The black middle class: middle class Afro-Caribbeans: a racial fraction of the British middle class or a class fraction of a racial group

This research examines the relationship between 'race' and class in Britain. This is achieved by considering how these two concepts articulate in the overall structuring of class relationships in a society which is typified by the incorporatation of black labour into a majority white society, This relationship is examined through an investigation of those black workers who occupy a position in the objectively defined middle class. The basic theme underlying this research is that 'race, in the form of structural racism, plays a significant role at two levels. Firstly, it serves to structure the class position of black labour in Britain. Secondly, it serves to determine the type of race, class and political consciousness generated by black labour. The study was carried out in the London area. Occupation was used as an indicator of 'objective' class position when selecting respondents to be included in the two survey populations required for the research. A 'network' approach was used to actually locate the respondents. In-depth interviews were carried out with all the respondents. The study concludes that the concepts of 'race' and class are not independent of each other in the overall structuring of class relationships between black and white labour. It is argued that the inter-relationship identified between these two concepts serves to highlight the fact that the structural position of black labour, the type of consciousness generated and the type of decisions taken by those who took part in the research are to a large extent a result of the structural constraints deriving from the effects of structural racism in Britain.

The mathematical modelling of the environmental performance of buildings as an aid in the design process

This thesis is a theoretical study of the accuracy and usability of models that attempt to represent the environmental control system of buildings in order to improve environmental design. These models have evolved from crude representations of a building and its environment through to an accurate representation of the dynamic characteristics of the environmental stimuli on buildings. Each generation of models has had its own particular influence on built form. This thesis analyses the theory, structure and data of such models in terms of their accuracy of simulation and therefore their validity in influencing built form. The models are also analysed in terms of their compatability with the design process and hence their ability to aid designers. The conclusions are that such models are unlikely to improve environmental performance since: a the models can only be applied to a limited number of building types, b they can only be applied to a restricted number of the characteristics of a design, c they can only be employed after many major environmental decisions have been made, d the data used in models is inadequate and unrepresentative, e models do not account for occupant interaction in environmental control. It is argued that further improvements in the accuracy of simulation of environmental control will not significantly improve environmental design. This is based on the premise that strategic environmental decisions are made at the conceptual stages of design whereas models influence the detailed stages of design. It is hypothesised that if models are to improve environmental design it must be through the analysis of building typologies which provides a method of feedback between models and the conceptual stages of design. Field studies are presented to describe a method by which typologies can be analysed and a theoretical framework is described which provides a basis for further research into the implications of the morphology of buildings on environmental design.

State-of-the-art in integrated vehicle health management

Integrated vehicle health management (IVHM) is a collection of data relevant to the present and future performance of a vehicle system and its transformation into information can be used to support operational decisions. This design and operation concept embraces an integration of sensors, communication technologies, and artificial intelligence to provide vehicle-wide abilities to diagnose problems and recommend solutions. This article aims to report the state-of-the-art of IVHM research by presenting a systematic review of the literature. The literature from different sources is collated and analysed, and the major emerging themes are presented. On this basis, the article describes the IVHM concept and its evolution, discusses configurations and existing applications along with main drivers, potential benefits and barriers to adoption, summarizes design guidelines and available methods, and identifies future research challenges.

Wage and employment decisions of enterprises in downsized industries:deliverable No. 11 to 13

The 5th framework programme research project ACCESSLAB researches the capability of candidate countries’ regions to deal with asymmetric shocks. Its goal is to provide analysts and policy makers with research results relevant to the process of enlargement. The project takes a broad and comparative view of labour market adjustments to address these issues. It examines the topic from both a macroeconomic and microeconomic viewpoint. It considers different adjustment mechanisms in depth and compares results with the European Union. It draws on a) the experiences in transition countries in the last decade, b) the experience of German integration and c) the experiences of border regions to gain insights on the likely regional labour market effects of accession of the candidate countries.

Disentangling Double Politikverflechtung? The implications of the federal reforms for Bund-Länder relations on Europe

The recent reforms of German federalism (Reform I) have established a new framework for Bund–Länder co-operation on EU policy. These seek to safeguard Germany's ability to co-operate in Europe by disentangling the joint roles and responsibilities bound up within the complex arrangements of the EU policy-making system, defined as a multiple framework of joint decisions, or doppelte Politikverflechtung. Whilst on the surface, the reforms enacted may be read as a success for the Länder in their bid to secure autonomy on European issues, closer analysis reveals that these changes may in fact hamper the Länder agenda on European issues, closing off new opportunities for influence.

