Thesis (M.S.P.H.)--University of Michigan, 1934.

Thesis (M.S.P.H.)--University of Michigan, 1934.

Thesis (Ph. D.)--University of Texas at Austin, 2008. / Vita. Includes bibliographical references.

ABSTRACT:The purpose of this literature study is to study the dental caries status (DMFT) of 12-years-olds in Scandinavia and describe and compare the different preventive strategies and methods used by different dental care personal in each country and between these three countries. To achieve the objective information from scientific literature and publications, and data from WHO database on these three countries were used.DMFT for 12-year olds in Norway was 1.7 (2004), 0.7 for Denmark (2008) and in Sweden 0.9 (2008). During the past decade, changes have occurred in the prevention system of population- based prevention to individual-based prevention. This is a result partly of the low caries prevalence and partly because of a disproportional distribution of caries in this target group. It is regarded as a smart solution to be able to access the most affected or at risk patients who have the most dental care needs.The results showed different dental personals used different preventive strategies. Choices related to the use of fluoride vehicles were also varied. There were also differences in prevention strategies between different countries. This shows that despite the similarities in the dental teams, free and subsidized dental care for children there are also differences in quality of the offering of policies and practices. All this data confirm the differences between all three countries in choice of preventive method for risk and none-risk patients. This seems to be influenced by different cultural patterns within the dental professional communities of each country. Differences in caries incidence probably could be due to different combinations of preventive methods. There is a need for more research in this area. There is a need for a consensus about which strategy and approach is most effective and which one should be used against dental caries in risk and non risk patients, a consensus in which all countries agree to implement.

The role that dental team members can play in the smoking cessation field is largely unevaluated. The work of this PhD thesis encompasses two phases, the first was to develop a means of determining smoking status, using analysis of continine, a nicotine metabolite. The second phase looked at the efficacy of dental hygienist-delivered smoking cessation advice in a dental setting. The aim of the first study was to compare continue levels in different biological fluids collected from both smokers and non-smokers, and to relate the findings to self-reported smoking status. Patients recruited to the study were asked to provide samples of urine, blood and saliva (both stimulated and unstimulated). Data collected from patients by questionnaire included information on smoking behaviour, such as daily number of cigarettes smoked, and environmental exposure to smoke. Following sample collection, patients were asked to rate the acceptability of each sampling method. Samples were analysed using enzyme immunoassay (EIA) kits. In total, 80 patients participated, with 49 smokers and 31 non-smokers. There was clear differentiation between smokers and non-smokers (p<0.001) for all the different samples in terms of cotinine concentration. A significant relationship was seen between cotinine levels and daily number of cigarettes for both salivas and urine (all p < 0.001) but not for serum. Participants found serum and urine collection methodologies 'very acceptable' (67% and 66%, respectively) whereas 9% found collection of stimulated saliva 'not at all acceptable'. Thus, continine, as analysed by EIA kits, whatever the collection method, shows good differentiation between smokers and non-smokers. Salivary samples have the advantage of being non-invasive. However, collection methodology is important, as continine levels may vary.

Previous research has suggested the existence of socio-economic and gender variation in uptake of hospital cardiology services but it is not known at which stage of the care pathway these variations arise. This thesis aims to address this gap in the literature by exploring the perceptions of an behaviour in response to chest pain of men and women living in two socio-economically contrasting areas of Glasgow. It has 3 objectives: to describe respondents' perceptions of and actions in response to chest pain; to ascertain whether there are differences in perceptions and behaviour associated with socio-economic status or gender; and, to relate any observed differences to the known variations in uptake of cardiology services. Respondents' interpretations of chest pain were related to their perceived vulnerability to heart disease and their previous illness experience. Their decisions of whether to present to a general practitioner were influenced by the quality of previous encounters with doctors and by their lay care and self-care. Women generally felt less vulnerable to heart disease than men, and often believed that their health problems were secondary to those of family members. These factors led women to report a reluctance to present with chest pain. Compared with more affluent people, those from the deprived area generally felt more vulnerable to heart disease but the perception that they were to blame for their ill-health often led to reluctance to present with chest pain. Differences in perceptions and behaviour might partly explain gender inequities in access to hospital cardiology services but socio-economic inequities in uptake of services have proved more difficult to explain.

