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Background In England there is a comprehensive framework of tobacco control policies to reduce smoking-related harm. Policy evaluation helps to ascertain how policies may be improved so that they have the greatest impact; ineffective policies can be dropped or improved, while effective policies can be kept and improved further in order to optimise their impact. The evaluation of tobacco control policy requires high quality and timely data on smoking and smoking cessation behaviour. Time series analysis (TSA) is a robust way of evaluating policy, as it takes existing trends into account, but requires frequently collected data in large samples over long time periods. The aims of this thesis were to investigate the suitability of a range of existing data sources for evaluating the impact of tobacco control policies in England on quitting behaviour, validate potentially suitable measures, and use validated measures to evaluate the impact of recent tobacco control initiatives in England using TSA. Methods A range of data sources which provide information on smoking cessation behaviour were analysed to determine their adequacy for evaluating tobacco control policies, and previously unvalidated measures were validated. Different approaches to TSA – interrupted time series analysis and multiple time series analysis - were employed to evaluate the impact of the introduction of a new smoking cessation medication, varenicline, the broadening of the indications for nicotine replacement therapy (NRT) to include people with cardiovascular disease and adolescents, and the effect of anti-tobacco mass media campaigns on quitting behaviour. Results Two key indicators of quitting behaviour are quit attempts and smoking prevalence; however, there are currently no frequently collected data from large enough samples covering a long time period on these measures. Survey data are generally not suitable for policy evaluation because they are infrequently carried out and often have small sample sizes, making it difficult to detect small and transient changes in behaviour. In contrast, routine sources of data such as electronic medical records data are often frequently collected in large samples over long time periods. A validation study showed that primary care data from The Health Improvement Network are an accurate source of data on prescribing of smoking cessation medication. Time series analyses of these data showed that both the introduction of varenicline, and the broadening of the indications for NRT, did not increase rates of prescribing for smoking cessation medication. Another study found that tobacco control mass media campaigns appear to be more effective at triggering quitting behaviour than pharmaceutical company NRT campaigns. Conclusions Although there are significant gaps in the existing data available, there are some high quality time series data which can be used to evaluate the impact of tobacco control policies in England. There is a need for regular collection of data on key indicators of quitting behaviour, and the use of time series analysis in policy evaluation can play a vital role in strengthening the evidence for the effectiveness of policies, both in tobacco control, and in other areas of public health. The time series studies in this thesis suggest that recent changes to the availability of pharmacological smoking cessation aids have not had a significant impact on public health, and that recent cuts in tobacco control advertising are likely to have reduced quitting behaviour. .

Tobacco smoking is the leading avoidable cause of death and disability in the world. The UK is unique in that it offers a dedicated smoking cessation service providing behavioural support to all smokers, freely available through the National Health Service and with pharmacotherapy available at prescription cost. The service has been proven effective and cost-effective, yet only a small minority of smokers are currently using these services. The research in this thesis examines smokers’ use of support and how more smokers might be identified and encouraged to use it. The first study investigated whether proactive identification of smokers in a primary care setting and referral into such services is a potential means by which awareness and use of services may be increased. As such a study is reliant on the identification of smokers from primary care records and the accuracy of this data, a precursor to this study investigated the completeness and accuracy of smoking status recording in primary care medical records. General practices in this study had a smoking status recorded for between 42.4 and 100% of patients, and comparison of medical records with responses to self-completion questionnaires revealed that this recording is likely to be inaccurate in approximately 20% of cases. Even so, approximately 40% of smokers who responded to the questionnaire were interested in speaking to a smoking cessation advisor when asked, indicating