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Aim: Psychosis and related disorders are a major public health issue. Early identification and prevention for those at high risk (at-risk-mental-state, ARMS) is important. General practitioners (GPs) are often the first point of contact for health services. In this review we aim to identify 1) the most common methods for identifying individuals with an ARMS in primary care, 2) the methods for improving identification of individuals with an ARMS in primary care, and 3) the most common barriers that prevent GPs from screening for individuals with an ARMS. Methods: We conducted a systematic review (PROSPERO CRD42021245095) of quantitative and qualitative studies with no date restriction. Searches were performed in September 2021. Studies' quality was appraised using Mixed Methods Appraisal tool (MMAT). Results: We identified 16 eligible studies, and all but one provided quantitative data. Nearly two-thirds of studies were classified as 'medium' quality. Employing narrative synthesis, we identified three themes relating to 1) improving GP knowledge and confidence in identifying individuals with an ARMS, 2) balancing the over- and under-identification of individuals with an ARMS in primary care, and 3) supporting GPs as significant stakeholders in early diagnosis and treatment of individuals with an ARMS. Conclusions: Improved identification of individuals with an ARMS is needed. We identified various strategies, including development and implementation of identification methods (e.g., screening measures), educational interventions for GPs (e.g., workshops), and systemic interventions (e.g., simplifying referrals to secondary care, developing integrated services). When implemented successfully, these interventions may help facilitate the access to appropriate care for individuals with an ARMS.

Parental domestic violence and abuse (DVA), mental ill-health (MH), and substance misuse (SU) are three adverse childhood experiences (ACEs) that are prevalent, (potentially) interrelated, and detrimental to parents and children. This thesis explores how we can better prevent and address co-occurring parental DVA, MH, and SU. This thesis comprises: 1) a secondary data analysis utilising the Millennium Cohort Study to explore how parental DVA, MH, and SU co-occur during early childhood and how this impacts child MH trajectories; 2) a systematic review of family focused interventions that aim to address parental DVA, MH, and SU in combination; and 3) a qualitative study involving interviews with service users and focus groups with service providers and senior leadership/commissioners to develop an understanding of stakeholders' experiences of current service provision for parental DVA, MH, and SU. The secondary data analysis found parental DVA, MH, and SU co-occur during early childhood and that this can negatively impact children at age three. Families experiencing these co-occurring adversities were more likely to be experiencing socio-economic disadvantage. The systematic review identified no family focused interventions that had combined positive impacts on parental DVA, MH, and SU. Interventions mostly targeted mothers, those from low-socioeconomic backgrounds, and used an identification and referral approach to addressing multiple needs. The qualitative study highlighted the importance of early, relational support that addressed wider determinants. However, joined-up provision was challenged by an overwhelmed workforce and siloed services. Overall findings highlight a lack of evidence on what works to prevent and address parental DVA, MH, and SU in combination. Working at the intersection of these ACEs is likely to require early, 'think family' support that addresses wider determinants, as well as more fundamental systems change. Future work should re-frame parental DVA, MH, and SU as a syndemic and co-develop approaches to better support families.

