Consultant Nephrologists were explored using a phenomenological approach. Findings revealed three superordinate themes: 'Defining my professional identity', 'Relating to the patient' and 'Coping with the job'. Clinical implications of the findings and recommendations for future research are discussed. Chapter three continues the theme of healthcare relationships in a reflective paper based on a journal kept by the author throughout the research process. This paper considers the challenges of conducting psychological research in medical settings, in particular, the researcher’s own initial reservations about these challenges and how the researcher feels now the study is complete. Such reflections may be beneficial for psychologists conducting future research in this area.

Understanding the complexities associated with physical activity behaviour is problematic as it is a complex phenomenon that the majority of the population do not engage with. Sedentary lifestyles have been associated with a range of diseases, more prevalent in areas of social deprivation than in affluent areas. The objective of this research was to gain a comprehensive understanding of the experiences of a group of patients and their referring health professionals, in respect to what the experience meant to them and its impact on their lives. A qualitative longitudinal approach was used to maximise the ecological validity of the study. The practice based exercise referral scheme took place in a South West Devon city. The data collection phase comprised of two parts. Twelve interviews were carried out with referred patients on three occasions (0, 8 and 12 months). The second phase consisted of six interviews with the referring health professionals on two separate occasions (0 and 8 months). Grounded theory methodology guided the analysis resulting in two conceptual models. The first model emerged from the health professional’s data. It depicted the context in which the patients were referred into the scheme and represented the phenomena ‘patient take-up of a practice based exercise referral scheme’. The second model emerged from the patient’s data, depicted the context in which the patients experienced the scheme and represented the phenomena ‘the impact of long term involvement with an exercise referral scheme on patient’s perceived health status. These findings were interpreted further to gain insights into the core categories of ‘easier referral’ and ‘feeling better’, which emerged from the first and second models respectively. The analysis highlighted the multidimensional nature of these two categories. ‘Easier referral’ embraced a wide range of notions. For example, structural systems, interactional tactics and training needs. Barriers to referral included not prioritising referrals and gender stereotypes. Enablers included tactics to engage the patient with the scheme. ‘Feeling better’ embraced a wide range of beliefs held by the patients. For example, the impact of the scheme on perceived health status, the impact of sedentary behaviour on disease aetiology and the support systems necessary for adherence. Key motivators for adherence were, feeling good, health status and medical implications. Through unpacking the two concepts of ‘feeling better’ and ‘easier referral’ the findings provide new knowledge on the potential that exercise referral schemes have to improve long term quality of life for patients. The findings also suggest methods that health professionals can improve patient take-up of schemes. This insight can inform researchers and future evaluation design of exercise referral schemes to be more representative of the genuine long term impact on the health of patients. Future schemes would benefit by developing: engagement tactics; training to reduce risk to health professionals; fostering gender neutral patient perceptions; and identification and use of support systems by exercise professionals. This context specific evidence adds to the current research and as such can inform future practice and research. This study has shown that a practice based exercise referral scheme can enable patients to develop long term physical activity behaviour, apply learnt behaviour to their lifestyles, help to manage medical conditions and improve perceptions of health status.

The National Institute for Clinical Excellence (NICE) recommends that the treatment of eating disorders should generally be managed on an outpatient basis using psychologically informed approaches (Clinical Guideline 9, NICE, 2004). As such, carers and psychological therapists are crucial in providing support to individuals with eating disorders. Although there is a wealth of research literature focusing on the understanding and treatment of eating disorders, further consideration of carers and therapists in this area is warranted. This thesis therefore gives prominence to these two groups. Chapter 1 reviews the literature on education and support interventions for carers of those with eating disorders. Findings suggest that face-to-face and self-help interventions show effectiveness in reducing negative carer symptoms and meeting carers’ needs. Methodological limitations, research recommendations and clinical implications are outlined. Chapter 2 presents an empirical study which explores the impact of eating disorders work on eight psychological therapists, including the effects on their eating and body image. A grounded theory approach is adopted. Findings illustrate that therapists are affected by the complexity of their day-to-day work in many ways and that they have a number of means of coping. Recommendations are made for clinical practice and future research. Chapter 3 provides a reflective account of the research journey. It gives an overview of the research process and provides an opportunity for the researcher to be considered in this.

Traditionally the biomedical approach has characterised dementia care. This approach predominantly attributes the patient's presentation and deterioration to the dementia. A more holistic approach to dementia care involves considering a range of factors, in addition to the dementia, that may account for the patient's presentation and deterioration; these include psychogenic, biogenic, social and environmental factors. The current thesis sought to explore the impact of some of these potential factors. Caregivers play a vital role in looking after people with dementia. Caregiver presentation may be impacted directly by caregivers' own psychogenic, biogenic, social and environmental factors, as well indirectly by care-recipient psychogenic, biogenic, social and environmental factors. The current thesis sought to explore the impact some of these potential factors on caregiver presentation, in an attempt to further understand some of the reasons underlying positive and negative caregiving experiences. Chapter 1 details a review of the literature investigating the associations between Attachment Style/dimension and clinical presentation in people with dementia and caregivers. Chapter one thus explores a possible psychogenic factor influencing the presentation of people with dementia and caregivers. Chapter 2 is a piece of empirical research investigating how a co-morbid physical health problem suffered by a Person with Dementia (PwD), specifically infection, impacts on a PwD as well as on their caregiver; the impact of hospitalisation of the PwD is also explored, both on the PwD and on their caregiver. Chapter two thus explores possible biogenic, social and environmental factors influencing the presentation of people with dementia and caregivers. Chapter 3 details some of my reflections on and learning from the process of conducting this empirical research.