The increasingly important role of the family in providing home care for a relative diagnosed with dementia has become a recognised feature of contemporary heahh care. Few studies exist, however, that have examined the relationship these carers develop with the professional assigned to help them undertake care-giving. The relationship held with a key-worker may significantly influence their ability and motivation to undertake the tasks and lifestyle changes necessary for this role. This study's aim was to examine this relationship in detail and generate a theoretical explanation allowing a clearer understanding of the influential factors associated with creation and enhancement of this relationship. Grounded theory was considered the methodology best suited to this aim. Its principal advantage is that it allows the researcher to generate rather than simply test theory and it also provides the necessary degree of flexibility essential for such an exploratory study. In order to meet ethical approval requirements a purposive, rather than theoretical, sampling approach was used for the selection of carers. Approach into the carer sample was through the consultant psychiatrist who forwarded research packs to potential participants via the person with dementia. Eighteen carers met the entry requirements and were subsequently included within the study; along with their chosen key-workers who numbered eleven in total. The key-worker group were all front line workers from either a health or social care background. Nine of this key-worker group were qualified and registered worregistered workers while the remaining two were unqualified care workers working under the direct supervision of a registered social or health care professional. The carerlkey-worker pairs were interviewed in tandem and all interviews recorded. These were then analysed using the constant comparative method, a process helped by the use of NUD*IST computer software. The analysis progressed from initial data categories through to the final core category that provided an explanation of all subordinate data. This core category became the title for the theoretical framework that eventually emerged. Subsequently, a theoretical explanation of the relationship's development was generated along with how it impacted upon the care-giving environment. The theory began with the major category 'The Enhanced Relationship Drivers', which highlighted that while characteristics associated with this relationship were often obscure, there were significant qualities and actions that clearly enhanced the relationship. Once these were engaged both parties moved towards the closer 'therapeutic alliance' contained within the second major category area, 'Models of Action'. Here shared qualities and attributes were more successfully directed towards the care of the person with dementia. A direct outcome of this alliance was a potentially closer and more productive working relationship for both the carer and key-worker. This could result in the creation of an improved therapeutic milieu, minimising the more negative interpretations associated with care-giving. These more negative perceptions of care-giving were highlighted within the third major category 'Impact upon the World of Caring'. However, when the enhancing influences of the preceding major categories were enacted, a more 'Rewarding Care Experience' was possible. External mediators could impinge upon the relationship, either impeding or enhancing its development. These included factors such as the management style of the key-worker's employing authority, the availability of alternative support networks for the carer, as well as the educational/life experience of both members of this dyad. The derived theory has been diagrammatically represented to provide a clear demonstration of all theoretical links between codes and categories, facilitating a better understanding of the developed theory. The study provided a clear insight into the interpersonal processes associated with the carerlkey-worker relationship and how this relationship may more effectively be initiated, managed and strengthened. This theory has important implications for future research into similar psychosocial aspects of care-giving. These findings have ramifications for carer training as well as education and training courses preparing professionals to work more effectively with carers. It has implications for health and social care managers in terms of their level of awareness of the importance of this relationship and the need for investment in it. lt is important that this theory is exposed to more rigorous empirical study allowing for a more confident prediction that its propositions will produce the direct benefits for this relationship that this theory suggests.

No description available.

The assessment of need underpins the delivery of community-based care. Following the NHS and Community Care Act (1990), the principle of needs-led assessment was reinforced as it applied to the assessment and care management process. Translation of needs-led assessment into practice in Scotland has been further influenced by policy-based organisational change including the introduction of Single Shared Assessment and Community Health Partnerships. This study seeks to describe the political and practice landscape within which needs-led assessment exists, identify and explore factors which influence needs-led assessment, and consider the practice implications of the policy driver for community-based practitioners across the main disciplines of health and social care. Following a short pilot, the main study was undertaken using sequences vignettes within a semi-structured interview involving 105 social workers, health and housing staff. Key findings indicated a cloak of consensus around definitions of need and assessment with perceptions based upon a medical or social model of care or a professionally or personality-driven assessment of need. A preoccupation with the outcome of assessments caused many respondents to describe needs with reference to the interventions or resources required to address them. The practice of needs-led assessment, according to study results, was hampered by an awareness of resource availability, concerns over client compliance and risk and, an underlying alignment to the values and principles upheld by the employing discipline.