that there is potential to intervene with smokers identified in this way in primary care and that there is a need which is currently not being met. In the trial, all smokers in 12 intervention practices were proactively identified and offered referral into evidence based support, and compared to 12 ‘usual care’ control practices, a significantly greater proportion of these smokers reported using local smoking cessation services (16.6% and 8.9% respectively). Validated 7-day point prevalence from smoking at 6 months was higher in the intervention than the control groups, although this difference was not statistically significant (3.5% and 2.5% respectively). Post-hoc analysis in the sub-group of smokers who had initially reported that they wanted to speak to a smoking cessation advisor did, however, reveal a significant difference between intervention and control groups (4.0% and 2.2% respectively). A proactive approach to enrolling smokers in smoking cessation services is, therefore, effective if you can identify smokers who want support for their quit attempt. Use of an NHS support service traditionally involves some degree of pre-planning. Anecdotal evidence from the proactive trial indicated that many smokers did not pre-plan their quit attempts and as recent evidence from elsewhere has indicated that a large proportion of smokers make an attempt to quit smoking without any pre-planning, this may in part explain the relatively low proportion of smokers accessin0g services. The next study therefore was a questionnaire survey designed to investigate the occurrence, determinants and use of support in planned and unplanned quit attempts. The study findings revealed that over one third of quit attempts were made without pre-planning, and over half of these unplanned attempts were made without the use of any support and unplanned quit attempts appeared to be more likely to be successful, in line with previous findings. However, the use of evidence-based support is known to increase the likelihood of a quit attempt being successful and thus for each successful unplanned and unsupported quitter there are likely to be many more who are unsuccessful. There has been no detailed exploration of how unplanned quitters engage in quit attempts, why they may or may not choose to use support and their attitudes to the support currently available. Gaining a greater insight into these factors may result in the identification of better ways to support those who make unplanned quit attempts. The final study therefore involved qualitative research with a group of unplanned quit attempters and revealed that smokers’ reports of ‘unplanned’ quit attempts may indeed involve elements of planning and delay, and often this delay is in order to gain access to cessation support. The majority of smokers and ex-smokers interviewed were receptive to the idea of support being immediately available whether or not their last quit attempt had involved support. Engaging smokers in using support at an appropriate time, without the need to delay their quit attempt in order to achieve this, may be a potential means of increasing smokers’ uptake of effective cessation support and subsequently improving quit rates. It is therefore important to investigate ways in which smoking cessation support can be made available to potential quitters within a much shorter timescale.

Background: Integrated Care Pathways (ICPs) are prearranged processes of care which are being increasingly used to deliver mental health services. The literature reveals difficulties in their development and implementation, and a lack of empirical evidence to support their use. Aims: The aim of this research was to investigate how an ICP has been used to manage mental health care in one selected mental health Trust in England. Methods: A case study approach was adopted with several units of analysis. The views of healthcare professionals using semi structured interviews; the experiences of service users and carers using focus groups; contrasting hospital episode and performance statistics with a comparison Trust and documentary analysis of the ICP. Findings & Discussion: Of the healthcare professions, only nurses used the ICP. No professionals used the ICP to support clinical decision making and risk management. However, just over two-thirds (67.2%) of the interventions described in the pathway were delivered. There was no statistically significant difference when comparing performance indicators for an equivalent episode of care between the ICP Trust and non ICP Trust. Service user and carers' experiences revealed that peopled did not feel that their care was individualised to them, although amongst them they had different perceptions of the care process. Conclusions: Mental health ICPs need to reflect the relationships between stakeholders, variability of illness and individual ways of living if they are to provide a framework for managing care in the future that accords with the needs of people using mental health services.

