The aim of this research was to evaluate a relatively young technology, Geographical Information Systems (GIS), in a specific applications environment. The application adopted was that of searching for environmental causes of childhood cancer, in particular that of Acute Lymphoblastic Leukaemia (ALL), in Northern England. It is also relevant in terms of the WHO's intention to develop a Health and Environment GIS, and therefore the research aims to satisfy their recommendations for pilot studies. The subject matter of this thesis therefore covers two very high profile topics, which it is believed will mutually benefit from the research carried out. Firstly, very little is known about the aetiology of ALL, and thus any new methodology which is introduced to help analyse sensitive issues of causation is welcomed not only by those in the medical field but also the public. The application was made possible with the provision of detailed cancer data for Northern England and a weak but interesting hypothesis that environmental factors may be an attributable mechanism for causation. Key questions which are asked include; Where are incidences of ALL located? Why are they there? Is there a cluster? and What could be the cause? Secondly a Geographical Information System, in this case the proprietary software package ARC/INFO, was considered an excellent medium for tackling this spatial epidemiological problem. Especially with its capability to store large volumes of diverse data, and its inherent flexibility to deal with spatial information pertaining to health and environmental factors. More importantly the application itself offered a means of evaluating the implementation of a GIS. Establishing the advantages and pitfalls which accompany all stages of 'The GIS Process' and an invaluable documentation of the experiences acquired as an initiator, developer and implementor of this new technology. In addition, this research offers fresh ideas and techniques for improving those areas of the technology which appear to be lacking in these early phases of its development. The problems of spatial analysis in GIS and the provision of useful tools such as 'pattern spotters', 'relationship seekers' and 'error handlers' are discussed as alternative techniques. To ensure an exciting future for GIS technology in application environments the latter and other key areas of research which should be persued are highlighted in this thesis.

The North of England Study of Standards and Performance in General Practice was set up to investigate whether the setting of clinical standards was an effective way of improving clinical performance (North of England Study, 1991). Doctors from 60 training practices met in small groups to set standards of good clinical performance for five symptomatic conditions of childhood-acute cough; acute vomiting; itchy rash; bedwetting; and recurrent wheezy chest. Data on the process and outcome of care were collected both before and after standard setting process. Some of the baseline data was fed back to the doctors to enable them to evaluate their performance in the first phase of the study. The clinical standards and baseline data were disseminated to the small groups of doctors according to a Latin square design. By comparing responses obtained during the second phase of data collection (after standards had been set) with those obtained in the first, it was possible to estimate the effects of standard setting and other methods of performance review on what doctors did (the process of care) and on the resulting outcome of care for their patients. The general analytic approach adopted was to fit generalised linear models to try and explain the variation in the observed data. Within this general framework, methods were developed for coping with a wide range of statistical problems including: heteroscedasticity correlated binary responses loss of orthogonality arising because of the incompleteness of many of the data sets; and overdispersion. Abstract The setting of clinical standards was found to have influenced doctors' prescribing of drugs and was found to have had a beneficial influence on outcome of care for children suffering from recurrent wheezy chest. Implications for the design of future studies to evaluate this type of intervention in the health service are discussed.

There are few data from repeated cross-sectional studies to indicate the changes in dietary intake in the UK, yet this information is valuable in assessing the impact of dietary-related health education. One of the least investigated aspects of food habits in Britain, particularly for children, is food consumption outside the home. This project investigated the change in dietary intake of 11 to 12-year old children 1980 to 1990, and the place of purchase of food in 1990. In 1990, three-hundred and seventy-nine 11 to 12-year old children completed two 3-day dietary records. Each child was interviewed by one dietitian to verify and enlarge upon the information recorded. These children attended the same seven middle schools in south Northumberland as 405 children, of the same age, who had recorded their food intake using the same method in 1980. In addition, the children in 1990 were questioned on the place of purchase of the foods recorded. It was found that: • Energy intake by boys (but not girls) had fallen. The per cent of energy derived from fat and total sugars was unchanged at about 40 and 22 per cent, respectively. In 1990, 17 per cent of energy was derived from non-milk extrinsic sugars. • Calcium intake by girls was unchanged but had fallen in boys. Iron, vitamin C and unavailable carbohydrate intakes had increased for both boys and girls and the nutrient density of the diet improved for these nutrients in all sex and social groups. In 1990, 90 per cent of girls and 56 per cent of boys had iron intakes below the Reference Nutrient Intake (RNI) and 66 per cent of girls and 83 per cent of boys had calcium intakes below the RNI. • A social trend, evident in 1980, persisted in 1990 with children from low social class groups consuming the poorest quality of diet. • Food 'purchased' outside the home contributed approximately 31 per cent of the total energy intake, although there was significant variation in the nutrient quality of the food obtained at each place of purchase. It is concluded that whilst there had been improvements in some aspects of the diet, the mean dietary intake of the children in 1990 fell short of current dietary recommendations, and that social inequalities persisted.

