This thesis explores the issues around stress in the UK Health Service, with a particular focus on stress in the Hospice Service and the benefits of a group coaching intervention for this staff group. Section A provides an introduction to the thesis, explaining the rationale behind the choice of research and how the different sections link together. Section B reports on the research aspects of this thesis which exists of three phases. Phase 1 is a cross-sectional study to assess the levels of stress and the main work-stressors as experienced by members of staff working within two hospices in the UK. Phase 2 is a qualitative study using two focus groups, one at each hospice, to obtain a deeper understanding of the findings of phase 1. Phase 3 is an evaluation of a brief group coaching intervention for stress management, which has been informed by the findings of phase 1 and 2. The theoretical framework of the coaching intervention was Cognitive Behavioural Coaching (CBC). Section C of the thesis presents a case study of a one-to-one stress-coaching intervention. This study also uses CBC as its theoretical framework and uses the same coaching format as was used in the group coaching session described in section B. Using the same model for both the group and one-to-one coaching intervention provides an opportunity to explore the versatility and usefulness of CBC within the context of stress coaching. The critical literature review presented in section D of the thesis examines the effectiveness of traditional stress management programmes used within the nursing profession, which provides a base-line for the development of an effective coaching intervention. The findings of this thesis add to the current understanding of stress in the UK hospice service and provide the foundations of a new approach to staff support and stress management within the Health Service using a CBC coaching model.

The aim of this study was to develop a method for measuring an individual's fat content, which was both simple and inexpensive and could therefore be used by relatively inexperienced researchers in large scale field studies. At present the most popular field methods for assessing 'overweight' are weight for height tables based on Insurance Company data, and weightheight indices. The methods chapter points out the major limitations of these methods and describes how they cannot differentiate between weight due to bone, muscle, water or fat. Another popular field method is to measure skinfolds at a few predefined si tes and convert these to a fat content using regression equations. Al though this method allows 'fatness' as opposed to 'overweight' to be assessed in the individual, it has the disadvantage that the observer requires some training, which is not· always feasible, and carefully calibrated skinfold calipers are essential. It is for these reasons that a new field method, requiring minimal training and equipment was sought. This study was carried out on a group of 6,495 males and 2,304 females aged 16-64y, selected, as described in Chapter 2, from both the British Armed Forces and the civilian population. The measurements taken from each individual were height, weight, 4 circumferences, 4 boney diameters and 4 skinfolds. Using the equations of Durnin and Womersley (1974) and Siri (1956) the skinfolds were converted into a value for percent body fat, and fat free mass (FFM) was calculated by subtracting fat mass from body weight. The height and weight results were compared with the results of the Office of Population Censuses and Surveys (OPCS), 1981, UK survey. Since the OPCS survey was believed to be representative of the UK population, the comparison allowed an assessment of possible sampling errors. Variations in' anthropometric results related to geographical origins and social class (SC) were also examined, within Chapter 3, together with age related changes. Within the Forces, civilians and OPCS samples respectively, mean height had values of 175.9cm, 175.6cm and 173.8cm. Within the female samples, these 3 values were 163.6cm, 162.4cm and 160.7cm. The differences between the 3 populations were due mainly to the facts that the Forces selection procedure includes a minimum height cutpoint for many occupations and that the civilian selection was not very random. When predicting percent fat or FFM however, these differences appeared to be relatively unimportant. Although height appeared to vary little with age, it did vary in relation to geographical region. In general, -the northern regions had slightly smaller means for most of the anthropometric measurements, when compared to the southern regions. In addition, there was a slight tendency fof height to decrease with se. Mean weight increased with age from 65.5kg in the Forces male 16y olds to 80.0kg in the 5O-56y olds. The Forces and civilian females kept their .weight around 61 and 57kg respectively, between 17 and 29y, after which it rose steadily. Most of these weight increases were due to increases in fat content, since between the 16-17y and over 50y olds, mean percent fat rosefrom 13.4% to 27.2% and from 28% to 35.7% in the Forces males and females respectively. FFM also varied slightly with age, especially in the male sample. In the male Forces it averaged 56.5kg, 61.8kg and 59.6kg in the 16y, 25-29y and 50-56y olds. The initial rise was mainly reflecting growth in the younger subjects. The subsequent changes are discussed in detail in Sections 3.2.10 and 3.2.11. When matched for height and age the Forces males had FFM values on average 2.5kg larger than the civilians and this reflected a larger mean 'build'. This had to be taken into account in order to produce prediction equations applicable to both populations. There was little difference in fat content between the 2 groups. The Forces females were of a similar 'build' to the civilians, but on average 1-2% of body weight fatter. regression equations. This made no difference to the Section 3.4. describes the calculation of regression equations which predicted fat content and FFM. Although initially both FFM and percent fat were used as dependent variables, the prediction of FFM was the more accurate and therefore it was used in preferance. The males were ini tally divided into height, weight then age groups but since the regressions predicting FFM in age groups were the most accurate, age was chosen as the final grouping variable in both sexes. The number of age groups depended on the similarities between different ages, and was calculated using a F-test. Using the BMDP package of computer programmes, the variables height, weight, calf circumference and ulnar diameter were chosen from those measured as the 'best' to predict FFM in the male sample. In the females, the 'best' variables were height, weight and upperarm circumference. The regression equations are in Tables 90 and 91. The final 7 male and 2 female age related regression equations were ini tially calculated from the Forces data, and cross validated on the ci vUian sample. The range of standard errors of the estimates (SEE) in· both samples was 1.54-2.39kg in the males and 1.44-1.80kg in the females. Approximately 95% of the prediction errors would lie within! 2xSEE• Overall, FFM and hence percent fat could be predicted with greater accuracy using these regression equations than using weight-height indices or tables. The method is also simple enough to be used by untrained observers, in field studies.

