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Genital chlamydia is the most commonly diagnosed sexually transmitted infection. In August 2008, the Scottish government directed its health boards to involve community pharmacies in providing chlamydia testing and treatment for young people. Lothian Health Board envisaged a pharmacy-based chlamydia testing and treatment (CT&T) service to be able to reach deprived population. This research project set out to evaluate the implementation of the CT&T in Lothian, Scotland. However, the Lothian CT&T service suffered from setbacks such as; implementation delays, minimal advertising of the service, low uptake, withdrawal by central government of specific funding to support the service costs, and subsequent termination of the service in Lothian by March 2011. As it turned out, the CT&T service ran in Lothian for only 10 months. As events unfolded, the aims of the PhD research were successively revised so as to undertake an integrated set of studies that provide important insights and generalizable knowledge about the rationale for such a service, the process of implementation, including barriers and facilitators, and the potential to utilise routine data to assess the impact of a new service. An additional component was added, in that I undertook an analysis of an anonymous routine data on chlamydia testing obtained from the microbiology reference laboratory of Lothian to describe the epidemiology of chlamydia in Lothian (2006-2010) and to report an impact of recent policy changes (2008-2009) on chlamydia surveillance activity. Methods The Centre for Disease Control (CDC) framework for programme evaluation was used to guide design the evaluation of the CT&T service, and a subset of ‘strategic’ stakeholders for the service was involved throughout. Four studies were undertaken towards the evaluation, and these employed diverse methods, as follows: (i) A training need survey of pharmacists and their support staff was undertaken in 166 community pharmacies in Lothian, to inform the training session held prior to the CT&T service launch. (ii) A survey of 33 strategic stakeholders in Lothian was undertaken to provide input to the evaluation objectives and to identify their perceptions and concerns in relation to the CT&T initiative and its evaluation. (iii) A survey of potential service users, young people aged 15-24 years, was carried out at the Genito-Urinary Medicine (GUM) clinic and two other sexual health drop-in clinics in Lothian. The survey ascertain their preferences regarding specific aspects of the CT&T service, and their views on issues identified in previous literature as facilitators or barriers with regard to utilising of such a service. (iv) In order to understand the service provider’s perspective on setting up and delivering of the CT&T service, in-depth interviews were undertaken with participating and nonparticipating pharmacists. Eleven pharmacists were purposively sampled from 66 pharmacies invited by NHS Lothian to pilot the service roll-out. Finally, after the Lothian CT&T service had been terminated, 3 strategic stakeholders for Lothian, and a Scottish Government representative were contacted by email, to elicit their views on factors contributing to policy decisions regarding pharmacybased CT&T services. Results The analysis of disaggregated (individual) routine laboratory data showed that age, gender, year of testing and deprivation were associated with the chlamydia testing outcome measures. The before-and-after analysis, with respect to recent major policy/guidance changes (that is, publication of the sexual health service standards for Scotland in 2008, and of SIGN guidelines for chlamydia in 2009), showed that surveillance activity for chlamydia increased only transiently (i.e. in 2009 only). The annual surveillance target for women aged 15-24 years, of 300 tests / 1000 population, was achieved in 2009 only, but targets for males aged 15-24 years (of 100 tests / 1000 population) were not achieved. With respect to the evaluation studies, the training needs survey (i) had a 53% pharmacy response rate from the pharmacies comprised 41% pharmacists, 32% technicians and 26% counter assistants. The survey showed differences in selfassessed training needs between pharmacy staff groups (pharmacists/ technicians/ counter staff). With regard to pharmacist-only competencies, the highest rates of substantial training needs were for clarity regarding the medico-legal aspects (Fraser guidelines), taking a sexual history, criteria for referral and reviewing own and staff competencies for the CT&T service (83% to 77%). With respect to all staff competencies, the greatest self-reported training need was for inter-communicative aspects of providing the service – for respondents overall, 56% to 83% across competencies within this domain. For the stakeholder survey (ii), the response rate was 52% (n=17). Sixteen stakeholders indicated their strong or moderate concern regarding young peoples’ knowledge about the service. The stakeholders also acknowledged the difficulty inherent in promoting the service to those who might benefit from using it. A view commonly expressed by respondents was that sexual health counselling concomitant with testing would be difficult to deliver through the CT&T service, due to: the difficulty in achieving privacy; a busy retail environment; and pharmacists tending not to have the necessary skills. However, they also acknowledged that chlamydia service delivery is problematic everywhere and not just in pharmacies. The key benefits of the service suggested for young people included increase accessibility, normalization of chlamydia testing and its ability of provision of sexual health service to hard-to-reach population. Such a service was perceived to enhance the role of pharmacist in public health provision. The survey also sought input of strategic stakeholders to ensure that the evaluation questions of most importance to them were included. All the proposed evaluation questions were marked as important. Some suggested questions such as client’s satisfaction with the service or related to the service logistical planning could not be incorporated in the later components of the intended evaluation as the service uptake was too low to answer those questions. The survey of potential service users (iii) had an overall response rate of 20% (n=78). Young people who responded indicated that they felt confident that a pharmacy would offer complete confidentiality for testing, provide reliable test results and have knowledgeable staff to provide the service (90% to 93%). That said, these respondents indicated a preference to be tested in GUM clinic (32%) or drop-in clinics (34%), with only 11% indicating a preference for being tested in a pharmacy. Those who had not previously been tested for chlamydia placed more importance on a toilet facility in a pharmacy they would chose for chlamydia testing, whereas younger respondents (≤ 19 years) placed more importance on a less busy pharmacy. Analysis of in-depth interviews with pharmacists (iv) comprising interviews with 11 lead pharmacists (4 respondents from pilot pharmacies and 7 from non-pilot pharmacies) found that pharmacists were enthusiastic about their newly developed public health role. The respondents foresee a shift to pharmacies for being a first port of call for clients. They were also generally positive about the anticipated attitude of general practitioners and pharmacy support staff towards their provision of chlamydia service. From a pharmacist’s perspective, barriers to delivering the CT&T service were identified as workload and lack of adequate physical infrastructure within a pharmacy such as a consultation room and a toilet facility. On the other hand, the assurance of financial incentives for providing the service was a facilitator.