In April 2002, five years after the Blair government’s proposals to create a ‘New NHS [National Health Service]’, the government outlined the key priorities that would mark the NHS reform. The main reforms involved patient choice supported by a system of ‘Payment by Results’ (PbR) under which hospitals would be funded on the activity they undertook. PbR is a case based payment system, a type of system increasingly being adopted as the main form of provider payment across industrialised countries. The literature on this type of payment system and experiences from other countries identifies many di!erent behavioural incentives that can have both positive and negative impacts on quality of care. This thesis investigates the quality implications observed so far in England, for seven conditions which represent a spectrum of important clinical areas that are admitted through both emergency and elective admissions. In order to identify changes in quality, this thesis first considers how to construct an appropriate measure of quality. The first part of the thesis utilizes two di!erent methodological techniques used for quality measurement; a latent variable approach and a technique put forward by McClellan and Staiger (1999) using Vector Autoregressions. The results from these techniques indicate that quality measurement approaches di!er markedly with regards to how much measurement and systematic error they are able to filter out of raw outcome data. Finally, the new indicators created by these techniques are used to evaluate the quality impact the introduction of PbR as the main form of hospital payment has had in England. The analysis indicates that since the policy’s implementation, there have been di!erential quality e!ects on the di!erent conditions. However, for the most part this indicates an improvement in mortality outcomes, and a reduction in the variation of outcomes across hospitals. As found, the interpretation of readmissions has to be approached with caution as more severe patients being kept alive through quality improving measures on mortality create more mixed signals for the readmission indicators. In two conditions we find changes in activity that are indicative of e"ciency gains, in the form of better coding and adoption of new technology, both as a result of differences in reimbursement categories.

This thesis explores conceptualisations of ethical subjectivity in the stories of people who have, or have had, cancer and who use complementary therapies and self-help (complementary self-health). In England the increasing emphasis on individual responsibility and choice in healthcare means that those with cancer are now in the position where they have to make many of their own decisions about their treatment. For the people with cancer in this research this included choosing complementary self-health. The thesis explores the stories and experiences of people with cancer who used complementary self-health. The aim of the thesis is to document and make visible the many original ways people come to understand themselves as able to ‘heal’ their health, self and life. The thesis also reflects on the highly unusual position of the author, who was himself diagnosed with cancer mid-way through his fieldwork. The problems and challenges to the research are explored in the thesis, which became a story in itself. The thesis finds the ‘price that is paid’ for the way that the interviewees came to think of their selves in their subjectivity. The interviewees told open and ongoing stories of ‘balanced living’ and how they found ways to listen to their ‘embodied guides’. They also described how understanding ‘cancer as an opportunity for change’ helped to transform and transcend their previous ways of living. In doing so they provided themselves with new narratives of the past and future, which were situated by ‘living in the now’. The thesis explores the ethico-political repercussions of these new formations of subjectivity. In doing so it argues that the ‘spiritual’ component of the stories remains unaccounted for and under conceptualised in contemporary sociological theory of health. It concludes with suggestions of how to move contemporary analysis beyond its present ethical concerns with the subject.

The randomised controlled education intervention study recruited 430 adults aged 25-65 years with established diagnosis of T2DM (M = 130, F = 309) via a multi-stage double-blind stratified sampling procedure from 22 hospitals and health centres in Doha, Qatar. The intervention group (n = 215) were assigned to a six-week, 2-hourly structured educational class based on the specifically designed DPET, plus their usual one-to-one routine clinical care; the control group (n = 215) used the DPET for home self-study, plus their usual one-to-one routine clinical care. Adherence to the programme in the intervention group (n = 109; M = 40, F = 69) was 50.7% compared to 84% among controls (n = 181; M = 50, F = 131); an overall non-adherence rate of 32.6%. Repeated measures ANOVA showed a highly significant change in each of diabetes knowledge, attitudes and practice among intervention compared to controls at 12 month follow-up (p<0.0001). The intervention had no significant overall impact on systolic blood pressure (p = 0.632) nor diastolic BP (p = 0.421) but improvements in BMI among the intervention group (p = 0.001). Repeated measures ANOVA also showed differences in overall change in HbA1c (p = 0.012), fasting blood glucose (p = 0.022), HDL-cholesterol (p<0.0001) and albumin-creatinine ratio (p<0.0001) in the intervention group but not total cholesterol (p=0.204), LDL-cholesterol (p = 0.203) and total triaclyglycerol (p = 0.200) from baseline values after 12 months follow-up. Post-sessional self-assessment tests of knowledge, attitudes, practices and goal-setting used as a proxy measurement of empowerment showed a significant improvement in the empowerment scores from baseline in the intervention group (p<0.0001).

Background: Ethnicity is associated with childhood obesity, with Black African origin girls in particular being more vulnerable to overweight and obesity than their White European peers. In the UK, ethnic minorities often live and attend school in poor urban areas which may influence their opportunity for physical activity and a healthy diet. Aim: To examine neighbourhood and school effects on ethnic differences in Body Mass Index (BMI) and waist circumference trends in adolescence. Methods: Multilevel analysis of longitudinal data on BMI and waist circumference [standard deviation scores (SDS)] from 3401 adolescents in the Determinants of Adolescent Social well-being and Health (DASH) Study (870 White UK, 778 Black Caribbean, 504 Nigerian/Ghanaian, 386 Other African, 418 Indian, and 445 Pakistani/Bangladeshi). Forty-nine London schools participated in the study and the same pupils were surveyed at 11-13yrs and 14-16yrs. Neighbourhood measures included deprivation, crime, and ethnic density; school measures included ethnic density, school socioeconomic status (SES) (academic performance, free school meals, unauthorised absence) and ethos. Individual and family characteristics were also examined (including dietary and physical activity measures, family SES, and parental overweight). Results: Between 11 and 16yrs ethnic differences in BMI emerged in boys and persisted in girls; compared to their White UK peers Black Caribbean and Nigerian/Ghanaian boys and girls, and Other African girls, had a greater mean BMI SDS. These patterns were not observed for waist circumference, signalling ethnic differences in fat distribution or body composition. The DASH pupils overall had large waists compared to the 1990 Growth Reference population. The ethnic minority pupils, with the exception of the Indians, were more likely to live in more deprived, higher crime, less green areas than their White UK peers. However the ethnic minority pupils often attended better performing schools than the White UK pupils. The overall variance in body size at neighbourhood level or school level was small (<4%), and area or school context measures had little or no effect on ethnic differences in body size. Individual characteristics (such as age, pubertal status, and skipping breakfast) and maternal overweight were strong correlates of body size but did not explain the ethnic differences observed. Conclusions: There were significant ethnic differences in BMI in adolescence, emergent in late adolescence for boys. Neighbourhood and school contexts did not explain the ethnic differences in BMI age trends.

