Background: The 2009 influenza A (H1N1) pandemic was the first pandemic in the era of modern pandemic planning and preparedness. Although the mortality and morbidity caused by the pandemic was low compared with the previous pandemics, it gave the first opportunity for member states to implement an actual pandemic response reflecting on years of pandemic preparedness and planning. The objective of this study was to evaluate the usefulness of pandemic preparedness activities as well as to identify challenges and activities that require further improvement. Methods: The study was conducted in seven countries within the WHO regional office for Europe; six of them were identified through a stratified random sampling in order to get a representative sample across different levels of preparedness within the WHO European Region. These were Armenia, Bosnia and Herzegovina, Denmark (pilot country for the study), Germany, Portugal, Switzerland and Uzbekistan. Research teams visited each country and interviewed six key stakeholder groups at different administrative levels. These were Ministry of Health (MOH), National Public Health Authority (NPHA), Civil Emergency Response (CER) representatives, Sub- National Government Authority, and primary and secondary healthcare workers (HCWs). Focus group interviews were conducted using open-ended questions in semi-structured interview guides. Results: Six recurring themes were identified as essential aspects of pandemic planning activities. These were communication, coordination, capacity building, mutual support, leadership, and flexibility. The following aspects of pandemic planning activities were found to be inadequate and should be improved in the future: risk communication with the public and healthcare workers, coordination of vaccine logistics, flexibility and adaptability of pandemic plans, and surveillance in the secondary healthcare setting. Conclusions: Stakeholders interviewed reported that the pandemic preparedness activities were worthwhile and appropriate for the response measures carried out during the pandemic influenza (H1N1) in 2009. However, the findings identified areas of under planning that were common to most of the participating countries.

This thesis argues that ethical issues in Ghana and Malawi represent barriers to pandemic influenza management and prevention. The ways in which ethical issues arise and are manifested are poorly understood, in part because there is little knowledge and inadequate Planning for, and Response to, Pandemic Influenza (PRPI). Rather than offering simple answers, this thesis describes how ethical problems emerge in the course of pandemic authorities performing their everyday duties. The central aim is to understand what ethical issues mean to policymakers and how they may be resolved. An extensive review of the experiences of the 1918 influenza pandemic including the epidemiology is examined to illustrate the profound impact of the disease and lessons that can be learnt. The study operates at two distinct but related levels. Firstly there is an investigation of PRPI at a broad level. Secondly, an exploration of the ethical issues that emerges from PRPI within the analytical framework of decision-making models. A qualitative study using semi-structured interviews is used to conduct the study with a “purposive sampling” of forty six policymakers from Malawi (22) and Ghana (24). Utilizing existing normative ethical theories, but acknowledging theoretical and empirical approaches to public health ethics and bioethics, this thesis provides a contextual public health framework to study broad moral problems in particular situations. The findings of the study reveal that normative claims can successfully influence policy if substantiated with empirical evidence. Ethical problems are highly practical and contextual in nature, occurring differently in the context of particular settings, cultures, values and moral judgments. Policymakers interviewed identified ethical problems in relation to four key areas: the extent and role of resources in PRPI, the nature of public health interventions (PHIs), the extent of the impact of PHIs and the extent and process of decision-making, reasoning and justification. Policymakers resolved ethical problems by simply applying rules, work norms and common sense without moral and flexible principle-driven thinking. Policymakers’ technical knowledge of ethics is inadequate for balancing the hard pressed moral tensions that may arise between the demands of civil liberties and public health. These results underscore the need to update overall goals in pandemic operations, training and education. Most importantly, an ethical framework remains an important part of dealing with ethical problems. A process of developing an ethical framework is proposed, but the key to combating any ethical problem lies in understanding the PRPI strategy.

