This study is an exploration of the teaching and learning of nursing in the work environment. The research was designed to answer the following questions: 1. What routines and procedures are used for the induction, support and instruction of trainees in service areas? 2. How do trained nurses and nurse learners perceive teaching and learning? 3. What experiences do trainees consider result in significant learning? 4. What, in the learner's opinion, constitutes a missed learning opportunity? 5. Has the good 'teacher', viewed from the learner's perspective, any identifiable characteristics? 6. How do trained nurses communicate verbally with trainees? The attitudes and perceptions of ward sisters, student and pupil nurses were investigated by interviews. The data concerning the perceived characteristics of good teachers were developed into a questionnaire. The questionnaire was completed by a further 96 trainee nurses andthe results factor analysed. A profile was constructed from the factorsidentified. Finally, trained nurse-trainee verbal communications were observed, categorised and analysed on four wards for a four week period. This was followed by a further study of six identified good teachers. Analysis of the data leads to the conclusion that 'on the job' teaching of nurse learners is a complex global act in which the role model presented to the learner is a powerful influence. Nurses perceived as effective teachers express, generally, an attitude of care and concern for the welfare of others and a commitment to the training of nurse learners in particular. While it could not be said conclusively that 'effective' teachers use a 'participative' mode of communication, this trend was noted in two identified good teachers.

A community-based surveillance system was developed and implemented in rural areas in Cambodia. The system aimed to provide timely and representative information on major health problems and life events that would permit rapid and effective control of outbreaks and communicable diseases in general in rural communities. In the system, lay people were trained as Village Health Volunteers to report suspected outbreaks, important infectious diseases, and vital events occurring in their communities to local health staff who analysed the data and gave feedback to the volunteers during their monthly meetings. An evaluation conducted one year after implementation of the community-based surveillance system began found that the system was able to detect outbreaks early, regularly monitor communicable disease trends, and to continuously provide updated information on pregnancies, births and deaths in the rural areas. The sensitivity and specificity of case reporting by Village Health Volunteers were found to be quite high. In addition, the community-based surveillance system triggered effective responses from both health staff and Village Health Volunteers in outbreak and disease control and prevention. The results suggest that a community-based surveillance system can successfully fill the gaps of the current health facility-based disease surveillance system in the rapid detection of outbreaks, in the effective monitoring of communicable diseases, and in the notification of vital events in rural Cambodia. Empowered local people and health staff can accurately report, analyse and act upon significant health problems in their community within a surveillance system they develop, own and operate. The community-based surveillance system could easily be integrated with the current disease surveillance system. Its replication or adaptation for use in other rural areas in Cambodia and in other developing countries would be likely feasible and beneficial, as well as cost-effective.

The aims of this thesis are to identify and test alternative methods for analysing and predicting health care costs, to construct a framework for guiding analysts in making better cost predictions, and to identify future areas of research in this area. The thesis uses costs collected from a multi-country trial measuring the cost-effectiveness of an evidence-based programme of antenatal care. Detailed costing studies of maternity services (antenatal care, childbirth and postpartum care) were done in two trial countries (Cuba and Thailand), and also a nontrial country, South Africa. Costs are broken down and reviewed by cost components: prices, resource use, and health service use. The review initially considers the application of economic theory to public health care institutions, to identify factors likely to cause cost variation between setting. Then the review seeks empirical evidence proving or disproving the existence of these factors from the health care literature, as well as a review of the methods for analysing health care costs. The empirical analysis first compares health service use, unit costs and cost per pregnancy between settings (between: women with different case-mix, health facilities, trial arms and 'study countries) and examines the causes of variation, before testing alternative cost prediction methods. Variations in unit cost are found to be due to several factors, including different levels of resource productivity, occupancy levels, staffing patterns, prices and exchange rates (between country), input mix and health facility size. Also, uncertainty and measurement error are considered likely to cause some variation in unit costs. Variations in health service use are due to case-mix, clinical practice, and accessibility differences. Again, not all variation is explained. Finally, a range of different cost predictions methods are tested, and their results compared with observed costs in each country. The most accurate cost prediction method is to build costs based on expected changes in resource use, health service use and morbidity rates (called the incremental cost impact approach). The direct and adjusted cross-country transfer methods (transfering costs between countries), although accurate on occasions, are less reliable. Cost predictions using predictors from a regression analysis are highly unreliable for cross-country predictions. Methodological issues and policy implications in relation to cost prediction and generalisability are discussed, including the choice of cost-prediction approach, the valuation methods (opportunity cost and currency conversion methods for cross-country predictions), the measures used for comparing the performance of cost prediction methods, and the limitations· of cost analyses to understand costs. It was concluded that caution is needed in predicting costs both within study countries due to cost variability, and in lower-resourced settings where u,nit costs and health service use are lower. Further cost analyses and testing of cost prediction methods are needed in other areas of health care to compare with the results from this thesis, and build a fuller picture of cost behaviour as well as strengths and weaknesses of alternative cost prediction methods.