Colorectal cancer is a significant cause of morbidity and mortality in the West of Scotland. Socio-economic circumstances are known to be related with variations in health behaviour, risk factor exposure and outcome for a variety of diseases. However, the relationship between socio-economic circumstances and the risk of developing and surviving from colorectal cancer have been inconsistently reported using a variety of methodological approaches over recent decades in this region. Therefore, the principal aim of this body of work was to explore the relationship between socio-economic circumstances and the mortality, incidence and survival from colorectal cancer in the West of Scotland using robust methodology. Firstly, a population-based study was undertaken to explore recent temporal trends in colorectal cancer-specific mortality and the relationship with socio-economic circumstances. Incidence data from the Scottish Cancer Registry (SMR06) were linked to General Registry Office for Scotland (GROS) death records to produce age-standardised colorectal cancer-specific mortality rates. From 1985 to 2007, both colon and rectal cancer-specific mortality fell among women but remained unchanged in men. From 1996 to 2007, increasing levels of socio-economic deprivation were associated with higher rates of rectal cancer-specific mortality in both sexes and colon cancer-specific mortality in males only. This socio-economic inequality accounted for an estimated 859 excess deaths from colorectal cancer over 12 years in the West of Scotland. Further study of the underlying influences of the association between socio-economic deprivation and colorectal cancer-specific mortality was subsequently performed. Secondly, a population-based study to explore temporal trends in colorectal cancer incidence and the relationship with socio-economic circumstances was performed. Incidence data from the SMR06 were used to produce age-standardised incidence rates of colorectal cancer. From 1981 to 2007, colon and rectal cancer incidence rates increased significantly among men while remaining stable among women. From 1996 to 2007, the incidence rate of colon cancer in either sex and female rectal cancer were not associated with socio-economic circumstances. However, from 2002 a relationship between deprivation and a higher incidence of male rectal cancer became evident due to a significant reduction in incidence among the most affluent men. This emerging socio-economic inequality accounted for an estimated excess of 286 cases of male rectal cancer over the 6 year period to 2007. Subsequently, a detailed examination of temporal trends in relative survival following the diagnosis of colorectal cancer was performed. The relationship between survival from colorectal cancer and socio-economic circumstances was also examined using a population-based approach. SMR06 and GROS death record data were linked and relative survival analyses were performed. From 1991 to 2005, 5-year relative survival from colon and rectal cancer significantly improved in both sexes, especially in the first year after diagnosis. From 1996 to 2005, deprivation was associated with poorer survival from male colon cancer and rectal cancer in both sexes. This “deprivation gap” at 5 years arose due to early survival differentials between socio-economic groups in the first year after diagnosis. Furthermore, patients from the most deprived areas were more likely to be older at diagnosis, have rectal tumours, present with more advanced stage disease and were more likely to undergo non-curative treatment compared to the most affluent group. The association between deprivation and poorer survival was also found to become progressively stronger as stage of disease became more advanced. Even after adjustment for other factors associated with survival, deprivation remained independently associated with poorer survival, especially in the first year after diagnosis. Finally, to examine the association between socio-economic circumstances and short and longer-term survival after surgery for colorectal cancer, a study using clinical audit data linked to SMR06, Scottish Inpatient and Day-case Morbidity (SMR01) data and GROS death records was performed. From 2001 to 2004, this study confirmed that deprivation was independently associated with poorer post-operative (<30 days) and 5-year relative survival following surgery for colorectal cancer. Higher post-operative mortality among patients from more deprived areas was the main determinant of the longer-term deprivation gap in survival. This suggests that the main determinant of the observed longer-term socio-economic survival gradient occurred within the early post-operative period in patients undergoing surgery for colorectal cancer. Poorer short-term survival after surgery is likely to be influenced by higher levels of medical co-morbidity and reduced physiological reserve among more deprived groups. Therefore, by using a variety of data sources and robust methodological approaches, this thesis explores the relationship between socio-economic circumstances and colorectal cancer mortality, incidence and survival over recent decades in the West of Scotland. It demonstrates that deprivation was associated with poor short and longer-term survival, high cancer-specific mortality rates and became associated with higher rates of male rectal cancer incidence in the West of Scotland. These findings suggest that early survival differentials play a significant role in the observed deprivation gap in longer-term outcomes. Successful strategies to tackle this inequality are likely to involve multimodal interventions aimed at overall health improvements that are equitable to all. Strategies to improve early detection of colorectal cancer including national bowel screening initiatives and public health campaigns need to be further evaluated and, should they prove effective, tailored to ensure that high risk groups are engaged to participate. Additional interventions aimed at reducing post-operative mortality and morbidity in high risk individuals may also help reduce the observed socio-economic inequality in longer-term outcome. However, further detailed research using high-resolution prospectively collected clinical audit data is required so that modifiable determinants of socio-economic survival inequality can be identified to target future interventions.