The Chinese construction industry is China's third biggest industrial killer. Accidents causation analysis revealed that more than 80% of accidents are caused by unsafe human behaviour. The current research was focused on exploring and examining the factors affecting safety rule violations among Chinese construction workers through four main studies in which a combination of qualitative and quantitative methodologies were used. In the first study, on-site observation and organisational document analysis were conducted in fourteen construction companies to familiarise the author with the research settings and to obtain triangulation evidence for the following studies. It was followed by the second study in which interviews and focus groups were conducted among 97 managers, safety officers and workers in order to explore the factors associated with workers' rule violation. Thematic analysis revealed four main categories of factors, i.e., individual factors, managerial factors, sectoral and labour market factors, and national and cultural factors. The qualitative study was followed by questionnaire surveys (n = 700) to test in a larger management sample the qualitative study's results. Survey results complemented the qualitative study's findings. Based on the obtained results, a fourth study using the Delphi method and the modified G1 method was conducted among 17 experts in order to calculate the importance levels of each factor in influencing workers' rule violation. Although managerial factor was ranked as the most influential factor compared with other categories, some extra-organisational factors and situations were ranked at high positions amongst 24 specific factors. The results suggested that workers' behaviour need to be scrutinised not only within the context of organisational safety management, but also from the particular background and characteristics of Chinese migrant workers, Chinese construction sector, as well as the society and the culture.

Background Motor Vehicle Crashes (MVCs) are a major cause of morbidity and mortality worldwide. This thesis explores the potential use of large databases of primary care medical records to investigate the epidemiology of MVCs in the United Kingdom and to supplement the data available from national statistics, which are believed to understate both the number of crashes, and the number of injuries which occur as a result. Methods Details of all individuals enrolled in The Health Improvement Network (THIN) database whose primary care records indicated involvement in a MVC were used to calculate a series of summary measures describing the burden and consequences of MVCs. These were compared with data available from police accident reports and from hospital admissions. Data from THIN were used to conduct a series of studies of the impact of health and healthcare-related factors on the risk of involvement in MVCs. Specifically: a case-control study of the impact of modifiable lifestyle factors on the risk of MVC; case-crossover and self-controlled case-series studies of the effect of exposure to prescribed medications on the risk of MVC; a case-control study investigating the impact of disordered sleep on the risk of MVC; a case-control study of the risk of involvement in MVC among individuals with diabetes relative to the general population; and; a cohort study assessing whether there is evidence to suggest that involvement in a MVC may indicate the presence of undiagnosed disease which may impair driving performance. Results The socio-demographic characteristics of individuals involved in MVCs recorded in THIN differ markedly from those recorded in police accident reports and hospital admissions data. There was no evidence of consistent trends in MVC incidence over time in the three data sources. Differences in data collection methodology and the severity and scope of crashes recorded may account for these variations. Evidence was found of an association between having a high Body Mass Index and involvement in MVCs, and between past (but not current) smoking and involvement in MVCs, however the recording of data on lifestyle-related exposures such as smoking and alcohol consumption in the age-groups most likely to be involved in MVCs was poor, complicating interpretation of these results. Current exposure to benzodiazepines and preparations containing opioid analgesics was found to increase the risk of involvement in MVCs, as was longer-term use of non-benzodiazepine hypnotics, selective serotonin reuptake inhibitors and antihistamines. No increased risk of MVC was observed with exposure to beta-blockers or tricyclic antidepressants. Individuals reporting insomnia or snoring to their primary care practitioner were found to be at increased risk of MVC, as were individuals with diagnosed sleep apnoea. This association was independent the use of sedative or antidepressant medications. Individuals with diabetes were not found to be at an increased risk of MVC compared with the general population, and there was no difference in risk between those receiving different forms of treatment. Involvement in a MVC was associated with an increased risk of being diagnosed with cardiac disease in the two years following the crash. Conclusions Current sources of data about MVCs in the UK use different data collection methodologies, none of which is likely to accurately describe the overall burden of MVCs in the population. Primary care data remain a useful resource for those wishing to study the epidemiology of MVCs, but care must be taken to ensure that the uses to which the data are put are appropriate. Studies investigating lifestyle-related exposures are unlikely to produce reliable results as primary care recording of such factors is poor in the age-groups most likely to be involved in MVCs. Primary care data are more useful when studying the time course of pharmacological effects, or the effects of diagnosed illness, and can successfully detect previously observed associations. Primary care data is currently of little use in the study of injuries associated with involvement in MVCs as it is rare for both an injury and its proximate cause to be recorded. The investigation of methods by which this problem might be resolved is an important avenue for future research.