The central issue addressed in this thesis was the validation of a novel risk assessment system designed to meet the security requirements of a high secure forensic hospital. To this end, three research strands investigating the clinical, predictive and preventative utility of the system were pursued. This thesis reports the process of the development, adaptation and implementation of a system based on the HCR-20, called the Structured Clinical Judgement: Risk (SCJ: Risk). The first research strand involved investigation of the processes necessary implement a system of structured professional judgement. The conceptual and operational utility of the system were investigated, and successful implementation of the system within clinical practice was demonstrated by compliance of use by clinical teams. A survey was conducted, investigating the perceptions of clinicians in relation to the clinical utility and usability of the SCJ: Risk. Overall acceptance of the pilot and implementation phase of the system was demonstrated, and the system was perceived to assist clinical teams to structure and document risk-related decisions. The second research strand studied the validity of the SCJ: Risk in predicting intra-institutional behaviour. A prospective investigation of the application of the SCJ: Risk to a forensic population detained in conditions of high security was conducted and this demonstrated variation in the predictive utility of the system. The predictive accuracy of subscale items of the SCJ: Risk, and the individual risk factors comprising the subscales of the system were robust for behaviours relevant to violence and suicide/self-harm. However, prediction of behaviours relevant to escape/abscond, vulnerability to risk from others and subversion of security were not demonstrated. The third research strand involved exploration of the preventative utility of the system, specifically if the identification of a patient as high-risk would minimise the occurrence, or prolong the time to an incident of intra-institutional behaviour. Results illustrated the efficacy of the SCJ: Risk system in the identification of high risk individuals for behaviours relevant to any intra-institutional infraction, violence and self-harm. Patients identified as high-risk displayed a higher prevalence and earlier incidence of relevant intra-institutional behaviour. It is concluded that the system of Structured Clinical Judgement: Risk (as an adaptation of the HCR-20) contributes positively to the overall goals of clarity of risk communication, identification and management of high risk patients within forensic psychiatric practice. However, the extended risk assessment of the SCJ: Risk does not make a significant additional contribution to the parental system on which it is based.

Background: The common argument used against the implementation of tobacco control policies is that revenue from tobacco duty is considerably higher than the health care costs smoking imposes on society. This point is true as revenue in the United Kingdom (UK) totalled £9.1 billion while recent costs estimates for the treatment of smoking-attributable disease totalled £5.2 billion to the UK National Health Service. However, this argument becomes unclear when indirect costs such as productivity loss or cost of absenteeism are incorporated. In the UK, there were 29.2 million employed adults in 2011 of which 20% were current smokers. This equates to approximately 5.84 million employed adult smokers. There are currently no studies which have quantified the economic impact of smoking-attributable indirect costs to both employers and the wider society in the UK. These costs are suspected to impose a large economic burden to society but the best practice methodology for estimating indirect costs and the magnitude of these costs are still unknown. Therefore, the aims of this thesis were to quantify the economic impact of smoking-attributable indirect costs due to productivity loss from premature mortality and absenteeism of workforce and to evaluate workplace interventions which could potentially decrease the burden of smoking in the workforce in the UK. Methods: A number of methods were used along with a range of data sources which provided the information to quantify the economic impact of smoking in the workforce. Cost-of-illness methodology based on the human capital method was utilised to quantify the monetary burden of smoking in the workforce due to premature mortality in the UK. Systematic review and meta-analysis was used to examine the epidemiological association between smoking and absenteeism while also providing the necessary parameters to estimate costs of absence in the UK. Finally, decision analysis and Markov simulation modelling was used to conduct both cost-benefit analysis and cost-effectiveness analysis from the employer's perspective for evaluating workplace smoking cessation interventions of brief advice, individual counselling and nicotine replacement therapy with individual counselling. Results: Cost-of-smoking modelling estimated that smoking was responsible for 96,105 deaths (58% male) in adults aged 35 years and over (17% of all deaths) in the UK annually, resulting in 1.2 million years of total life lost and 357,831 years of productive life lost valued at £4.93 billion in 2010. From the systematic review of 29 longitudinal studies, current smokers had a 33% increase in risk of absenteeism and were absent for an average of 2.74 more days per year compared with non-smokers. Compared with never smokers, ex-smokers had a 14% increase in risk of absenteeism; however, no increase in duration of absence could be detected. Indirect comparison meta-analysis showed that current smokers also had a 19% increase in risk of absenteeism compared with ex-smokers. Consequently, smoking was estimated to cost UK employers £1.46 billion in 2011 from absenteeism in the workplace. Workplace interventions for smoking cessation provide a possible method for reducing the burden of smoking in the workforce. Cost-benefit analysis of workplace interventions resulted in brief advice being the optimal decision strategy for women while brief advice and individual counselling both were optimal decision strategies for men in terms of minimising total costs and maximising return on investment for the employer. If the employer valued maximising quitting instead, cost-effectiveness analysis showed that nicotine replacement therapy with individual counselling would be the optimal strategy given a maximised budget constraint. Conclusion: This thesis has provided the first indirect cost-of-smoking study quantifying the productivity loss due to premature mortality and absenteeism in UK; the first systematic review and meta-analysis which has explored the association between smoking and absence from work; and the first cost-benefit and cost-effectiveness analyses of workplace interventions for smoking cessation in the UK. The implications of this research have particular relevance for UK policy makers and employers to justify stronger tobacco control policy which promotes smoking cessation. However, these findings are not unique to the UK. The thesis has provided the framework and methodology for studies that can strengthen the evidence-base around the economics of smoking in other countries as well.