An initial review of the literature concerning anticipatory grief was executed to foreground a qualitative study focusing on the experience and conceptualisation of loss by adult daughter caregivers in dementia. A chronological overview was presented and key studies and major developments identified. Inconsistencies in empirical findings were summarised; and preceded a consideration of methodological issues including: problematic research design and definitional confusion regarding conceptual underpinnings. Key recommendations for further research were made. The main study adopted a grounded theory methodology and sought to explore the nature and process of losses experienced by daughters providing care for a mother with dementia. Open, in-depth interviews (N=10) functioned as the primary data source for analysis. Further data included: participant notes and letters; demographic details; researcher's notebooks and reflective and analytical memos. Concurrent data collection and analysis proceeded, in three phases, and the resulting, emergent, theoretical model was presented using Strauss and Corbin's (1990) framework. A full explication of the model followed and its relationship to relevant literature elucidated. Implications for clinical practice and further research were addressed. In the course of analysis it was noted that caregivers made reference to existential themes in their accounts of caregiving. This precipitated a further study in which Reker and Wong's (1988) dimensional model was used to guide the content analysis of the existing transcribed interview data. Findings indicated that participants expressed existential themes at both an implicit and explicit level. Considerable breadth, depth and diversity was observed in relation to caregiving experienced. Caregiving appears to pose both existential challenges and opportunities for growth. Implications for clinical practice and further research were identified.

This work started from initial questions in the field of transcultural psychiatry concerning the effects of culture and of seclusion on Asian immigrant women's experiences and on their concepts of mental well - and ill-being and their behaviour in face of this. In presenting data concerning the women's views and interactions with health workers, a tripartite framework is used as a way of understanding the logic of behaviours from the actor's perspective. Theoretical conclusions relate to this framework and to the nature of Concepts, in which the influence of structural and cultural factors are drawn out. Context and process are shown to be important in respect of Concepts, health care interactions and social research. The research was a small-scale study involving semistructured discussions with forty-six women, often in a group setting, seventeen of whom were interviewed in depth, and the use (in translation), of two Psychiatric Rating Scales. The women involved were Pathans, currently living in Bradford. This thesis is divided into four Parts, in addition to an overall introduction and conclusion. In each Part, issues concerning social influences on individual experience and behaviour are addressed through the presentation of data from the interviews. These issues concern research methodology (Part 1), social situation and interaction (Part II), the women's role as mothers (Part III) and health and illness experiences, Concepts and behaviours (Part IV). The work contributes to a number of fields of study, illustrating the dynamics of the processes at work in each area. It is, however, in combination that the Parts of the study demonstrate the contribution that can be made to the understanding of illness behaviours by a sociological analysis which is committed to elucidating the logic of these behaviours fram the actor's perspective, in the context of his/her other life experiences.