This thesis draws upon data gathered during research undertaken with a grant from the Resuscitation Council (UK). It explores the use of Automatic External Defibrillators (AEDs) by laypeople, which is known as Public Access Defibrillation (PAD). Whilst an abundance of research has been undertaken about this phenomenon, it has predominately been conducted using quantitative methods; however the data I am using was collected using a qualitative approach. During the research, fifty-three semi-structured interviews were carried out. Most of these were with laypeople who had been trained to use AEDs, and nine involved those who delivered the training. These interviews were conducted at sites typical of those where these devices have been introduced, such as railway stations and airports. The geographical area of these locations covered the East and West Midlands, South and West Yorkshire, Lincolnshire and Essex. The aims of the research were quite broad and included exploring how to make training more realistic, how debriefing and support for those who had used an AED should be organised and how the interviewees perceived the technology inherent in the AED. This thesis reanalyses the data that was collected during that research and focuses on two themes. Firstly, some of the theories of technologies in transition are used to illustrate how AEDs were developed in a laboratory and progressed from that setting to become commonplace in public locations. The actor-network theory is adopted to argue that these technological devices exert an influence on the human actors in the networks that exist within society. Specifically, my analysis is informed by the work of Timmermans (1998; 1999; 1997) whose theories about external chest compressions I have developed and applied to AEDs. They suggest that these devices achieved universality, in part, through the influence of debates and medical protocols. One significant factor was that AEDs allowed for defibrillation to be redefined from a medical, to a first aid procedure. Eventually, using these devices was included in the protocols for first aid and this legitimised their use by laypeople. These theories are observable in the data through the interviewees’ accounts of how they came to accept being trained to use AEDs. The experiences of those who had used an AED during a resuscitation attempt are provided and suggest that these are distressing and unpleasant events. Consequently, a key component of this thesis is a discussion of the necessity to provide psychological debriefing for those who have been involved in these incidents. The findings of this thesis suggest that laypeople who have used an AED usually have questions about the actions they took during the attempted resuscitation and need to address these with someone soon afterwards. Generally, they prefer to discuss these issues with a person who has experience of resuscitation and using a defibrillator. However, the provision of such support is often not well organised and individuals are sometimes not aware of what is available to them. I conclude by suggesting that it is important that those who are asked to use an AED have a clearly identifiable person to contact should they need to discuss any issues which may arise. I argue that the responsibility for ensuring that such mechanisms are in place lies with those who instigate the schemes which place AEDs in these locations. Public access defibrillation is a relatively new concept in the UK and I believe that this thesis makes an important contribution to the body of knowledge relating to this phenomenon.

This research explores the understanding of psychosocial risks and work-related stress by international multi-disciplinary experts in developing countries. It further explores their views on the perceived health impact of these issues. It identifies preliminary priorities for action while considering similarities and differences in conceptualizing these issues in industrialized and developing countries. Finally, it explores in what ways these issues can enter the policy agenda in developing countries. This research applies a triangular methodological approach where each stage provides the basis for the development of the next. It starts out with 29 semi-structured interviews to explore the views of experts and also to inform two rounds of an online Delphi survey, which then informed four focus group discussions. The total sample amounted to 120 participants (each sampled once). Key findings for developing countries indicate that a) psychosocial hazards need addressing due to an impact on workers' health; b) occupational health and safety priorities have changed during the last decade pointing to the need for monitoring of psychosocial hazards and the need to address work-related stress, violence, harassment and unhealthy behaviours together with other workplace hazards; c) socio-economic conditions and processes of globalization need attention in the study of psychosocial hazards and an extended research paradigm is required; and d) there is an ever present need for capacity building, stakeholder mobilization, infrastructure development and international exchange and collaboration to address all workplace hazards. Developing countries are not spared from the health and economic impact of psychosocial risks and work-related stress, and there will be a need to address these issues through policy development. To pave the way, this dissertation outlines a need for concerted action at different levels.