This thesis assesses the impact of the 1991 health care reforms on the British National Health Service with respect to one specialist service, coronary revascularisation, and examines the ways in which greater improvements in social welfare could be achieved. It is divided into three broad sections. The first section outlines the background to the reforms, the assessment criteria against which the reforms are to be measured and the service to be evaluated. The second section measures the impact of the reforms on efficiency and equity, the chosen assessment criteria, by means both of quantitative and qualitative analyses. The analyses describes the changes which had occurred since the introduction of market mechanisms into the NHS in 1991. Variations in the availability and use of coronary revascularisation services decreased and the contracting process became more sophisticated which suggested the reforms had been instrumental in increasing efficiency and equity. However, large variations remained and market mechanisms continued to cause a series of problems which signified that the reforms were still a long way off achieving an efficient allocation of resources. The third section considers how greater social welfare could be achieved. A strategy for improving social welfare involved managing the market for coronary revascularisations more effectively. An audit of waiting list management in three hospitals demonstrated that patients were often not treated within an appropriate time. The potential to improve efficiency and equity by more effective management of demand for coronary revascularisations therefore existed and the development of guidelines was recommended. Such guidelines were developed with the aim of prioritising patients according to their urgency of need. Finally, the thesis discusses the implications both for health care policy and future research.

This research examines the concept of participation and its application to the relationship between individuals and the state. It approaches the subject from two angles; firstly by considering the role of community work and community workers employed by the local state, and secondly by investigating the relationships that developed between community based groups and departments of the local state. The research was undertaken within Derbyshire and focuses on its Social Service Department, as the main employer of community workers within the County and because of this Department's relationships with the particular community groups studied.

In many parts of Scotland, breastfeeding is relatively uncommon and attempts to increase its prevalence appear to have had little success. Despite the clear evidence of the risks associated with bottle-feeding it has proved difficult to persuade mothers to change their behaviour in favour of breastfeeding. There are a number of factors associated with intention to breastfeed and with initiating and continuing breastfeeding. Among these factors are certain socio-demographic characteristics, maternal characteristics and the influences of health professionals and the social and peer group. Breastfeeding is inversely related to poverty, and children from poorer communities are disproportionately higher users of medical services. The proven health benefits of breastfeeding suggest that increasing breastfeeding is one of the most effective measures for improving health in disadvantaged communities. The aim of this study was to plan, implement and evaluate an innovative community-based intervention designed to increase the prevalence and duration of breastfeeding in a socioeconomically disadvantaged community. It was postulated that, since breastfeeding was influenced by the peer group and by positive role models, a community based system of peer support would be likely to have an impact on breastfeeding behaviour. Although the impact of this study on breastfeeding prevalence was relatively limited it did show a consistently positive trend in favour of breastfeeding in the intervention area, especially when socio-economic differences between the groups were taken into consideration. However, no differences in overall breastfeeding prevalence rates were demonstrated at six weeks whichever method of data analysis was employed. Women who stated an antenatal intention to breastfeed were assisted to achieve this and a few mothers who had not intended to breastfeed did so successfully. The intervention appeared to be acceptable to health professionals and mothers. It is possible that an intervention lasting longer than two years might have a greater impact on breastfeeding prevalence. Conclusion Despite the lack of impact of the intervention at six weeks, a positive trend in breastfeeding in the intervention group study suggests that peer support is a promising strategy for the promotion of breastfeeding in disadvantaged areas.

No description available.

No description available.