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Dissertation submitted in partial compliance with the requirements for the Master’s Degree in Technology: Chiropractic, Durban Institute of Technology, 2006. / Health care practitioners have known for some time that patients benefit from specific manual intervention effects, but also from the manner in which these are presented. The latter at times having as much impact on patient health as the former. Thus the purpose of this study was to determine the effect of the clinical ritual during instrument assisted adjusting whilst managing mechanical lower back pain. The study was a randomized prospective study comprising of sixty participants aged 18-59. These individuals were randomly allocated into two groups of thirty and then further stratified to control for gender. Both Groups were diagnosed according to the Activator Methods Chiropractic Technique (AMCT), however the tension was set at maximum for group A, whilst the device was set to the minimum tension for group B. Each patient received three treatments and one follow up visit over a two-week period. Subjective data was collected at the first, third and follow up visit. Subjective data was recorded using the Visual Analogue Scale, the Numerical Pain Rating Scale, the Roland Morris Questionnaire and the Short-form McGill Pain Questionnaire. Outcomes were analysed through with the SPSS statistical package at a 95% level of confidence. After analysis of the collected data it was found that there was no statistical difference between the groups, but there was a non-specific trend suggesting a better outcome in the full tension activator group (Group A). Thus, the research indicated that patients perceptions, the patient-practitioner relationship, and the assumption of an outcome of success as well as the power of placebo or non-specific effects play a large role in the managing of lower back pain in a chiropractic environment. / M

Dissertation submitted in partial compliance with the requirements for the Masters Degree in Technology: Chiropractic, Technikon Natal, 1998. / Mechanical neck pain is an extremely common condition. At any specific time, as many as 12% of the adult female population and 9% of the adult male population experience pain in the neck, with or without associated arm pain, and 35% of people can recall an episode of previous neck pain (Bland 1994:3). However, to date little research has been conducted to investigate which treatment protocolIs may be the most effective in the management of mechanical neck pain syndromes. The aim of this study was to investigate whether the combination of chiropractic manipulative therapy and intermittent, mechanical cervical traction would be more effective in the treatment of mechanical neck pain than chiropractic manipulative therapy alone. It was hypothesized that chiropractic cervical manipulative therapy and the combination of chiropractic cervical manipulative therapy and intermittent, mechanical cervical traction would both be effective in the treatment of mechanical neck pain. Moreover, with reference to objective and subjective clinical findings, it was hypothesized that the combination of chiropractic cervical manipulative therapy and intermittent, mechanical cervical traction would be more effective in the treatment of mechanical neck pain than chiropracic manipulative therapy alone. / M

