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Background. Although research has been carried out within higher education circles little is known about any educational benefits that may result from primary care professionals engaging in networked learning and what strategies may be used to overcome barriers to effective learning. Aim. This research was undertaken to identify specific educational strategies which may inform educators wishing to support continuing professional development for healthcare professionals within communication and information technology. Method. A model of networked learning was developed from the literature and using the experience of working models elsewhere. The model was implemented and evaluated over two case studies, and further refined in a third. The evaluation methodology used action research collecting data from surveys, interviews, observer participation, electronic text generated bye-mail discussions, and project documents. Results. Healthcare professionals were able to usefully communicate over a prolonged period with colleagues about clinical and professional matters, developing a number of process skills; using e-mail, web and on-line database searching. Compared to face -to-face small group learning, the added benefit of using e-mail discussions supported by web based learning resources was being able to use the method at a place, pace and time of their own choosing whilst still remaining committed to a shared educational experience. GPs were able to use the educational material to put to-wards a portfolio (personal learning plan) for accreditation for PGEA. Specific roles for an on-line facilitator in addition to small group learning skills were identified. However networked learning is acknowledged to have many obstacles, eg access, using software, lack of support which will need to be overcome. Managing a learning environment for CPO for healthcare professionals involves an integration of the teaching and learning strategy of the host organisation with a networked learning environment. Conclusion. A networked learning environment has the potential of supporting continuing professional development and its assessment with portfolios. For individual participants much depends on there own learning style, what they feel is relevant to learn at the time and their own preferences for a learning format. Much needs to be done to provide the necessary supporting infrastructure and integration of provision across traditional divides within healthcare education. This research describes a number of recommendations, which can inform action by educational stakeholders interested in healthcare education.

Insecticide-impregnated bednets are currently being promoted as one of the promising malaria control methods in endemic regions of most developing countries. Although, much is known about the entomological and epidemiological aspects of treated bednets, little is known about the efficiency of malaria control programmes in general, and bednets in particular. This cost-effectiveness analysis forms part of the evaluation of the Gambian National Insecticide-impregnated Bednet Programme (NIBP). The research was conducted in the rural Gambia where malaria is endemic. An integrated approach to data collection approach (qualitative and quantitative) provided information for the four objectives of the study, namely; 1. to calculate the total NIBP implementation costs (ie' direct and indirect costs); 2. to estimate the number of child (under 10 years) deaths averted in the intervention area; 3. to calculate the resources saved by averting a child death to the health sector and households both direct (ie saved treatment costs, saved preventive expenditures, postponed funeral expenses) and indirect (ie time costs saved by carers and relatives that can be spent on productive activities) and subtract these from the programme costs, to produce net cost-effectiveness ratios and 4. to investigate the effect of impregnated bednets on primary school attendance in terms of days and reasons for absenteeism. The study covered 64 government and non-governmental organization personnel, 179 village dippers, 306 women in groups of 5 8 in focus group discussions, 25 in-depth interviews of men, 134 carers of children, 50 women in random spot observations and 2182 pupils in school attendance study. The main findings of the study were; 1. The annual implementation cost of NIBP was D757,874.72. 2. The implementation and the net cost-effectiveness ratios per child death averted were D4,946.63 and D1,332.31 respectively and, 3 . Impregnated bednets were observed to reduce absenteeism due to ill-health. NIBP was an efficient malaria control method in rural Gambia and saved resources.