The current study sought to explore how, if at all, people construct an understanding of the origin and maintenance of their experience of hearing voices. An exploratory qualitative method, social constructionist grounded theory, was adopted throughout the research process. Theoretical sampling was utilised and eight participants who hear voices, or previously heard voices, and were distressed by this experience, were recruited through adult mental health teams. Each participant engaged in one digitally recorded interview. A cyclical process of data collection and analysis was undertaken, utilising Charmaz’s (2006) guidelines throughout. Three overarching descriptive categories were constructed regarding participants understanding of the development and maintenance of hearing voices which included; ‘Search for meaning’, ‘View of self’ and ‘Explanations for voices. A sentence summary of the ‘essence’ of the developing grounded theory constructed is stated below: Participants attempted to construct an understanding of their voices through drawing on three main frameworks (inter, intra and para-personal), but the relative ‘success’ of this pursuit, and potential usefulness of an understanding, is effected by the sense of agency, stigma and hope(lessness) perceived by the individual. This study highlighted participants’ attempts to search for meaning of their voices, but the utility of this was often linked to the hopelessness they experienced, and relatively few participants held an explicit theory of the development and maintenance of their voices. This research offers a unique and distinct contribution to the current literature through illustrating how voice hearers actively searched for meaning in relation to their voice-hearing experience. This highlights the importance of helping people engage in meaning-making processes to help individuals understand the experience of hearing voices. Furthermore, the implications of imposing one theoretical framework, which may be incongruent to the voice-hearers own understanding, to the experience of hearing voices are discussed. The study identified a number of clinical implications, such as the role of psychological formulation in generating a shared understanding of the voices. A number of methodological difficulties were encountered during the research process and are discussed. Future research is warranted to explore voice-hearers from a wider range of cultural, religious and spiritual backgrounds and to explore whether the experience of developing a shared framework to understand their voice hearing is valued.

In the field of personality psychology there is some consensus among researchers that human personality, at the broadest level, can be described in terms of five fundamental personality dimensions. Universally, these personality dimensions are referred to as the “Big Five” model or the Five Factor Model (FFM) of personality: Extraversion, Conscientiousness, Agreeableness, Emotional Stability versus Neuroticism, and Intellect or Openness to Experience. However, currently, there is little conceptual or empirical consensus about a meaningful taxonomy of lower-order facets that make up each of the Big Five personality factors. This thesis sought to identify a parsimonious and replicable taxonomy of lower-order facets of the Big Five personality factors, and test the lower-order facet structure for construct and criterion-related validity. Based on the US Eugene-Springfield community sample (ESCS) (N =375), Study 1 examined facet scale scores from nine widely used personality inventories using Exploratory Factor Analysis in order to identify a shared overall lower-order structure for each of the Big Five personality domains. Factor analyses of 162 facet scales revealed 29 facets for the Big Five which demonstrated good convergent validity. However, some facets (e.g. traditionalism, peacefulness, trust) showed less clear patterns of discriminant validity, and thus appear to be compound traits or blends of two or more Big Five factors. In Study 2, a new 232-item Big Five instrument, the Hierarchical Personality Assessment Questionnaire (HPAQ), was developed to measure the 29 lower-order facets derived in Study 1. In the development phase of HPAQ, the factor scores for the 29 facets from Study 1 were correlated with the International Item Pool (Goldberg, 1999) in order to generate an initial pool of items. An initial pool of 348 IPIP items to mark the 29 facets was then administered to a large sample of undergraduate and postgraduate students at a University in the English-speaking Caribbean (N = 778) with the intention of choosing 8 items that best marked each of the facets. Additionally, the HPAQ was validated in a second sample of undergraduate and postgraduate students (N = 807) against the NEO-PIR and its psychometric properties were further examined. The development and validation of the HPAQ was a first step in moving towards Study 3. Study 3 investigated the differential criterion-related validity of the 29 HPAQ lower-order facets in the prediction of job performance criteria (task performance, counterproductive work behaviour, and organisational citizenship behaviours). In addition, the incremental validities of the 29 lower-order facets in the prediction of job performance criteria were also examined. Overall, Study 3 found that the 29 lower-order facets demonstrated differential criterion-related validity and provided incremental validity beyond the global Big Five factors in predicting the job performance criteria and vice versa. Overall, this thesis empirically derives an initial taxonomy of lower-order facets of the Big Five personality factors based on nine personality inventories and developed a new Big Five personality instrument to measure explicitly this lower-order facet structure. The theoretical and practical implications of these results, limitations, and suggestions for future research are discussed.