Introduction: Early detection of mild cognitive impairment (MCI) is important for offering pragmatic risk reduction advice but also for engaging individuals who may be in the prodromal stages of Alzheimer's disease in clinical research or pharmacological interventions in the future. However, there is considerable uncertainty around the prognosis of MCI as individuals identified as having MCI may develop dementia, remain stable or revert back to normal cognition. The inherent uncertainty of this condition creates a complex dynamic between the clinicians' communication of MCI and the patient's understanding of test, risk and diagnostic disclosures. Aim: To understand the impact of risk disclosures in the MCI population and to examine whether the way clinical information is communicated to individuals with newly identified MCI could have an effect on the individuals' clinical outcomes and possibly lead to an altered prognosis. METHOD: The MCI adjustment study was a mixed methods longitudinal cohort study. Individuals suspected of having MCI were recruited across five memory assessment services in South-East Scotland (Jul 2018 - Jul 2019). Baseline assessments were undertaken prior to diagnostic disclosures and three follow-up visits were conducted over an average of two years after the risk disclosures. The main study employed primarily quantitative methodologies such as linear mixed effects modeling. Study outcomes included changes in cognition and psychological well-being with the explanatory variable individuals' own subjective rating of their risk disclosure experience as "good" or "not good". A subset of participants were included in a qualitative study about their experiences of risk disclosure at the memory clinic and clinicians at each of the participating sites were also interviewed about their views on MCI. Results: A total of 63 participants were recruited into the study, of whom n=38 (60.32%) were women. The mean age was 77.24 (SD=6.76) and mean number of years of education was 12.94 (SD=3.57) across the study. Risk disclosure experiences had no significant associations with cognition, sleep, or psychological well-being scores but a "not good" disclosure experience had an association which was just below the statistically significant cut-off of pDiscussion The findings within the current PhD indicate there may be a link between the subjective patient experience of risk disclosures and impact on psychological outcomes over time. The uncertainty of prognosis may contribute towards a negative disclosure experience and may lead to worse psychological adjustment to illness over time. The findings suggest that individuals referred to memory assessment services seek an intervention to reduce risk of dementia in the early stages of neurodegenerative disease, regardless of whether they considered their disclosure experience as "good" or "not good". Furthermore, patients may feel anxiety, embarrassment or stigma around memory decline. There is a need for more evidence on long-term adjustment to risk disclosures in the MCI population, focusing on patient centred outcomes. Conclusion: Risk disclosure in the suspected MCI population is characterised by uncertainty and varying levels of psychological adjustment to living with the risk of dementia. Evidence from the current PhD study is used to propose a number of recommendations for implementation in clinical practice. Disclosing diagnostic test results to individuals worried about their cognitive health should aim to promote autonomy and empower individuals to embrace strategies to maintain brain health to improve or sustain functioning for as long as possible. Supporting the individual to cope with uncertainty inherent to MCI should be a central consideration in achieving positive adjustment and emphasis should be placed on long-term adjustment to living with risk of dementia while accounting for individual health literacy levels.

Discourses around prevention and population health have been gathering momentum in UK mental health policy for over a decade. This trend has been influenced by an economic rationale, prominent reports into the social determinants of health and mental health, and pressure from national and international organisations to take a population based approach to address them. And yet despite this, there are indications that the political focus on mental health prevention has not resulted in clear preventative action. The current study aimed to address the social problem of prevention through a critical appraisal of the discursive features of recent mental health policy. The intention was to facilitate clinical psychologists' engagement with the political context of their work. A 5 stage framework for Critical Discourse Analysis (Fairclough, 2001) was utilised to explore the underlying conceptual frameworks of relevant policies, and the impact these had on the way preventative action was operationalised. This was undertaken from a critical realist epistemological position. On the basis of a historical analysis into prevention and population health discourses, two representative policies were selected for more detailed discursive analysis. These were Advancing our Health: Prevention in the 2020s (Department of Health and Social Care, 2019) and the NHS Mental Health Implementation Plan 2019/20 - 2023/24 (NHS England, 2019a). The analysis indicated that potential discursive obstacles to preventative action could be found in; how the target of prevention was conceptualised, conflicting notions of responsibility for prevention, and the malleability of the concept of prevention itself. This was discussed in reference to the network of policy structures and practices that also present a barrier to prevention. Implications for clinical psychologists in terms of individual, community and policy level actions were considered.

