This project aims to investigate the influence of UV on the properties under natural and artificial weathering. The real-time outdoor weathering exposures provide the most accurate results but, they are very slow and manufacturers cannot afford to wait in order to see if a new or improved product formulation is really an improvement. So, accelerated testing methods are designed to simulate natural weathering with the combined action of the most weathering damaging factors; UV radiation, oxygen, temperature and water. Whatever the application, there is a concern regarding the durability of the products because if its useful lifetime can be estimated in short time, their maintenance and replacement can be planned in advance. In this study, recycled PET samples were exposed to UV outdoors and to accelerated weathering up to 13,000 hr. The mechanical behaviour (tensile and impact), thermal behaviour (DSC), molecular structure analysis (FTIR), flow characteristics (MFI) and surface properties (colour and gloss) of the samples were investigated. The whole body of the samples was substantially unaffected by degradation for long exposure time and this is confirmed by MFI and DSC results. However, the surface of the samples is affected which is seen in FTIR analysis, colour and gloss change. This explains that the photodegradation is a surface effect. FTIR analysis shows an increase in the gauche ratio and decrease in the trans ratio for both types of weathering indicating a less ordered structure after the UV radiation due to chain scission by Norrish Type I and II mechanism. Carboxylic acid is formed as a result of degradation and increases with the extent of UV exposure in both types of weathering, the formation of carboxylic acid by Norrish II is dominated over Norrish I. Colour and gloss measurement shows that the effect of degradation takes place strongly in the first 2000 hr of exposure in natural weathering and extended up to 5000 hr in accelerating weathering due to the formation of microcracks. Mechanical tests show that the UV effect was not significant on bulk properties such as yield stress and elongation at yield for accelerated weathering samples up to 1000 hours, then dropped by 62% and 57% respectively up to 13000hr of exposure and remained unchanged for the whole period of exposure for outdoors samples. The drop in the failure stress and elongation at failure for accelerated weathering samples right from the beginning indicate the formation of microcracks is from the early stages of exposure. For outdoor samples, failure stress remained unchanged for the first 1000 hr of sunlight exposure, then decreases progressively with increasing exposure in the environment. The elongation to failure is unchanged up to 13000 hours. After 13000 hrs of exposure to sunlight, r-PET samples failed to break while those exposed to UV lamps failed in a brittle manner under impact after 250 hrs and this indicates the transition from ductile to brittle behaviour just after 10 days of accelerated UV exposure because of crack formation. For accelerated weathering samples, the impact strength remained unchanged in the first 1000 hr of exposure, then a decrease up to 5000 hr of exposure when the effects of flaws become significant and dropped sharply by 85% after 5000hr of exposure. The correlation between both types of weathering shows that one year in natural weathering is equivalent to one and a half months in accelerated weathering according to colour measurements. The effect of accelerated weathering is much bigger than the natural weathering and this is due to higher radiation dosage, temperature and humidity during the test which accelerate chain scission rate that lead to faster crack growth.

Background: The MMSE is commonly used as a screening instrument for cognitive impairment in stroke services. However, recent research has shown that it has poor diagnostic validity for use in this patient population. The purpose of this study was to examine the validity of the ACE-R as an alternative screening measure for use in stroke. Objectives: The first objective was to determine whether the ACE-R is more accurate than the MMSE at detecting overall cognitive impairment in stroke. The second objective was to determine the accuracy of the ACE-R subscales for detecting impairments in specific cognitive domains. Methods: This study had a cross-sectional design. 40 patients were recruited from an inpatient stroke service. They were administered the ACE-R (which includes the MMSE), and a battery of more detailed neuropsychological tests, which served as the ‘gold standard’ for classification of impairment. The diagnostic validity of the ACE-R and MMSE was determined by ROC analysis. Results: Both the MMSE and the ACE-R were found to have inadequate diagnostic validity for the detection of overall cognitive impairment. No cut-scores scores could be identified which yielded test sensitivity of >80% and specificity of >60%. Levels of specificity were particularly poor. The ACE-R subscales showed a similar pattern of performance, indicating inadequate validity for the detection of impairment in specific areas of cognitive functioning. Conclusions: There was no support for the use of the MMSE or the ACE-R when screening for cognitive impairment in acute stroke. Further research should focus on the identification of an alternative measure.