Objectives: Increasing knowledge of genetics has found that a mutation to the BRCA 1 or 2 genes are associated with a high risk of developing breast cancer throughout the lifespan. A woman with this genetic mutation may consider preventive surgery to reduce the risk of breast cancer. This involves a prophylactic bilateral mastectomy to remove the breasts when there is no cancer present and may be followed by breast reconstruction. This study aimed to explore the lived experience and psycho-social impact on women of this surgery. Design: Interpretative phenomenological analysis was employed in an in-depth study of a small sample of eleven female patients with BRCA 1/2 genetic mutations who had undergone preventive surgery of prophylactic bilateral mastectomy. Methods: Semi-structured interviews were carried out. The transcripts of those interviews served as the data for an interpretative phenomenological analysis. Results and conclusions: Three themes were identified from the Interpretative Phenomenological Analysis to convey the lived experience of participants. These were (1) focus on reduced risk of cancer; taking control, relief and benefit finding, (2) a focus on relationships; family life, medical professional and BRCA support group and other women with lived experience, and (3) Focus on experiencing surgery and impact on self; the importance of reconstruction, loss of sexual attractiveness, impact on self from negative reaction of others and adjusting to surgical results. The implications are discussed in relation to the current literature and clinical practice.

Background: The incidence and prevalence of diabetes mellitus (diabetes) is increasing globally. The majority of people have type 2 diabetes, initially managed by lifestyle changes and the gradual introduction of oral, followed by subcutaneous, medications. Due to the increasing numbers of people with type 2 diabetes, different models of care management have been utilised within the United Kingdom. One Health Board within Scotland received funding to undertake a service redesign whereby the responsibility of care for people with type 2 diabetes was transferred from secondary care to primary care, with referral to specialist services based on clinical need. Aim: The aim of this thesis is to present the body of published work on an evaluation research study on the change in service delivery for people with type 2 diabetes. The published works have arisen from two funded research studies resulting in one peer reviewed report and five peer-reviewed papers published in international journals.