This is a doctoral thesis comprising a systematic literature review/meta analysis and an empirical paper. Systematic Literature Review: The efficacy of self-guided internet and mobile-based interventions (IMIs) for preventing anxiety and depression - A systematic review and meta-analysis. Background: Anxiety and depression are highly prevalent mental disorders which are associated with a considerable personal and economic burden. As treatment alone has a minimal impact on prevalence, there is now a growing focus on interventions which may help prevent anxiety and depression. Internet and Mobile based Interventions (IMIs) have been identified as a useful avenue for the delivery of preventative programmes due to their scalability and accessibility. The efficacy of IMIs that do not require additional support from a trained professional (self-guided) in this capacity is yet to be explored. Method: A systematic search was conducted on the Cochrane Library, PubMed, PsycARTICLES, PsycINFO, OVID, MEDline, PsycEXTRA and SCOPUS databases. Studies were selected according to defined inclusion and exclusion criteria. The primary outcome was evaluating the effect of self-guided IMIs on incidence of anxiety and depression. The secondary outcome was effect on symptom severity. Results: After identifying and removing duplicates, 3211 studies were screened, 32 of which were eligible for inclusion in the final analysis. Nine studies also reported incidence data (depression = 7, anxiety = 2). The overall Risk Ratios (RR) for incidence of anxiety and depression was .86 (95% CI [.28, 2.66], p =.79) and .67 (95% CI [.48, .93], p =.02) respectively. Analysis for 27 studies reporting severity of depressive symptoms revealed a significant posttreatment standardised mean difference (SMD) of −.27 (95% CI [ −.37, −.17], p < .001) for self-guided IMI groups relative to controls. A similar result was observed for 29 studies reporting severity of anxiety symptoms with an SMD of -.21 (95% CI [-.31, -.10], p < .001). Conclusions: Self-guided IMIs appear to be effective at preventing incidence of depression, though further examination of the data suggests that generalisability of this finding may be limited. While self-guided IMIs also appear effective in reducing symptoms of anxiety and depression, their ability to prevent incidence of anxiety is less clear. Empirical Study: Evaluating the effects of a self-help mobile phone application on worry and rumination experienced by young adults: A randomised controlled trial. Background: Improving the mental health of adolescents and young adults has been identified as a global priority. As well as preventing poor mental health, this includes the promotion of increased well-being by developing interventions which target known risk factors such as worry and rumination, also known as Repetitive Negative Thinking (RNT). Objective: The primary objective of this study was to test whether an RNT-targeting self-help mobile phone application (MyMoodCoach) could reduce levels of worry and rumination in young adults currently residing in the United Kingdom. A secondary objective was to test whether the app could achieve similar reductions in symptoms of anxiety and depression, as well as improve well-being. Methods: A web-based, single blind, two-arm parallel-group Randomised Controlled Trial (RCT) was conducted with N=236 people aged between 16 and 24 who self-reported high levels of either worry or rumination. Participants were recruited via social media adverts and directed to an open website. Eligible participants were randomised to an active intervention group (usual practice, plus up to 6 weeks of using the RNT-targeting mobile app) or a waitlist control group (usual practice with no access to the app). The primary outcome was changes in worry and rumination six weeks after randomisation. Secondary outcomes included changes in well-being and symptoms of anxiety and depression after six weeks and changes on all measures after 12 weeks. The waitlist control group was given access to the app at the six-week follow-up point. Results: Participants were randomised to access the RNT-targeting app (n = 119) or waitlist control (n = 117). The active treatment arm showed significantly lower levels of rumination (-2.92, 95% CI [-5.57, -.28], p <.031, ηp2 = .02) and worry (-3.97; 95% CI [-6.21, -1.73], p <.001, ηp2 = .06) at six-week follow-up, relative to the waitlist control. Similar differences were observed between the two arms for wellbeing (p <.001) and symptoms of anxiety (p = .03) and depression (p = .043). The waitlist control reported similar levels of improvement when given access to the app after six weeks. Improvements observed in the active treatment arm were maintained at the 12-week follow-up point where there were no significant differences between the two arms. In terms of adherence, 97 out of 119 participants in the active treatment arm (81.5%) and 53 out of 96 (55.2%) of the waitlist control signed into the app. Conclusions: The MyMoodCoach app had a significant positive effect on worry and rumination, well-being, anxiety, and depression in young adults, relative to waitlist controls. This suggests it has the potential to target a known prevention mechanism. Further research is needed to examine effect on incidence and whether the app can provide longer term benefits.