Dissertation submitted in partial compliance with the requirements for a Masters Degree in Technology: Chiropractic, Technikon Natal, 2002. / The purpose of this study was to determine the efficacy of a conservative chiropractic management approach in the treatment of symptomatic hallux abductovalgus (bunions). The study was a prospective, randomised clinical trial involving sixty subjects, thirty in each group, which were selected from the general population. Group A received a conservative chiropractic management approach, encompassing progressive mobilization of the first metatarsophalangeal joint, used in conjunction with cryotherapy and adjustment of all other fixations found in the foot and ankle. Group B received a placebo treatment by means of de-tuned Action Potential Therapy administered to the involved foot. Each group received six treatments over a two-week period and attended a one-week follow up consultation for data collection. Objective assessment was performed by measuring the pressure pain threshold using a digital algometer. Subjective assessment was by means of the Numerical Rating Scale-101 (NRS-101) and the Foot Function Index (FFI). The Hallux-metatarsophalangeal-interphalangeal Scale (HAL) incorporated assessment of both objective and subjective measurements. Assessments were taken at the first, third, sixth and one week follow-up consultations, for all the subjective and objective data. Statistical analysis was completed under the supervision of Mr K. Thomas at . the Technikon Natal, at a 95% confidence interval. The parametric two-sampled paired t-test, the Friedman's test and the Dunn's post test were used to analyse the data within each group (intra-group analysis), whilst the parametric two-sampled unpaired t-test and the non-parametric Mann Whitney unpaired U-test were used to analyse the data between the two groups (inter-group analysis). / M

Dissertation submitted in partial compliance with the requirements for the Master's Degree in Technology: Chiropractic, Technikon Natal, 1998. / Purpose: The purpose of this study was to determine the relative effectiveness of two seemingly different approaches to manipulation of the cervical spine in the treatment of cervical spine dysfunction. The researcher postulated that a manual manipulation would have a greater effect in reducing pain and increasing range of motion that accompanies cervical dysfunction than an instrumental, low force, high velocity thrust delivered by means of an Activator Adjusting Instrument. The reason for this is that it provides greater joint movement. Methods This randomised controlled trial consisted of two treatment groups. Each group consisted of 15 subjects, between the ages of 16 and 65 years, selected from the general population and randomly allocated to treatment group A or B. Group A received instrumental thrusts delivered by an Activator Adjusting Instrument (AAI), while group B received standard diversified manual manipulations to the dysfunctional joints in the cervical spine. Each subject was assessed by using subjective measures of the CMCC Neck Disability Index, Numerical Pain Rating Scale and McGill Short- Form questionnaire; and the objective measure of degrees of cervical range of motion obtained using a cervical goniometer (CROM). Two tailed statistical analysis was conducted at a = 0.05, using the non-parametric Wilcoxin Signed Rank Test and the Mann-Whitney U Test comparing intra-group and inter-group data respectively. Further assessment of the data was conducted using power analysis. This data as well as the descriptive statistics were presented in tables and bar charts. / M

A dissertation submitted in partial compliance with the requirements for a Master's Degree in Technology: Chiropractic at Technikon Natal, 1999. / The purpose of this study was to determine the efficacy of patella mobilization in patients suffering from patellofemoral pain syndrome, This was a prospective, randomized, placebo controlled, pilot study, Group A received patella mobilization, while Group B, the placebo group, received detuned ultrasound, The study involved 30 subjects, 15 in each group selected from the general population, Each subject was treated eight times within a four week period, however if they became asymptomatic prior to their eighth treatment the subjective and objective data normally collected on the eighth treatment was collected on their last consultation, patients were required to return for a one month follow-up from the date of their last consultation, Each subject was assessed by means of the short-form Mc Gill Pain Questionnaire, Numerical Pain Questionnaire and the Patient-Specific Functional Scale, Objectively their pressure-pain threshold and tolerance was assessed by means of an algometer, Assessments were taken at the first, eighth, and follow-up consultation for all the subjective and objective measurements, Algometer readings were also obtained at the fourth consultation, the pressure was applied at approximately one kilogram per centimeter squared per second, Excessively high or low readings were retaken, Statistical analysis was completed under the guidance of the statistician at Technikon, Natal, using the non-parametric Wilcoxon sign-rank test and the Mann- Whitney unpaired test comparing intra-group and inter-group data respectfully, / M