Background: The MMSE is commonly used as a screening instrument for cognitive impairment in stroke services. However, recent research has shown that it has poor diagnostic validity for use in this patient population. The purpose of this study was to examine the validity of the ACE-R as an alternative screening measure for use in stroke. Objectives: The first objective was to determine whether the ACE-R is more accurate than the MMSE at detecting overall cognitive impairment in stroke. The second objective was to determine the accuracy of the ACE-R subscales for detecting impairments in specific cognitive domains. Methods: This study had a cross-sectional design. 40 patients were recruited from an inpatient stroke service. They were administered the ACE-R (which includes the MMSE), and a battery of more detailed neuropsychological tests, which served as the ‘gold standard’ for classification of impairment. The diagnostic validity of the ACE-R and MMSE was determined by ROC analysis. Results: Both the MMSE and the ACE-R were found to have inadequate diagnostic validity for the detection of overall cognitive impairment. No cut-scores scores could be identified which yielded test sensitivity of >80% and specificity of >60%. Levels of specificity were particularly poor. The ACE-R subscales showed a similar pattern of performance, indicating inadequate validity for the detection of impairment in specific areas of cognitive functioning. Conclusions: There was no support for the use of the MMSE or the ACE-R when screening for cognitive impairment in acute stroke. Further research should focus on the identification of an alternative measure.

Background Sensory sensitivity (SS) is defined as the level to which an individual is able to regulate their responses to sensory input. Children with Autistic Spectrum Disorder (ASD) have been found to display unusual and abnormal levels of SS. These variabilities in SS have been associated with poorer levels of adaptive behaviour, behavioural difficulties and emotional problems. Parental questionnaires are frequently used to assess children’s SS. However concern has been raised regarding the use of parents as the sole informant. This study aimed to assess whether parental reports of children’s SS were consistent with alternative informants’ (school staff) reports. Methods The Short Sensory Profile (SSP: Dunn, 1999) was administered to 72 pairs of parents/caregivers and school staff, to be completed for children with ASD (aged 4 to 18 years). This 38 item questionnaire highlights variations of sensory modulation and provides a total score, and 7 factor/subsection scores relating to different aspects of sensory processing (e.g. auditory filtering). This study utilised intraclass correlation coefficient (ICC) values to assess the level of agreement.

In 2011 it was estimated that in Thailand there were 498,800 stroke survivors of both sexes but most were over the age of 65. They were served by only 625 occupational therapists (OTs). Occupational therapy (OT) plays a key role in the rehabilitation service for stroke patients, in particular, by enabling stroke survivors to reengage with activities of daily living and to resume work or family tasks. OT needs to be culturally appropriate and relevant to the therapists, stroke patients and their families. The Occupational Therapy Mahidol Clinic System (OT-MCS) has been designed to be culturally relevant and is based on collaborative teamwork which can better address the needs of the stroke patients. OT-MCS was introduced in 6 regional OT clinics. This study compared perceptions of stroke clients who took part in the new approach 8 weeks before and during the rehabilitation. One hundred and twenty stroke participants were divided into 2 functional groups (slow and fast stream rehabilitation). Stroke participants (N=120) and OTs (N=60) explored the arrangement of activity items into domains for creating a new activity card sort (ACS). Sixty stroke participants (slow stream rehabilitation) and 60 OTs were surveyed to investigate the attitudes of “satisfaction” and “importance” via 40 therapeutic activities. Sixty stroke participants (fast stream rehabilitation) evaluated the levels of their activity engagement in diverse cultural-therapeutic activities. Lastly, 23 stroke participants (slow and fast stream rehabilitation) were interviewed in order to ascertain their lived experiences after the use of OT-MCS and the data were analysed using thematic analysis. The integrated analysis demonstrated strong satisfaction and engagement with OT-MCS. The use of the activity catalogue met with positive attitudes from the stroke participants and in particular the collaborative approach of OTs and participants gave meaning to the activities and a sense of self management. In addition in the fast stream rehabilitation participants reported satisfaction with the transferability of the activities to the home and external environment and their relevance to supporting family life. The OT-MCS for Thai stroke rehabilitation is a comprehensive OT service, which improves the perception of benefit in stroke clients enabling them to perform meaningful and purposeful activities based on their local and regional lifestyles. This culturally appropriate approach helps stroke clients to re-develop their life-skills. Through the use of meaningful and relevant activities which meet their specific needs, stroke clients can lead more satisfying and fulfilling lives.