This thesis describes a study that estimated the health care need for prostatectomy in a typical district of 250,000, among men who have both the appropriate indications for treatment and who would choose treatment if offered. It established the appropriate indications for prostatectomy using a literature review and a nominal group type consensus panel consisting of 6 urologists and 3 general practitioners. These were expressed in terms of different combinations of type of retention, type and severity of symptoms, and level of comorbidity. A 2-stage community survey of 2000 men aged 55 and over randomly selected from 8 general practices, using postal questionnaires, was conducted in North West Thames health region. The surveys collected information about: (1) self-reported frequency and severity of lower urinary tract symptoms; (2) the impact of these symptoms on daily activities and on health status; (3) the advice-seeking behaviour of men with symptoms and consequent action of GPs and urologists; and (4) patient preference for treatment. These results were combined to estimate the number of prostatectomies required in a typical district. The overall response rate was 66% (initial survey=78%, follow-up survey=84%). 20% of men reported moderate or severe lower urinary tract symptoms. Of these, 28% found their symptoms to be a medium or big problem and that, depending on the activity, between 9% and 39% experienced interference with their daily activities. Health status, as measured by either the Nottingham Health Profile or the SF-36, worsened as symptom severity increased. Forty five per cent of men with symptoms had seen their general practitioner for their symptoms. Of these, 62% were referred on to a urologist, of which the majority (71 %) were offered, and accepted surgery. When presented with details and information on the risks and benefits of prostatectomy, a substantial proportion (22%) of men with lower urinary tract symptoms, reported that they would probably, or definitely, refuse treatment, while a 47% of men were unsure. The estimate of required number of prostatectomies in a district with a population of 250,000 ranged from 225 to 4329 depending on the level of appropriateness, symptom severity and preference adopted. The decision about which estimate to use in purchasing prostatectomy for lower urinary tract symptoms must be made by local authorities.

This thesis explores the way changing constructions of hepatitis B have mediated between science and policy during the past fifty years. Research-based 'facts' were filtered in the policy arena according to social, political and economic pressures. Central policy processes depended heavily on expert advisers, who emerged from networks of researchers. This account draws on scientific, clinical and epidemiological research, central policy documents, and interviews with people working with or suffering from the disease. Though epidemiologically close to AIDS, hepatitis B has rarely attracted public attention: there are an estimated 100,000 carriers in the UK, but few deaths due to the acute form. The disease was a major problem in the blood supply, and featured as a hospital infection, with notable outbreaks from 1965 in renal dialysis units. It was seen as an occupational hazard for laboratory workers, doctors, nurses and dentists. The introduction of a test for hepatitis B around 1970 opened up opportunities for epidemiological research. Hepatitis B was increasingly recognized as a sexually transmitted disease, widespread among gay men; also, because of needle sharing, prevalent among drug users. Another outcome of research in the 1970s was the development of a vaccine. However, availability of a vaccine in the UK from 1982 afforded no immediate resolution of public health issues raised by hepatitis B. The legacy of a restricted screening policy from the 1970s, emphasizing prevention via hygiene precautions among health care workers, facilitated a limited vaccine policy throughout the 1980s. While discussing negotiations over hepatitis B in the past five decades, this thesis aims to contribute to a broader analysis of interactions between science and policy, between centre and regions, and between interest groups.

Many authors suggest that low anthropometric levels are associated with higher mortality risk in adults, In developing countries however there have been few opportunities to test this hypothesis. In addition, there is increasing interest in the role of women's nutritional status in their own health and survival as distinct from its impact on infant outcomes. This thesis describes the results obtained from a longitudinal historical follow-up of a cohort of 2,314 rural Bangladeshi women over a period of 19 years (1975-1993). The demographic, socio-economic, and anthropometric characteristics of the study cohort are described with reference to the methods of data extraction, preparation and validation. The risk of mortality associated with different levels of the anthropometric indicators (height, weight, arm circumference and body mass index) were analysed using Cox's proportional hazards models. In addition to the basic survival models, the effects of confounding, early mortality, missing data, and young subjects, on the estimates are discussed. A significant association between BMI and mortality (p=0.009) was found in adjusted analyses which used categories that distinguished the women in the highest and lowest 10% of the cohort BMI distribution. Women with BMI levels between 10% and 90% and >90% had hazard ratios of 0.45 (95% confidence intervals 0.27,0.73) and 0.55 (0.25,1.22) respectively, when compared to women with BMI <10%. The strength of the association between BMI and mortality risk was reduced after adjusting the models for early mortality (<4 years), (p=0.068). No significant associations were found between height, arm circumference and mortality risk. In conclusion, these data provide no evidence that these anthropometric indicators would be useful in population-based screening programmes in rural Bangladesh to identify women at higher mortality risk. The findings are considered with respect to the study's methodological constraints and comparisons with other studies in order to produce recommendations for those working in research and health programmes in women's nutrition.