This thesis presents research on the epidemiology and transmission dynamics of healthcare-associated infections (HCAI) and focuses on the antibiotic resistant hospital pathogen methicillin-resistant Staphylococcits aureus (MRSA). First, a stochastic mathematical model of MRSA transmission dynamics is developed in which patient movement within and between both hospital and community populations is considered. The effects on transmission of both surveillance and control within this setting are explored. Significant interplay is found to exist between surveillance and control; surveillance is shown to be essential to control success and in addition allows quantification of the level of control achieved. Furthermore, patient movement between hospital and community populations is shown to have a considerable impact on transmission dynamics and on the success of infection control strategies. Analyses of the demographics of a hospital population using a real hospital dataset are presented and the heterogeneous nature of the patient population described. Differences in admission patterns and length of hospital stay between age groups, gender and speciality are explored. Combining these analyses highlights the patient groups constituting the majority of patient days. Further to this, the heterogeneous nature of patient readmissions is described and the existence of a 'core group' of most frequently readmitted patients is illustrated. Overall, readmissions are found to be far more likely than previously thought, with the majority of patient admissions to hospital being readmissions. Given this finding of increased readmission, the hospital admission data is used to inform the development of a model in which real patient movements between the hospital and community are simulated and transmission within this setting explored. Endemic behaviour results and the change in movement patterns is found to influence control strategy success. Further to this, the model is extended to simulate transmission within a multi-centre setting where patient movements within a three-hospital and community network are simulated. This increase in heterogeneity within the patient population appears to allow endemic behaviour throughout all hospitals 11 within the network.

This thesis shows how it was possible to listen to health visitors relate their personal views about their work in such a way that new insights on being a woman as a health visitor have been identified. This contributes to the debate about the 'invisibility' of health visiting as a reality and also shows invisibility to be a metaphor for care and the caring aspects of the work, for the management of personal lay knowledge rooted in experience and for gender blindness in client relations based on surveillance. It shows health visiting operating on three levels that represent the public face of the work, the private lay knowledge and the hidden personal feelings. The thesis highlights the importance of remaining open to new ways of viewing and interpreting practice and makes suggestions for educational changes in the preparation of health visitors. The study draws upon qualitative data from semi-structured interviews with 35 health visitors. It examines ways in which professional and personal experiences contribute as resources to the activity of health visiting in a public work arena where the emphasis on identifying targets and measurable outcomes increased during the 1990s. The health visitors who participated in this research all identified private and personal experiences which contributed to the process of their work but without any model to validate these as legitimate resources for their clients. The findings suggest that without a transformed outlook these potential resources will continue to be hidden and undervalued. The analytical tools, drawn from feminist theories of care, epistemology and power relations were each applied to the data and demonstrated ways in which feminist understandings could lead to a heightened sense of being a 'woman worker'. It is suggested that becoming more aware of gender in client interactions can lead to a model of practice which values the needs of women and would enable health visitors to improve their practices with women.

This study considers the social history of the Birmingham and Midland Hospitals for Women Incorporated between 1871 and 1948. The hospitals were an integral part of the voluntary hospital system in Birmingham, where two general infirmaries and a range of smaller specialist institutions had been set up to deal with the health care needs of a growing population during the period of industrialization. Two underlying historiographical themes are discussed throughout the thesis; the motivation of those that founded and supported such institutions and the feminist critique of the developments in the practice of gynaecology. Much of the current literature on women's health in this period concentrates on the underlying ideology rather than health care. Here the emphasis is reversed; it is to the medical care and treatment of diseases associated with women's sexual and reproductive organs that this thesis is directed. I have adopted a broadly chronological approach, with Chapters 1 to 4 exploring the founding of the hospital in 1871 and the important early years during which it became established. Chapters 5 to 7 consider developments during the Edwardian period and the inter-war years. In the organization of the individual chapters I have adopted a thematic approach considering the association that different group of people had with the hospital; the governors, medical staff and patients, both within the context of their health care and the lives and circumstances of working-class women in the wider sense. To provide an analytical framework for this study, the dominant historiographical paradigms in the field of women's health are discussed in the introduction to this thesis.