Recent cross-sectional studies have confirmed that the prevalence of mental disorder in English prisons is high but they provide little insight into the fate of the mentally disordered in prison. This thesis concentrates on a longitudinal study of mental disorder in 569 unconvicted adult male remand prisoners received into Durham prison between 1 October 1995 and 30 April 1996. Subjects were interviewed at reception by psychiatric researchers and monitored throughout the remand period. The data collected was used to establish the prevalence of mental disorder and substance misuse at reception into prison, effectiveness of prison reception screening, number of mentally disordered subjects identified and referred for psychiatric assessmentn, ature of psychiatric interventions, and final disposal of all subjects. Additional research was undertaken at Durham to evaluate health care provision at this prison, and, in order to comment on the generalisability of the findings, health care facilities at other prisons in England and Wales were investigated. More than a quarter of subjects at Durham prison were suffering from mental disorder. Serious disorders were especially prevalent and one in twenty remands was acutely psychotic. Drug and alcohol misuse was the norm. More than half of our subjects received current substance abuse or dependence diagnoses. Prison reception screening failed to identify nearly 80% of subjects with mental disorder, including 75% of those with acute psychosis. The treatment needs of the majority of mentally disordered subjects were overlooked in prison. Just over one quarter of mentally disordered subjects were referred for a psychiatric assessment. Contact with psychiatric services was frequently hampered by the prison regime and the actions of the courts. This resulted in acutely psychotic prisoners being released without adequate treatment or follow-up. Help for prisoners with drug and alcohol related problems was minimal. Detoxification regimes were insufficiently prescribed leaving the majority of subjects addicted to opiates, benzodiazepines and alcohol at risk of serious withdrawal. Inadequate resources, a lack of suitably trained health care staff, low morale and staff sickness hampered the delivery of effective health care at Durham prison. However, staff attitudes, institutionalised practices and negative responses from prisoners also made a significant contribution. Further inquiry indicates that Durham. prison is not unique in these respects. Problems of a similar nature are endemic in the Prison Health Service. Indeed, when the history of this organisation is traced it is apparent that such difficulties have plagued it throughout its existence.

Despite the large scale utilisation of nursing auxiliaries (NAs) within the health service, there is a paucity of research evaluating their effectiveness. This study aimed to compare the contribution to patient care of NAs with that of qualified nurses (QNs) using a qualitative indicator, nurse-patient verbal interaction. Different grades were also compared in terms of activities performed and perceptions of their work environment. The organisation of nursing work also has major implications for the roles of QNs and NAs. The study therefore also sought to evaluate the effect of three organisational modes, primary, team and functional nursing, on the work and work perceptions of both grades. A questionnaire was developed which discriminated between organisational modes. This was used to select three wards from each mode (nine in total) for participation in the study. Within each ward, four QNs and four NAs were chosen randomly for inclusion. Data were collected by direct observation and semi-structured interviews. Each subject also completed a Work Environment Scale. The most important differences were found across organisational mode, with QNs and NAs within modes engaging in similar patterns of work, verbal interactions with patients and regarding their work environment similarly. This suggests a culture exists within each organisational mode which permeates the work of both grades of staff. Primary wards were generally found to differ from team and functional wards, with both QNs and NAs regarding their work more positively and working in more therapeutic ways. The study has important implications for the debate about which grade of staff is most suited to caring for elderly patients. It is argued NAs are capable of providing therapeutic care for elderly patients within a pattern of ward organisation which facilitates sustained nursing staff-patient allocation and appropriate supervision and direction in the form of QNs working with NAs.

No description available.

This thesis investigates whether community care policy and service delivery is rhetoric or reality. The social policy and under-pinning ideologies that surround community care are reviewed. Important benchmarks are presented in the form of a chronology and aetiology of The National Health Service and Community Care Act, 1990. An interview schedule was designed from the perspective of older people and was used with a sample of 40 older people, 20 at Luton in an inner-city setting and 20 in Redbourn (Herts), a rural location. The qualitative research design allowed the respondents to express themselves with minimal interference from the researcher. The purpose of the in-depth interviews was to explore their lives including everyday experiences, the process of retirement, important Governmental influences and views of themselves. Their access to services was also considered. The data gave detailed descriptions of everyday life, including the concerns of economic and political influences. From the data the concept of 'Economic Fragility' was developed, this replaced Social Class as a variable. Similar patterns of experience emerged for some groups of respondents, these included connections with 'pervasive economics', gender and the semiotic of language. Further analysis highlighted conceptual connections at both a micro and macro theoretical level, the former focusing on life cycles and the latter revealing how political social control, in its present form, marginalises and manipulates certain groups of older people into becoming 'problem' populations. The relationship between the micro/macro concepts is of major significance to the programme in the identification of a predictable career path for the 'Economically Fragile'. This culminates in personal experiential journeys through the Social Incarceration Spiral. Further, some theoretical considerations are explored and some alternative policy proposals are made. Finally, this programme argues that Community Care as an ideology, current policy and service, as propounded by the current Government, is seriously flawed.

No description available.

No description available.

No description available.