Background: Obesity has emerged as a major public health problem across the globe. Unfortunately, all the efforts, to date, to treat obesity have limited success. Despite the increased publicity on health and economic consequences, its prevalence continues to rise, even in countries that were previously battling under-nutrition. The annual weight gain which may lead to obesity if it remains uncontrolled, is small, averaging 0.7-1.0kg/year. Aiming to halt this small weight gain could be a solution towards combating the obesity epidemic and thus reduce its prevalence. One of the critical life stages where weight gain occurs is the transition between adolescence and young adulthood and especially evident in those attending higher education in the US. There is very limited data from the UK on the magnitude of weight gain in this population. This thesis aimed to explore the weight changes occurring during that life-stage, identify factors affecting those weight changes, explore weight gain prevention data and design and test interventions aiming to prevent any weight gain. Methods: Several studies were carried out during this PhD programme in order to answer all the research questions. Three systematic reviews were employed to examine 1) weight changes in young adulthood, 2) weight gain prevention studies in young adulthood and 3) the effect of calorie-labelling on calories purchased as an anti-obesity measure. A pilot study was carried out to test and explore methodologies for collecting data from young adults on lifestyle and lifestyle changes. A qualitative study was carried out to supplement the data from the pilot study on the importance of any weight changes for young adults. A prospective cross-sectional study was carried out to examine the weight changes and lifestyle changes occurring during the first year of studies in young adults. An interrupted time-series study was carried out to test the hypothesis that calorie-labelling might have an effect on preventing weight gain in young adults. A cross-sectional study was carried out to test the effect of calorie-labelling on sales and choices in independent catering facilities where young adults represent a significant proportion of the customers. Lastly, a randomised trial was carried out to test the hypothesis than on-line programmes based on two different behavioural theories could help young adults to avoid any unwanted weight gain. Results: The systematic literature review of weight changes in young adults identified 27 studies reporting a mean weight increase of 0.7-3.75kg in those attending higher education. The pilot study examining methodologies and weight changes in young adults attending higher education in the UK found a weight increase between 0.5-5.5kg by 56% of the participants and the best recruitment method to be the on-line method compared to mail or in-person recruitment. The prospective study that looked at weight changes among first-year students attending a large university in the UK found a weight change of 1.8kg in a 9-month period. Baseline weight explained 48% of the variation observed in weight changes. Despite the belief that physical activity or consumption of fruit and vegetables is linked to weight management, neither of these protected against weight gain. The literature review on weight gain prevention studies among young adults, identified twelve studies (five of those conducted in higher education settings). Six of the studies found an effect on preventing weight gain or maintaining weight. No specific techniques were identified to be more effective as the studies that found an effect followed similar techniques with those that did not. The systematic review and meta-analysis on the effect of calorie-labelling on calories chosen/purchased identified seven studies. Overall, there was no effect of calorie-labelling on calories chosen/purchased, however customers noticing the calorie-labels, reduced the calories chosen/purchased by 124.5kcal. Students are generally supportive of the presence of calorie information in a range of products and settings including alcohol products. In the time-interrupted study which was conducted over two years, young adults that were exposed to calorie information did not gain the expected weight observed in young adults in the same setting in the year prior to the implementation of calorie-labelling. The cross-sectional study conducted in an independent catering outlet examined the effect of calorie-labelling on sales of products. Prominent calorie-labelling led to substantial reduction in sales of all labelled products but mostly among those that were high calorie products. The randomised controlled trial led to weight loss among those who were randomised to the intervention groups while those in the control group gained the anticipated weight over a 9-month period. Conclusion: Young adults in the UK gain weight when starting higher education. The weight-gain is similar to that observed in young adults in higher education in other countries but higher than the weight gain observed in the general population. Interventions based on different behavioural models were all successful at abolishing this weight–gain. Applying these interventions in a larger scale or making them part of future public health policies could be a significant step towards halting the obesity epidemic.

This thesis examines the changes in health governance at both global and country levels brought by the Global Fund to Fight AIDS, Tuberculosis and Malaria (the Global Fund), a self-described public/private partnership intended as a financing mechanism to achieve Millennium Development Goal (MDG) 6. Since the G8 announced the Global Fund's creation in 2001, it has succeeded in mobilising over US$30 bn in commitments, primarily from donor governments. This thesis is rooted in the 'high politics' of International Relations (IR), and in particular its literature on globalisation, governance and international institutions. Where this literature has failures or gaps, it draws from the Development Studies and International Political Economy (IPE) literatures. It also relies on key informant interviews undertaken in Geneva, Lilongwe and Zomba with executives of international institutions, and those involved in Malawi's HIV/AIDS response including government representatives and staff from the National AIDS Commission, donors, NGOs and those working on the front line. This thesis relies on a descriptive, single case study to create a 'thick' narrative. Rather than deriving generalisations, it provides a basis for further research into the nature and effects of systemic change in how health is governed that the Global Fund signals. This thesis makes three contributions to knowledge: 1) It provides a basis to evolve the IR literature on globalisation, governance and international institutions to consider the nature, significance and effects of the Global Fund as a form of institutional innovation which is disrupting the traditional multilateral order, particularly for international institutions working in health; 2) It challenges the use of the term 'country ownership' to mean 'putting the country in the driver's seat', and instead notes the double deficit in external accountability that arises when global politics and country evidence collide in a Global Fund convened elite, mediated space for country ownership; and 3) It synthesises observations from field work in Malawi on the exercise of the Global Fund's authority and its dislocation from external accountability when failures occur. The IR literature is silent on the rise of the Global Fund's authority. It fails to contend with the notion that country ownership is as much about the burden of responsibility as it is about agenda setting. This highlights the dislocation between the loci for authority and accountability despite the Global Fund's growing authoritative territorial claims.