In 2011, a period began in which the United States demographic will change to include the largest, least prepared, and most diverse elderly population in our nation’s history. That was the year the “Baby Boomer” generation started retiring and members of this large cohort will continue to do so for approximately twenty years (Kemper, Komisar & Alecxih, 2005). Chronic health conditions and the obesity epidemic may make retirement years less healthy ones than for previous generations of older adults. Lifestyle changes in Baby Boomers as compared to previous cohorts of elders – increased divorce, fewer children, nontraditional family relationships – may result in less support for frail elders when they can no longer care for themselves, thereby increasing their vulnerability to long-term care placement (Cherlin, 2010; Ryan, Smith, Antonucci & Jackson, 2012

This thesis describes some models that attempt to forecast the number of occupied beds due to emergency admissions each day in an acute general hospital. Hospital bed managers have two conflicting demands: they must not only ensure that at all times they have sufficient empty beds to cope with possible emergency admissions but they must fill as many empty beds as possible with people on the waiting list. This model is important as it could help balance these two conflicting demands. The research is based on data from a district general and a postgraduate teaching hospital in South East London. Several tests indicate that emergency bed occupancy may have a nonlinear underlying data generating process. Therefore, both linear models and nonlinear models have been fitted to the data. At horizons up to 14 days, it was found that there was no statistically significant difference in the errors from the linear and nonlinear models. However at the 35 day forecast horizon the linear model gives the best forecast and tests indicate errors from this model are within 4% of mean occupancy. It is noted that a Markov Switching model gave very good forecasts of up to 4 days into the future. A search of the literature found no previous research that tested emergency bed occupancy for nonlinearities. The thesis ends with a gravity model to predict the change in number of Accident and Emergency (A&E) attendances following the relocation of an A&E Department in South East London.