Introduction Regular cycling has been shown to improve health and well-being and has a role in tackling obesity and inactivity. Cycle collisions, particularly those involving motorised vehicles, can lead to significant mortality and morbidity and are currently a barrier to wider uptake of cycling. There is evidence that the conspicuity of cyclists may be a factor in some injury collisions. Low-cost, easy to use retro-reflective and fluorescent clothing and accessories (’conspicuity aids’) are widely available. Their effectiveness in reducing the risk of cycling collisions is currently unknown. This study was designed to investigate the relationship between the use of conspicuity aids and risk of collision or evasion crashes for utility and commuter cyclists in an urban setting in the UK. Methods A matched case-control study was undertaken. Cases were adult commuter and utility cyclists who were involved in a crash resulting from a collision or attempted evasion of a collision with another road user. Cases were recruited at a large UK emergency department. Controls were commuter and utility cyclists matched by time and day of travel, season and geographical area of cycling. Controls were recruited at public and private cycle parking sites. Data on the use of conspicuity aids, crash circumstances, participant demographics, cycling experience, safety equipment use and journey characteristics including an estimate of the bicycle crash risk for each chosen route (the number of previous crashes per 100 million kilometres travelled by bicycle calculated for each participant route) were collected using self-completed questionnaires and maps. Conditional logistic regression was used to calculate crude and adjusted odds ratios and 95% confidence intervals of the risk of a crash involving a collision or evasion of a collision with another road user when cyclists reported they were using any item of fluorescent or retro-reflective clothing or equipment vs. none. Unconditional logistic regression was used to analyse associations between participant characteristics and conspicuity aid use. Continuous variables were dichotomised where there was a non-linear relationship to the bicycle crash outcome variable or the primary exposure variable. The sensitivity of the study models to selection, recall and information biases and the effect of missing data was assessed using independent records of conspicuity aid use by potential participants during recruitment. Observations of conspicuity aid use within the study source population at sites across the study catchment area were also conducted by the researcher during the recruitment phase. Results There were 76 cases and 272 controls cyclists who were eligible for inclusion in the primary analysis (response rate of 13% and 54% respectively). The proportion of cases who reported using any item of fluorescent or reflective materials on their clothing or equipment (excluding bicycle mounted reflectors) was higher than for matched controls (cases users 69.7%; 95% CI 58.1% to 79.8% vs. control users 65.4%; 95% CI 59.5% to 79.1%). The unadjusted odds ratio for a collision or evasion crash when using conspicuity aids, was 1.2 (95% CI 0.66 to 2.17). Two alternative modelling strategies were employed. After adjustment for confounding from age, gender, socio-economic deprivation, number of years of cycling experience, bicycle crash risk along each route and cycle helmet use the odds ratio was 1.77 (95% CI 0.74 to 4.25). After adjustment for confounding from age, gender, socio-economic deprivation, bicycle crash risk along each route and history of previous cycle crash involvement the odds ratio was 2.4 (95% CI 1.06 to 5.7). The odds ratio was not significantly affected by adjustment for possession of a driving licence, reported bicycle safety training in childhood, psychometric associates of risk taking behaviour, cycle helmet wearing, years of experience of cycling, distance or number of trips cycled in the previous seven days, type of bicycle, the use of bike-mounted lights or reflectors, weather or lighting conditions, familiarity with the route or alcohol consumption within 8 hours prior to the recorded journey. There was a significant difference between the measure of bicycle crash risk along each route for cases and controls with controls reporting travelling on routes with lower objective bicycle crash risk (median (IQR); cases 378.5 (232.4 to 548.3) vs. controls 268.5 (192.6 to 464.5); p= 0.006). There were no significant differences in route risk for users vs. non-users of conspicuity aids (route risk median (IQR) for conspicuity aid users vs. non-users; 308.1 (198.0 to 504.3) vs. 272.3 (203.7 to 413.4; p= 0.22). Conspicuity aid use was associated with increased length of participant route (unadjusted OR 3.25 for reported route greater than median; 95% CI 2.04 to 5.17 p<0.001), higher numbers of police-recorded bicycle crashes (unadjusted OR 2.26 for greater than median; 95% CI 1.43 to 3.55; p<0.001) and lower numbers of observed cyclists on each route (unadjusted OR 0.999; 95% CI 0.998 to 1.000 p=0.015). Route risk data were missing for 50 participants (15 cases