Understanding institutional conversion:the case of the National Reporting and Learning System

This article focuses on one type of institutional change: conversion. One innovative approach to institutional change, the “political-coalitional approach”, acknowledges that: institutions can have unintended effects, which may privilege certain groups over others; institutions are often created and sustained through compromise with external actors; and institutions’ external context can vary significantly over time, as different coalitions’ power waxes and wanes. This approach helps explain the conversion of one institution drawn from the UK National Health Service, the National Reporting and Learning System. However, the shift of this system from producing formative information to facilitate learning to promote safer care, towards producing summative information to support resource allocation decisions, cannot be explained merely by examining the actions of external power coalitions. An internal focus, which considers factors that are normally viewed as “organisational” (such as leadership and internal stability), is also required.

A simulation study of the shift system at a UK police communications centre

The UK Police Force is required to operate communications centres under increased funding constraints. Staff represent the main cost in operating the facility and the key issue for the efficient deployment of staff, in this case call handler staff, is to try to ensure sufficient staff are available to make a timely response to customer calls when the timing of individual calls is difficult to predict. A discrete-event simulation study is presented of an investigation of a new shift pattern for call handler staff that aims to improve operational efficiency. The communications centre can be considered a specialised case of a call centre but an important issue for Police Force management is the particularly stressful nature of the work staff are involved with when responding to emergency calls. Thus decisions regarding changes to the shift system were made in the context of both attempting to improve efficiency by matching staff supply with customer demand, but also ensuring a reasonable workload pattern for staff over time.

The idea of the hybrid texts and translation:contact as conflict

Intercultural communication in the global environment frequently involves recourse to translation. This generates new phenomena which, in turn, raise new questions for translation theory and practice. This issue is concerned with the concept of the hybrid text as one of these phenomena. In this introductory chapter, a hybrid text is defined as: „a text that results from a translation process. It shows features that somehow seem ‘out of place'/‘strange'/‘unusual' for the receiving culture, i.e. the target culture”. It is important, however, to differentiate between the true hybrid, which is the result of positive authorial and/or translatorial decisions, and the inadequate text which exhibits features of translationese, resulting from a lack of competence. Textual, contextual and social features of hybrid texts are postulated (see discussion paper). These are the object of critical reflection in sub-sequent chapters, in relation to different genres. The potential of the hybrid text for translation research is explored.

Small businesses and flood impacts:the case of the 2009 flood event in Cockermouth

Flooding can have a devastating impact on businesses, especially on small- and medium-sized enterprises (SMEs) who may be unprepared and vulnerable to the range of both direct and indirect impacts. SMEs may tend to focus on the direct tangible impacts of flooding, limiting their ability to realise the true costs of flooding. Greater understanding of the impacts of flooding is likely to contribute towards increased uptake of flood protection measures by SMEs, particularly during post-flood property reinstatement. This study sought to investigate the full range of impacts experienced by SMEs located in Cockermouth following the floods of 2009. The findings of a questionnaire survey of SMEs revealed that businesses not directly affected by the flooding experienced a range of impacts and that short-term impacts were given a higher significance. A strong correlation was observed between direct, physical flood impacts and post-flood costs of insurance. Significant increases in the costs of property insurance and excesses were noted, meaning that SMEs will be exposed to increased losses in the event of a future flood event. The findings from the research will enable policy makers and professional bodies to make informed decisions to improve the status of advice given to SMEs. The study also adds weight to the case for SMEs to consider investing in property-level flood risk adaptation measures, especially during the post flood reinstatement process. © 2012 Blackwell Publishing Ltd and The Chartered Institution of Water and Environmental Management (CIWEM).

UK and US board director perceptions of the significance of gender and racial diversity on board governance

This mixed-methods study examines the perceptions and opinions of United Kingdom FTSE 350, and US Fortune 500 board of director members regarding the significance of gender and racial diversity on board governance. Perceptions were gathered from eighty-two directors using self-reported surveys and semi-structured interviews. This thesis provides: (1) an opportunity to investigate the perceptions (opinions) of directors regarding the effects of board gender and racial diversity on new board appointments and on the dynamics of board decision making (2) an opportunity to investigate the perception (opinions) of directors regarding the effects of social capital, new board appointments and the dynamics of board decision making, and (3) an opportunity to investigate comparatively the differences between UK and US director perceptions regarding the effects of board gender and racial diversity on new board appointments and board decision making. My findings indicate that directors believe that expertise and experience are by far the most important attributes when decisions on the selection of new directors are being considered. While US directors report observing tangible benefits to gender and racial diversity, for their firms, as well as a willingness to consider diversity as an attribute in the selection process; most UK directors were strongly opposed to positive discrimination measures.1 A majority of directors do not believe that their own demographic characteristics, such as race or gender were attributes to their being selected to a board position; however white males perceive that these attributes were considered attributes to the appointment of diverse directors. Moreover, in the United Kingdom, male directors reported that they may be at a disadvantage for board selection when compared to their female counterparts, hence advocating for a selection process with minimal considerations of the demographic characteristics of new directors. Directors do not seem to consider diverse social capital of directors when making board appointments. Instead, US directors were more likely to be assisted in board appointments by their having similar social capital, and UK directors indicated that they only consider director expertise, and that expertise is considered to ensure a broad mix of skills and professional experience on the board.