The role of community pharmacy (CP) in health promotion has developed over the last decade and a half following the introduction of the new National Health Service (NHS) plan in 2000. CPs have been turned into healthy living centres where individuals can access a variety of services designed to prevent disease and promote health. In 2005, three types of pharmacy service were introduced; essential, advanced and enhanced (currently known as locally commissioned). Enhanced pharmacy services were provided by Primary Care Trusts (PCTs) (until 2010) based on local needs identified by PCTs. In 2010, the Government decided to abolish the PCTs by 1‘"t April 2013; hence, PCTs entered a transition phase between 2010 and April 2013. By February 2011, each PCT was required to publish Pharmaceutical Needs Assessment (PNA) report regarding the provision and need for pharmacy services. The national commissioned vascular and sexual health enhanced pharmacy services in England are Stop Smoking Service (SSS), NHS health check, Emergency Hormonal Contraception (EHC) and chlamydia screening and treatment services. In 2012, the Healthy Living Pharmacy (HLP) scheme, which was piloted in Portsmouth PCT, was expanded to 30 PCTs known as HLP pathfinder PCTs. The aim of this research was to identify the correlation between needs, provision and uptake of vascular and sexual health pharmacy services at a PCT and CP level. It also aimed to investigate whether the provision of those services was cost effective. Finally, it aimed to determine the impact of the introduction of the HLP scheme on the provision and uptake of those services. At a PCT level, the PNA reports were used to identify the CP provision of SSS, EHC service and chlamydia screening service for the financial year 2009/2010. The local need for SSS (prevalence of smoking adults) and EHC services (rates of teenage pregnancy) were obtained from Health Profiles for each PCT. The need for chlamydia screening service (prevalence of positive chlamydia infection) was obtained from the National Chlamydia Service Programme (NCSP). Uptake and cost attributed to provision of those services for the financial year 2009/2010 were obtained from a short questionnaire targeted the public health leads for the related services in PCTs where the provision of services and the needs were identified. Simple cost-effectiveness analyses were performed on CP SSS and CP EHC provision, based on identified uptake and cost. At a CP level, a cross-sectional survey was conducted on 1 249 CPs in 28 PCTs across England in 2013. PCTs were chosen based on provision of SSS, EHC and chlamydia screening service identified in the PNA reports. 7 PCTs out of 28 PCTs were HLP pathfinder PCTs. CPs were allocated to one of five groups based on deprivation. The response rates for SSS, EHC and chlamydia screening surveys were 30% (42/138), 30% (42/139) and 19% (21/111) respectively. Data analysis identified that the need for SSS and EHC services were highly correlated with deprivation, with Spearman's rank correlation coefficients (rho) of 0.76 and 0.83 respectively (both P 0.001). The correlation between deprivation and the need for a chlamydia service was weak (rho = 0.25, P = 0.009). Higher number of CPs per 25 000 population were observed in more deprived PCTs (rho = 0.63, P < 0.001). CP provision (percentage of CPs offering a service out of total CPs in a PCT) of SSS, EHC and chlamydia service did not correlate with needs. The uptake of SSS, EHC and the chlamydia screening service did not correlate with increasing need or deprivation. However, pharmacists in areas of higher need dealt with a greater number of clients in relation to SSS and EHC services to meet their local needs, with rho of 0.4 and P of 0.01 in case of SSS and Pearson's correlation coefficient (R) of 0.36 and P of 0.02 in case of EHC. A cost-effective analysis of CP SSS provision found it to be cost effective when compared to no intervention based on NHS perceptive and the incremental cost per Quality Adjusted Life Year (QALY) gained. was £1 511. Similarly, the CP EHC service was also found to be cost effective with an NHS saving of £689 per unintended pregnancy prevented. The response rate for the CP survey was 19.3% (241/1 249). No significant differences were identified in terms of provision or uptake of SSS, EHC, chlamydia screening and NHS health check services between CPs with different deprivation neighbourhoods. 18.5% (31/168) of the respondent community pharmacists were working in HLPs. The uptake of SSS through HLPs (median = 6) was higher than that through non-HLPs (median = 4; P = 0.02)._Playing a more active role in health promotion was cited as the main driver for pharmacists to adopt an HLP scheme. Respondent pharmacists indicated that the introduction of an HLP scheme had improved public awareness of vascular and sexual health services available in CPs and they suggested the use of social media websites to further improve public awareness. Lack of time and the provision of similar services via other providers were considered the main barriers. Local Authorities should increase the provision of vascular and sexual health pharmacy services to meet the needs of their localities. They should use the latest technology to improve public awareness regarding availability of those services in CPs.

Pre-existing dementia is associated with poorer functional outcome after stroke. It is unclear however whether this is due to lack of access to, or inequality in, stroke rehabilitation. This PhD used mixed methods to understand whether pre-existing dementia is a factor considered by clinicians when referring/admitting patients for rehabilitation, when providing rehabilitation interventions, and whether there is a difference in rehabilitation received by patients with and without pre-existing dementia. A background literature review informed the first study, which was a systematic review examining factors influencing clinical decision-making about access to stroke rehabilitation. The systematic review suggested that pre-stroke cognition influenced referrals/admission to rehabilitation, however, no studies examined this specifically. The qualitative study therefore used interviews (n=23) to explore clinicians experiences of decision-making about rehabilitation for patients with pre-existing dementia/cognitive impairments. The findings highlighted that clinicians own knowledge influenced their decision-making, with a common perception that people with pre-existing cognitive impairment lack potential to benefit from rehabilitation. The third study, a prospective cohort study, examined differences in rehabilitation received by patients with and without pre-existing cognitive impairments (n=139). People with pre-existing cognitive impairments received less rehabilitation than those without, particularly physiotherapy and referral to community therapies and more non-patient facing occupational therapy. This PhD identified that people with pre-existing dementia/cognitive impairment receive less rehabilitation when compared to those without. This may be, in part, due to clinicians decision-making about which patients should receive stroke rehabilitation. These findings have multiple clinical implications, particularly around the number of patients in stroke services with undiagnosed pre-existing cognitive impairment. Decisions can become more equitable by ensuring clinicians have access to relevant education, training and skills to work alongside patients with pre-existing dementia/cognitive impairments.

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