The thesis explores the focus of district nursing practice in order to identify areas of study for inclusion in the district nurse curriculum. The "focus" is defined as the point of greatest activity (Chambers, 1991) and so evolves from nursing actions. It is assumed that some nursing actions are dependent upon the patients'needs/problems identified in the assessment process. As all district nurse students are Registered General Nurses they are familiar with nursing needs in hospital and the knowledge that underpins them. The problems experienced frequently by patients at home were explored and compared with those that occur frequently in hospital. The differences in the problems between the two settings enabled knowledge specific to district nursing to be identified. Data was collected from hospitals and the community in one outer London Health Authority. The research was structured through Facet theory which allowed the focus and parameters of the study to be made explicit. The data was analysed using a multiple sorting task, multidimensional scaling procedures and statistical tests. The results demonstrated that a relationship exists between some problems and illustrated those that are likely to occur together. A difference was found between some common problems experienced by patients at home from those experienced in hospital. However, other problems occur with equal frequency and severity in both settings. This suggests that the focus of care is different at home from hospital but that a family resemblance exists. It was argued that the focus of district nursing is on health teaching, which is facilitated by the giving of physical care. Concepts fundamental to district nursing, which underpin the focus of care at home, were identified. Areas of study for inclusion in the district nurse curriculum were suggested and questions for further research raised.

Growing evidence suggests that dietary n-3 very long chain polyunsaturated fatty acids (eicosapentaenoic acid; EPA and docosahexaenoic acid; DHA) reduce the risk of coronary heart disease and stroke, alpha-linolenic acid (alpha-LNA) is the natural precursor of EPA and DHA and is an abundant and accessible source of dietary n-3 PUFA that can be further elongated and unsaturated in vivo. The overall aim of the project is to examine the conversion of alpha-LNA to its long chain metabolite, most importantly DHA. This aim was accomplished by a combination of a human dietary intervention study to assess accumulation of EPA and DHA from dietary alpha-LNA, and 13C-tracer studies of alpha-LNA & linoleic acid (LA) conversion to their long-chain metabolites. The dietary intervention trial was a 12-week parallel design in men expressing an atherogenic lipoprotein phenotype, a common source of lipid-mediated coronary heart disease risk. Diets were enriched with 18 g of alpha-LNA as flaxseed oil (n=21), with a high LA oil (n=17), or with fish-oil (6g/d n=19) as a positive control group. Thus the intention was to provide an increased intake of alpha-LNA with a low ratio of n-6 to n-3 PUFA (1:1 or less), minimizing competition between alpha-LNA and the abundant LA and, in theory, increasing the conversion of alpha-LNA to LC n-3 PUFA. The results from the dietary intervention indicate that, dietary alpha-LNA as flaxseed oil can increase n-3 membrane fatty acid contents, through a 3-fold increase in alpha-LNA (p <0.001)) and 2.5 fold increase in EPA (p<0.001) at week-12, decreasing in n-6:n-3 ratio (p =0.001), but not changing DHA level. In contrast the fish oil diet increased both EPA and DHA. Dietary alpha-LNA had 7% of the efficacy of preformed EPA from fish oil to increase membrane EPA levels. Subjects on the 13C tracer study were a sub-group of the intervention study, studied after 12-weeks on the high alpha-LNA (n=6) or high n-6 (n=5) diets. Subjects were given an oral mixture of 400 mg each of uniformly 13C labelled alpha-LNA and LA in a milk shake after an overnight fast. 13C enrichment was measured in fatty acids isolated from plasma at 1,2,3,7,10 and 14 days after the dose. Of the dose appearing in the plasma 35-45% was converted to EPA with no dietary effects. Some conversion to DHA did occur especially in the high n-6 group (3.9% of dose) compared with the flaxseed-oil group (mean value 0.8% of the dose; p < 0.05). In the single subject studied on the fish-oil diet there was a much lower conversion rate compared to the flaxseed-oil diet. The variability between subjects for percent conversion to DHA ranged from zero to 6.2% of the dose appearing in plasma. Taken together these results clearly establish the effectiveness of dietary alpha-LNA as a method of increasing the concentration of EPA, but not DHA, in membrane phospholipids, with up to 7% of the efficacy of preformed EPA. The increase in the EPA: AA ratio (eicosapentanoic: arachidonic acid) in membrane phospholipids with dietary alpha-LNA is likely to reduce the overall inflammatory environment with beneficial effects for long-term health.