A randomised controlled trial of the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia:the ECLIPSE trial

BACKGROUND: Heavy menstrual bleeding (HMB) is a common problem, yet evidence to inform decisions about initial medical treatment is limited. OBJECTIVES: To assess the clinical effectiveness and cost-effectiveness of the levonorgestrel-releasing intrauterine system (LNG-IUS) (Mirena(®), Bayer) compared with usual medical treatment, with exploration of women's perspectives on treatment. DESIGN: A pragmatic, multicentre randomised trial with an economic evaluation and a longitudinal qualitative study. SETTING: Women who presented in primary care. PARTICIPANTS: A total of 571 women with HMB. A purposeful sample of 27 women who were randomised or ineligible owing to treatment preference participated in semistructured face-to-face interviews around 2 and 12 months after commencing treatment. INTERVENTIONS: LNG-IUS or usual medical treatment (tranexamic acid, mefenamic acid, combined oestrogen-progestogen or progesterone alone). Women could subsequently swap or cease their allocated treatment. OUTCOME MEASURES: The primary outcome was the patient-reported score on the Menorrhagia Multi-Attribute Scale (MMAS) assessed over a 2-year period and then again at 5 years. Secondary outcomes included general quality of life (QoL), sexual activity, surgical intervention and safety. Data were analysed using iterative constant comparison. A state transition model-based cost-utility analysis was undertaken alongside the randomised trial. Quality-adjusted life-years (QALYs) were derived from the European Quality of Life-5 Dimensions (EQ-5D) and the Short Form questionnaire-6 Dimensions (SF-6D). The intention-to-treat analyses were reported as cost per QALY gained. Uncertainty was explored by conducting both deterministic and probabilistic sensitivity analyses. RESULTS: The MMAS total scores improved significantly in both groups at all time points, but were significantly greater for the LNG-IUS than for usual treatment [mean difference over 2 years was 13.4 points, 95% confidence interval (CI) 9.9 to 16.9 points; p < 0.001]. However, this difference between groups was reduced and no longer significant by 5 years (mean difference in scores 3.9 points, 95% CI -0.6 to 8.3 points; p = 0.09). By 5 years, only 47% of women had a LNG-IUS in place and 15% were still taking usual medical treatment. Five-year surgery rates were low, at 20%, and were similar, irrespective of initial treatments. There were no significant differences in serious adverse events between groups. Using the EQ-5D, at 2 years, the relative cost-effectiveness of the LNG-IUS compared with usual medical treatment was £1600 per QALY, which by 5 years was reduced to £114 per QALY. Using the SF-6D, usual medical treatment dominates the LNG-IUS. The qualitative findings show that women's experiences and expectations of medical treatments for HMB vary considerably and change over time. Women had high expectations of a prompt effect from medical treatments. CONCLUSIONS: The LNG-IUS, compared with usual medical therapies, resulted in greater improvement over 2 years in women's assessments of the effect of HMB on their daily routine, including work, social and family life, and psychological and physical well-being. At 5 years, the differences were no longer significant. A similar low proportion of women required surgical intervention in both groups. The LNG-IUS is cost-effective in both the short and medium term, using the method generally recommended by the National Institute for Health and Care Excellence. Using the alternative measures to value QoL will have a considerable impact on cost-effectiveness decisions. It will be important to explore the clinical and health-care trajectories of the ECLIPSE (clinical effectiveness and cost-effectiveness of levonorgestrel-releasing intrauterine system in primary care against standard treatment for menorrhagia) trial participants to 10 years, by which time half of the cohort will have reached menopause. TRIAL REGISTRATION: Current Controlled Trials ISRCTN86566246. FUNDING: This project was funded by the NIHR Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 19, No. 88. See the NIHR Journals Library website for further project information.