and 35 controls). Validation of the primary exposure showed that there was moderate agreement between participants’ self-reports and independently collected data (kappa 0.42; 95% CI 0.32 to 0.51) but independent data were collected on only 4 eligible cases. Self-reported use of conspicuity aids was higher amongst cases and controls in this study than that observed for cyclists in the study area during the recruitment period (23%; 95% CI 22% to 24%). Discussion The results of this study show a non-significant increase in the odds of a crash for users compared to non-users of conspicuity aids whilst cycling. This association was increased after adjustment for confounders but most models generated to adjust for confounding remained insignificant. No reduction in crash risk could be demonstrated. This is not consistent with the large body of evidence suggesting that conspicuity aids increase the distances from which wearers can be detected and recognised by drivers in a variety of settings. There was evidence that cases were cycling along routes with greater exposure to traffic danger than controls although there were many participants with missing data for this variable potentially introducing a further source of bias. The route risk estimates did not vary significantly between conspicuity aid users and non-users. Residual confounding may have occurred if conspicuity aid users were taking more risks when encountering similar traffic conditions to non-users. This could not be measured but may go some way to explaining these results. If cyclists over-estimate the likely effect of their conspicuity aid use this could result in over compensation and a net increase in crash risk. Adjustment for route risk may have introduced bias by the loss of some participants from the analysis or by acting as a positive suppressor variable increasing the influence of uncontrolled confounding if conspicuity aid use were leading to risky riding over and above the objective risk arising from differing road and traffic conditions. The association between the odds of crash and travelling on roads with higher incidences of previous cycle crashes and fewer cyclists provides support for the “safety in numbers” effect reported in other studies. Differential selection and misclassification biases may also have resulted in over representation of conspicuity aid users amongst cases compared to controls. Social expectation from involvement in a collision crash may have resulted in cases who were not using conspicuity aids being less likely to participate than controls who were non-users. For similar reasons cases may have been more inclined to over-estimate their conspicuity aid use than controls.

Whilst the training of healthcare staff is seen as a key element to the prevention and management of violence and aggression, questions remain as to the effectiveness of these programmes in preparing staff to apply this to clinical practice. To date there is a relative paucity of well-designed studies into the effectiveness of the training to prevent and manage violence and aggression in healthcare settings. Within this context a study was conceived to examine the effectiveness of two aggression management training programmes in preparing staff for clinical practice. In order to provide a meaningful and evidence-based evaluation of the two programmes, Pawson and Tilley's Realistic Evaluation model was adopted for use in this study. In keeping with the chosen methodology, data was collected using a combination of methods including surveys, semi-structured interviews, and participant observation of training. A total of 64 participants were eligible for inclusion in the study; which ran over the course of a calendar year. The research highlighted that training should have relevance to the staff group undergoing instruction. That training should be conducted wherever possible in staff groups, tackling real problems, with participants reflecting and learning from their experience and from each other. It should also provide measures of competency that describe both workplace and organisational outcomes and describe the requirements of assessment. That training should be engaging and integrate decision-making, planning, organization and skill building and cover a range of interventions. Most importantly, was the need to help staff transfer what they had learnt as part of training to clinical practice. These factors are brought together in a model of training devised as part of this study called the PROMPTS Aggression Management Training Model ©. As the first study to apply realistic evaluation in aggression management research, it was a good fit, particularly given the growing emphasis on understanding how context influences evidence-based practice. The strengths and limitations of the approach are considered, including how to operationalize it. This approach provided a useful interpretive framework with which to make sense of the multiple factors that were simultaneously at play and being observed through various data sources, and for developing explanatory theory about aggression management training and its implementation in practice.