In order to examine how personality disorder and related concepts have been deployed in UK psychiatric literature over the last 50 years, a number of methodological and theoretical approaches are initially examined. It is concluded that a Foucauldian discourse analytic approach, supported and informed by findings from Corpus Linguistic techniques would provide a means of uncovering discourses surrounding the use of personality disorder in such literature. A new combined methodology is proposed that uses evidence from a Corpus Linguistic analysis to support Willig's six step methodology for Foucauldian Discourse Analysis (Willig 2001b). Three diachronic corpora of UK psychiatric articles are created, covering the 1950s, 1970s and 2000s. These are interrogated using word frequencies, concordance and collocational approaches in order to uncover patterns which reflect discourse changes over these periods. Evidence for a move from Narrative Discourses towards a dominant Statistical and Scientific Discourse is presented and discussed along with the implications and subject positions associated with these.

Introduction: The notion of mental health has been used to designate a range of concepts and a great deal of controversy surrounds discussions about the meaning of the construct. Despite its elusive nature, there is a growing body of research indicating that the ways in which healthcare professionals conceptualise mental health may have important clinical implications. It is argued that the quantitative methodologies employed by previous studies have not been able to capture the complexity of healthcare professionals’ accounts. Objective: This study aimed to explore clinical psychologists’ accounts of mental health and its effects by using a qualitative methodology sensitive to the performative, variable and contextual aspects of discourse. Design: A discursive psychological approach was taken in the analysis of data from semi-structured interviews. Method: Data was collected from eleven interviews conducted with clinical psychologists in the East Midlands region of the UK. Results: The findings demonstrated a wide range of constructions of mental health available to clinical psychologists, implying that their accounts are considerably more complex and flexible than previous quantitative studies have outlined. The study demonstrated how clinical psychologists use various discursive strategies to construct their accounts as credible and to manage issues of accountability. Clinical psychologists who constructed mental health in realist terms tended to draw on a biopsychosocial framework and employ discursive strategies such as case examples and stake inoculation to present their accounts as factual. Those who viewed mental health as a social construction focussed on the language associated with mental health and the implications of using this. This functioned to warrant a political analysis and to create a rationale for introducing alternative views of mental health. Participants drew on a discourse of moral concern for clients in considering the effects of their ideas about mental health on their clinical work thus allowing clinical psychologists’ talk to be viewed from a moral framework where accountability could be managed within interactions. Discussion: The study offers a novel approach to the exploration of mental health, highlighting the various difficulties that clinical psychologists face in negotiating this concept and its effects. The constructs and discursive strategies drawn on by clinical psychologists in this research were consistent with past discursively informed studies, showing a cross-topic relevance by demonstrating how clinicians rely on particular rhetorical devices to ‘get things done’ in verbal interactions. The results of this study suggests that there is a need for clinicians to be honest about the contingent and situated nature of their language and knowledge and to be mindful of the effects of their use of language on different stakeholders in talking about mental health. Clearly, if clinicians are not open about such issues there is a risk of service-users passively complying with a process that they do not understand or feel they benefit from, thereby ethically compromising clinical psychologists’ practice.