Psychological influence of the media on patients commencing oral anticoagulation in atrial fibrillation:a qualitative analysis

Background: Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF); however it is still underutilized and sometimes refused by patients. Two inter-related studies were undertaken to understand the experiences and what influences this un- derutilisation of warfarin treatment in AF patients. These studies explored physician and patient experiences of AF and OAC treatment. The paper focuses on specific sub-themes from the study that explored patients’ experiences will be discussed. Aim: The study in question aimed to explore the experiences which influence patients’ decisions to accept, decline or discontinue OAC. Methods: Semi-structured individual interviews with patients were con- ducted. Three sub-groups of patients (n = 11) diagnosed with AF were interviewed; those who accepted, refused, and who discontinued war- farin. Interpretative phenomenological analysis (IPA) was used to examine the data. IPA is a qualitative method that focuses on how participants make sense of an experiences phenomenon Results: Three over-arching themes comprised patients’ experiences: (i)the initial consultation, (ii) life after the consultation, and (iii) patients’reflections. In the last theme, patients reflected on their perceptions ofaspirin and warfarin. Aspirin was perceived as a natural wonder-drugwhile warfarin was perceived as a dangerous drug usually given to peo-ple at the end of their life. Interestingly they perceive both drugs as‘old’. However, for aspirin it had a positive association, old meaningtried and tested. While for warfarin, old meant ‘has been around fortoo long’.Conclusion: Media had an important role in how patients’ perceptionsof these two drugs were influenced. Literature shows that framingtechniques, i.e. using certain words or phrases such as ‘rat poison’, areprocesses adopted by media to alter medical knowledge into lay per-son’s language. Patients in turn form negative cognitive schemas,between the word ‘poison’ and warfarin, leading to the negative per-ception of warfarin which could influence non-adherence to treatment.This qualitative research highlighted the potential influences of themedia on AF patient perceptions commencing OAC treatment. Theassociation between media stimuli and patient perceptions on OACshould be further explored. The influential power of lay-media couldalso be instrumental in disseminating appropriate educational materialto the public

Discovering biomarkers for antidepressant response:protocol from the Canadian biomarker integration network in depression (CAN-BIND) and clinical characteristics of the first patient cohort

Background: Major Depressive Disorder (MDD) is among the most prevalent and disabling medical conditions worldwide. Identification of clinical and biological markers ("biomarkers") of treatment response could personalize clinical decisions and lead to better outcomes. This paper describes the aims, design, and methods of a discovery study of biomarkers in antidepressant treatment response, conducted by the Canadian Biomarker Integration Network in Depression (CAN-BIND). The CAN-BIND research program investigates and identifies biomarkers that help to predict outcomes in patients with MDD treated with antidepressant medication. The primary objective of this initial study (known as CAN-BIND-1) is to identify individual and integrated neuroimaging, electrophysiological, molecular, and clinical predictors of response to sequential antidepressant monotherapy and adjunctive therapy in MDD. Methods: CAN-BIND-1 is a multisite initiative involving 6 academic health centres working collaboratively with other universities and research centres. In the 16-week protocol, patients with MDD are treated with a first-line antidepressant (escitalopram 10-20 mg/d) that, if clinically warranted after eight weeks, is augmented with an evidence-based, add-on medication (aripiprazole 2-10 mg/d). Comprehensive datasets are obtained using clinical rating scales; behavioural, dimensional, and functioning/quality of life measures; neurocognitive testing; genomic, genetic, and proteomic profiling from blood samples; combined structural and functional magnetic resonance imaging; and electroencephalography. De-identified data from all sites are aggregated within a secure neuroinformatics platform for data integration, management, storage, and analyses. Statistical analyses will include multivariate and machine-learning techniques to identify predictors, moderators, and mediators of treatment response. Discussion: From June 2013 to February 2015, a cohort of 134 participants (85 outpatients with MDD and 49 healthy participants) has been evaluated at baseline. The clinical characteristics of this cohort are similar to other studies of MDD. Recruitment at all sites is ongoing to a target sample of 290 participants. CAN-BIND will identify biomarkers of treatment response in MDD through extensive clinical, molecular, and imaging assessments, in order to improve treatment practice and clinical outcomes. It will also create an innovative, robust platform and database for future research. Trial registration: ClinicalTrials.gov identifier NCT01655706. Registered July 27, 2012.