Dissertation submitted in partial compliance with the requirements for the Master's Degree in Technology: Chiropractic, Technikon Natal, 1997. / This study was done in order to compare the effectiveness of chiropractic treatment in association with a wellness approach, to chiropractic treatment without a wellness approach in the management of Mechanical Low Back Pain. Low back pain is an enormous problem in today's society. Vast amounts of money are spent annually on the investigation into and treatment of low back pain, and numerous work days are lost due to absenteeism. Chronic low back pain also affects the individual's life\xB7style, and can lead to psychological problems. Thousands of low back operations are done yearly, with a significantly high failure rate. (Frymoyer et al. 1980.) In this study factors such as cost, recovery tine and incidence of reoccurrence were used as criteria to determine the effectiveness of chiropractic treatment applied to the two groups of patients. The concept of holise was applied to one group, whereas the other group was treated without this approach. The study was conducted as a clinical trial, with two experimental groups. Thirty patients who had responded to an advertiselOent were selected and randomly divided into two groups. The patients were selected fro~ the general population on the grounds of their signs and sylllptoos. Group A received chiropractic treatment in association with the wellness approach. This comprised patient education in the form of guidance towards life-style changes and exercises. Patients were also given a detailed explanation of their problems, leading to an understanding of their conditions. Group B received chiropractic treatment only. Their condition was not explained, and they did not receive any of the holistic aspectts mentioned for group A. / M

Obesity is an increasing public health issue in many parts of the world. Lifestyle treatment is the recommended first-line treatment although the weight reduction over time is limited. Food addiction (FA) is an upcoming perspective viewing some individual’s eating behaviors as similar to substance abuse described in DSM-IV-TR. What impact FA might have in lifestyle treatment is unclear. Self-efficacy for physical activity (SEPA) is a well-known predictor for physical activity and a variable in lifestyle treatment. The purpose of this explorative cross-sectional study was to investigate how FA and SEPA separately and together relate to days in lifestyle treatment for obesity. The study had 41 participants in different stages of lifestyle treatment. Instruments used to measure FA and SEPA were Yale Food Addiction Scale – Swedish (YFAS-S) and Exercise Self-Efficacy Scale – Swedish (ESES-S). FA and SEPA did not relate to each other or to number of days in treatment, indicating that the two factors are unaffected by lifestyle treatment. Future studies investigating if FA affects weight regain after treatment are suggested. / Fetma är ett växande folkhälsoproblem i många delar av världen. Livsstilsbehandling är den rekommenderade första behandlingsåtgärden trots att viktminskningen på längre sikt för de flesta är låg. Matberoende (FA) är ett relativt nytt perspektiv som förklarar vissa individers förhållande till mat som likvärdigt andra missbruk beskrivna i DSM-IV-TR. Vilken påverkan FA har i en livsstilsbehandling mot övervikt är ännu inte klarlagt. Self-efficacy för fysisk aktivitet (SEPA) är en välkänd prediktor för fysisk aktivitet och en variabel i livsstilsbehandling. Den här tvärsnittsstudien ämnar undersöka hur FA och SEPA enskilt och tillsammans relaterar till antalet dagar i en livsstilsbehandling. Mätningar av FA och SEPA gjordes med Yale Food Addiction Scale – Swedish (YFAS-S) och Exercise Self-Efficacy Scale – Swedish (ESES-S). FA och SEPA korrelerade inte med varandra eller med dagar i behandling vilket indikerar att de två faktorerna inte påverkas av livsstilsbehandling. Framtida studier som undersöker FA:s eventuella påverkan på återgång i vikt efter behandling föreslås.