In Bangladesh, mothers rarely breastfeed exclusively. The national programme promoting exclusive breastfeeding has focused mainly on hospitals, but the majority of mothers deliver at home, and it is important to reach them there. This research aimed to assess the impact of community-based peer counsellors on the prevalence of exclusive breastfeeding. Other objectives were to assess the impact on infant morbidity and growth, and the acceptability of the lactational amenorrhoea method (LAM) for contraception. In Dhaka, 40 localities were randomised as intervention and control clusters. One woman in each intervention cluster was trained as a peer counsellor. The intervention comprised a minimum of fifteen counselling visits (two in the third trimester of pregnancy, two within 5 days of delivery, one between 10-14 days and then fortnightly), to help mothers establish and continue exclusive breastfeeding for 5 months. A total of 726 mothers, with mean of 4.5 years of school, from the lower-middle socioeconomic class, were enrolled during 1996, of whom 573 completed 5 months of follow-up. In the intervention group, 69% of mothers fed their infants colostrum as the first food compared to 11% of the controls (p<0.0001), and 70% breastfed exclusively for 5 months versus 6% of the controls (p<0.0001). Despite small differences in morbidity from diarrhoea, cough and fever, there was a substantial impact on weight gain. At the end of 5 months, the mean weight-for-length Z score was +0.1 (SD 0.8) in the intervention group and -0.9 (SD 0.8) in the control group (p<0.0001). The majority of mothers who breastfed exclusively, also accepted and practised the LAM (59% at 5 months). This trial has demonstrated that trained community-based peer counsellors can significantly increase exclusive breastfeeding and appropriate contraceptive practices, with benefits to infant health. Inclusion of peer counsellors in mother and child health programmes is recommended.

The thesis describes the development, research and evaluation of the applicability of a new model of care that involves GPs being employed on a sessional basis in A&E departments to treat patients attending with primary care needs. The main aim of the study was to research its cost and clinical effectiveness. A multi-faceted approach was taken to include consideration of patients' needs and preferences, professional concerns, organisational and structural issues within the health service, and planning and policy issues. Clinical, sociological, epidemiological, and economic perspectives are drawn upon, reflecting the context of the service development and to provide a firm base for discussion about the generalisability and applicability of the findings. The first two chapters provide a detailed review of the epidemiological, sociological, clinical, and organisational literature relating to the primary care/A&E interface. The incentives and disincentives that may act to increase or reduce demand and supply are explored, in addition to issues relating to the 'appropriateness' of demand, the organisational culture of A&E departments, and strategies used to curtail or cope with demand. The demand for primary care at A&E departments appears to cross national boundaries and hence, literature from other countries (particularly the USA) is included and its applicability to the UK considered. Relevant literature relating to the quality of A&E care, patient satisfaction, and the costing of care is also discussed. The main study was a prospective controlled trial that was conducted at King's College Hospital. This compared process variables, clinical outcome and costs of 'primary care' consultations performed by senior house officers (SHOs), registrars, and general practitioners working three-hour sessions in A&E. A new system of nurse triage was implemented to allow the prospective identification of patients presenting with primary care needs. A total of 27 SHOs, three registrars and one senior registrar were included, and the patient sample comprised 1702 patients seen by GPs, 2382 by SHOs, and 557 by registrars or the senior registrar. GPs were found to practice considerably less interventionist care than A&E medical staff, and the resource implications were substantial. The findings are discussed critically, and their applicability is considered drawing on empirical data from recent evaluations of A&E Primary Care Service developments in other parts of London. The policy and service implications of the study are considered and further research needs identified.