Is pregnancy a teachable moment for diet and physical activity behaviour change? An interpretative phenomenological analysis of the experiences of women during their first pregnancy

OBJECTIVES: Pregnancy may provide a 'teachable moment' for positive health behaviour change, as a time when women are both motivated towards health and in regular contact with health care professionals. This study aimed to investigate whether women's experiences of pregnancy indicate that they would be receptive to behaviour change during this period. DESIGN: Qualitative interview study. METHODS: Using interpretative phenomenological analysis, this study details how seven women made decisions about their physical activity and dietary behaviour during their first pregnancy. RESULTS: Two women had required fertility treatment to conceive. Their behaviour was driven by anxiety and a drive to minimize potential risks to the pregnancy. This included detailed information seeking and strict adherence to diet and physical activity recommendations. However, the majority of women described behaviour change as 'automatic', adopting a new lifestyle immediately upon discovering their pregnancy. Diet and physical activity were influenced by what these women perceived to be normal or acceptable during pregnancy (largely based on observations of others) and internal drivers, including bodily signals and a desire to retain some of their pre-pregnancy self-identity. More reasoned assessments regarding benefits for them and their baby were less prevalent and influential. CONCLUSIONS: Findings suggest that for women who conceived relatively easily, diet and physical activity behaviour during pregnancy is primarily based upon a combination of automatic judgements, physical sensations, and perceptions of what pregnant women are supposed to do. Health professionals and other credible sources appear to exert less influence. As such, pregnancy alone may not create a 'teachable moment'. Statement of contribution What is already known on this subject? Significant life events can be cues to action with relation to health behaviour change. However, much of the empirical research in this area has focused on negative health experiences such as receiving a false-positive screening result and hospitalization, and in relation to unequivocally negative behaviours such as smoking. It is often suggested that pregnancy, as a major life event, is a 'teachable moment' (TM) for lifestyle behaviour change due to an increase in motivation towards health and regular contact with health professionals. However, there is limited evidence for the utility of the TM model in predicting or promoting behaviour change. What does this study add? Two groups of women emerged from our study: the women who had experienced difficulties in conceiving and had received fertility treatment, and those who had conceived without intervention. The former group's experience of pregnancy was characterized by a sense of vulnerability and anxiety over sustaining the pregnancy which influenced every choice they made about their diet and physical activity. For the latter group, decisions about diet and physical activity were made immediately upon discovering their pregnancy, based upon a combination of automatic judgements, physical sensations, and perceptions of what is normal or 'good' for pregnancy. Among women with relatively trouble-free conception and pregnancy experiences, the necessary conditions may not be present to create a 'teachable moment'. This is due to a combination of a reliance on non-reflective decision-making, perception of low risk, and little change in affective response or self-concept.

Oral anticoagulation in atrial fibrillation, the patients and physicians experiences of the consultation:a qualitative study

Background: Oral anticoagulation (OAC) reduces stroke risk in patients with atrial fibrillation (AF), however it is still underutilized and sometimes refused by patients. This project was divided in two inter-related studies. Study 1 explored the experiences that influence prescription of OAC by physicians. Study 2 explored the experiences which influence patients' decisions to accept, decline or discontinue OAC. Methods: Semi-structured individual interviews were conducted in both studies. In Study 1four sub-groups of physicians (n = 16) experienced with OAC in AF were interviewed: consultant cardiologists, consultant general physicians, general practitioners and cardiology registrars. In Study 2 three sub-groups of patients (n = 11) diagnosed with AF were interviewed; those who accepted, refused, and who discontinued warfarin. Results: Study 1: Two over-arching themes emerged from doctors' experiences: (1) communicating information and (2) challenges with OAC prescription for AF. Physicians still adopt a paternalistic approach to decision-making. They should instead motivate patients to take part in treatment discussions and choices should reflect the patient's needs and concerns. Physician education should focus more on communication skills, individualised care and time-management as these are critical for patient adherence. Continuous OAC education for AF should adopt a multi-disciplinary approach. Further, interpreters should also be educated on medical communication skills. Study 2: Three over-arching themes comprised patients' experiences: (1) the initial consultation, (2) life after the consultation, and (3) patients' reflections. Patient education during the initial consultation was critical in increasing patient's knowledge of OAC. On-going patient education is imperative to maintain adherence. Patients valued physicians' concern for their needs during decision-making. Patients who had experience of stroke were more receptive to education aimed towards stroke risk reduction rather than bleeding risk. Patients' perceptions of warfarin are also influenced by the media. Comment: Qualitative research is crucial in exploring barriers to treatment as it provides an excellent insight into patients' experiences of healthcare. A patient-centred approach should be adopted and incorporated into physicians' education. Education and patient involvement in the decision-making process is essential to promote treatment acceptance and long-term adherence