Clinicians working with women in forensic secure environments will be acutely aware of the diverse risks, complex treatment needs and unique responsivity issues found in this multifaceted marginal group. Women make up 5% of the prison population and approx 20% of the secure forensic psychiatric population (approx 4,500 and 1,085 women respectively). What animates the studies of women is not so much numbers of offenders but the particular circumstances of the women and girls “behind” the numbers. There is a common perception that women make up such a small number of the criminal justice service (CJS) population that devising gender sensitive environments and interventions is unnecessary. However studies of patients detained in high and medium security have identified significant gender differences. Women are more likely to commit minor offenses, be diagnosed with a personality disorder, present with self injurious behavior and have suffered childhood victimization. Thus, women and girls who are caught up in the justice system enter it as a result of circumstances distinctly different from those of men. Up until recently the needs of women were inadequately met in services centered on the needs of men and it is only relatively recently that the need to address these glaring differences has been thrashed out in the public arena. Following a number of high profile reviews and reports mixed sex wards have been become a exceptional, strip searches of women in prison have been abolished and large numbers of women have been reviewed and stepped down to lower levels of security. A less well researched area of women’s secure care centers on the profound impact of adjusting to a new environment which involves coping with severance of social support networks.

There are 17,571 homeless women in Vrindavan, a major pilgrimage town in North India (State Government Report, 2012). The town is spread across 4.56 square kilometers and the number of homeless women is increasing continually (NCW, 2010). The living conditions are inadequate and the majority live below the poverty line (Rai, 2010). In the last two decades, various attempts have been made by the government and non government organizations to build physical amenities, but psychological well being remains ignored (Rana & Misra, 2010). In literature, these women have often been portrayed as the victims of various tragedies, presenting only the vulnerable side. The present thesis attempts to explore the thriving side of these women, along with the vulnerable one. This thesis aims to study the changes, following various adversities, which homeless women of Vrindavan have faced in their lifetime. The study takes a critical stance of the medical model of negative changes following adversities, and endorses the understanding offered by positive psychology. Within positive psychology, the present thesis rejects the use of the term ‘Posttraumatic Growth’ because of the medical and universal implications that the term “trauma” brings, ignoring the cultural differences. Therefore, ‘Changes Following Adversities’ is used as the preferred term. Amongst various factors affecting changes following adversity, religious coping is one of the factors. Its significance has been studied less often than other factors such as social support, personal strengths, personality and optimism. The western perspective is still sceptical about the role of religion in changes following adversity, both methodologically and theoretically. Interestingly, with the population under study, the influence of religion was speculated to be large, because of the religious significance that Vrindavan has. Therefore, to capture the complexity of the experiences, grounded in the culture, a narrative approach was used. Thirty four life narratives were transcribed and translated for the analysis. Thematic analysis was employed to understand the changes across different participants. Overall, the thematic analysis indicated three major themes – adversities, coping strategies and changes following adversities. There were multiple adversities faced by the participants which were based in communal riots, poverty and patriarchal subjugation. Amongst all the coping strategies, emotion focused coping, particularly religious coping, emerged as one of the dominant themes. Ideographically, there were mixed findings on adversity related changes experienced by the participants. Changes in self and philosophy were the two major positive changes reported by the participants. Mental suffering in the form of worries, grief, somatic complaints and depressogenic thoughts were found as negative changes following adversities. A model was derived from the analyses to consolidate the findings, elaborating on the cognitive and emotional processing, leading to changes following adversities. The research has three fold implications-theoretical, methodological and practical. Theoretically, the study has implications for broadening the term trauma and post traumatic growth; using narrative to foster growth; and integrating religion in psychotherapy. Methodologically, the study has implications for cultural nuances faced while studying culturally variant populations, such as translations, and sample characteristics. The practical implications of the study indicate future interventions directed more towards wellbeing than welfare for the population under study.