The thesis examines the formation and evolution of medical provisions in Wakefield and Huddersfield between circa 1780 and 1870. The survey covers 'institutional' facilities, namely hospital and dispensary provisions and Poor Law medical services, friendly society facilities for the sick and the development of 'fringe' or 'peripheral' medical practices. The thesis also discusses the structural, professional and social development of medical communities in the two towns. A wide range of source material was utilised, to include Poor Law material (pre- and post-1834), the records of friendly societies and medical charities census returns, newspapers, trade and medical directories and parliamentary reports and returns. The use of such a combination of material gives a better indication of the range of facilities available and their relative importance. It will be suggested that the emphasis medical historians have put on institutional provisions has been misplaced. The importance of previously neglected options, the friendly society and 'peripheral' forms of treatment, will be stressed. Leading on from this, it is possible to suggest that self-help forms of medical relief (compared with those 'provided' by the wealthy classes for the poor) were of greater significance-than has previously been assumed. An attempt has been made to place the development of medical services against the backdrop of the communities that they evolved in. The growth of institutional provisions and the progress of self-help forms are linked to the organisation of the two communities, their class structure and social, civic and economic developments. The leading role of laymen in creating a demand for, and in the setting up and evolution of, medical provisions has also been stressed. It is hoped an analysis of these factors will lead to a clearer understanding of how and why medical facilities developed-as they did, and to a greater insight into the relationships between medicine and society.

In recent years there has been a great increase in work on epidemiological modelling, driven partly by the increase in the availability and power of computers, but also by the desire to improve standards of public and animal health. Through modelling, understanding of the mechanisms of previous epidemics can be gained, and the lessons learnt applied to make predictions about future epidemics, or emerging diseases. The standard SIR model is in some sense quite a simplistic model, and can lack realism. One solution to this problem is to increase the complexity of the model, or to perform full scale simulation—an experiment in silico. This thesis, however, takes a different approach and makes an in depth analysis of one small improvement to the model: the replacement of a constant birth rate with a birth pulse. This more accurately describes the seasonal birth patterns observed in many animal populations. The combination of the nonlinearities of the SIR model and the strong seasonal forcing provided by the birth pulse necessitate the use of numerical methods. The model shows complex multi annual cycles of epidemics and even chaos for shorter infectious periods. The robustness of these results are proven with respect to a wide range or perturbations: in phase space, in the shape and temporal extent of the birth pulse and in the underlying model to which the pulsing is applied. To complement the numerics, analytic methods are used to gain further understanding of the dynamics in particular areas of the chosen parameter space where the numerics can be challenging. Three approximations are presented, one to investigate very small levels of forcing, and two covering short infectious periods.

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The formal management of risk was an idea in its early stages of introduction into the National Health Service when this research started. In this thesis I document the development of my thinking as an acute hospital risk manager over the last five years as I developed the Trust's risk management system. Using Action Learning as the research approach, I explored theories and concepts and tested them in the fire of real world action and reflective questioning of experiences. The definition of risk is explored in relation to health care, as are the approaches used to manage these risks. A key finding is that risk management decision making does not generally fit into either programmed or non-programmed decision making models but neither do decision makers guess. Decision makers tend to use heuristics, which are simple rules of thumb, which generally help them make the right decision with minimum mental effort. However, heuristics also tend to be applied inappropriately and can result in an organisation being exposed to unacceptable levels of serious risk. A number of key heuristics are identified and they appear to fall into two general types, B-heuristics and E-heuristics. The B-heuristics are 'basic' in form and can be summarised as a simple sentence while, E-heuristics have an 'extended' form which can be summarised as a list of related simple sentences. Knowledge of heuristics helped in the design of the Trust's risk management which has been implemented and its effectiveness tested in the field. This field testing has demonstrated that the worst effects of heuristics can be mitigated by effective soft-system design.