Rugby union is a contact team-sport played by nearly 500,000 school children on a weekly basis in England. The contact nature of the game means there is an inherent risk of injury, and the development and implementation of rugby specific injury prevention strategies is vital to protecting the health of young players. Various strategies have been developed to prevent rugby injuries, including law changes, equipment, and neuromuscular training programmes; however, it was unclear whether the implementation of these interventions has been assessed. The first study of this thesis (chapter two) used the RE-AIM ('Reach', 'Effectiveness', 'Adoption', 'Implementation', 'Maintenance') Framework to evaluate implementation factors reported in the literature. Intervention 'Effectiveness' was the primary focus of most studies, whereas 'Adoption', 'Implementation', and 'Maintenance' were largely not reported despite their influence on 'Effectiveness'. The Activate injury prevention exercise programme has been shown to lower rugby injury risk. Activate is endorsed and disseminated by the Rugby Football Union (governing body for English rugby union) but assessment of its implementation had not yet been undertaken. As such, chapter three assessed Activate implementation in English schoolboy rugby union. Coaches had good baseline awareness of Activate and reported moderate adoption during the study, but often did not implement Activate as intended, shortening the duration or session frequency. Chapter four assessed how attendance at a coach education workshop could influence behavioural determinants of Activate use. Attendees had significantly greater Activate adoption and adherence during the season, which was associated with greater post-season task self-efficacy. Barriers and facilitators to implementing Activate in English schoolboy rugby union were assessed in a qualitative study (chapter five), with coaches generally holding positive views towards Activate and injury prevention. However, most reported modifying Activate due to lack of time or to maximise player engagement. Coaches reported players often acted as delivery-agents, despite players appearing to lack awareness of Activate (chapter two). Although Activate efficacy was previously established, its effectiveness in the applied setting needed to be assessed. Chapter six describes a quasi-experimental study investigating the injury risk of schoolboy rugby players exposed to Activate versus those who were not. Individuals on teams adopting Activate had lower training and match injury incidence, whilst those using the programme three times per week had a significantly lower match and training than those using the programme < 1 session per week. However, poor implementation was again noted with only one team using whole phases, exercise progressions and full adherence. This is the first body of work to assess the implementation and effectiveness of the Activate injury prevention exercise programme in English schoolboy rugby union. Whilst Activate was rarely implemented as intended, it was effective at preventing injuries in English schoolboy rugby union.

Introduction: Emotional problems in childhood and adolescence are the most common mental health concerns affecting young people in low- and middle-income countries (LMICs). The frequent co-occurrence of emotional problems such as anxiety and depression with risk factors is often associated with negative outcomes and can cause significant impairments that tend to persist into adulthood. Children and adolescents experiencing elevated depressive or anxiety symptoms, but not fulfilling the criteria for a diagnostic mental health disorder, are often left without adequate treatment. Despite important mental health implications for youth however, limited to no research in LMICs such as Mauritius has documented the prevalence of emotional problems in order to inform preventative interventions for children and adolescents with emotional problems. This thesis aimed to close this gap by firstly assessing the prevalence of emotional problems in LMICs and Mauritius and secondly by adapting a transdiagnostic evidence- based intervention programme (i.e. Super Skills for Life) for prevention of emotional problems among vulnerable children and adolescents living in residential care institutions (RCIs). Methods: To achieve these aims, four studies were conducted with a mixed- method research design. Study 1 examined the prevalence of emotional problems among children and adolescents in LMICs through a systematic review analysis of 43 studies (N = 95,512) across 20 LMICs. Study 2 specifically examined the prevalence of emotional problems and the associated risk factors among adolescents in Mauritius (N = 818). Study 3 examined the acceptability and feasibility of the SSL programme through a cultural adaptation of the intervention among a sample of children and adolescents (N = 36) in RCIs. The findings of Study 3 led to a randomised controlled trial in Study 4 (N = 100) in order to examine the effectiveness of the SSL in reducing emotional problems and building emotional resilience among children and adolescents in RCIs. Results: The prevalence of emotional problems across LMICs was found to be 41% with a similar prevalence rate of 32% among Mauritian adolescents who were at higher risk of emotional problems. The SSL was found to be acceptable and feasible through a cultural adaptation of the programme content, recruitment, procedures and research method design. The informed RCT study evidenced the effectiveness of the adapted SSL in reduction of emotional problems, behavioural problems, maladaptive emotion regulation strategies and inhibitory control following the SSL intervention and at follow-up. Across the studies, gender and emotion regulation strategies emerged as significant risk factors of emotional problems. Discussion: Overall, the studies indicated that Mauritius is not devoid of emotional problems and young Mauritian people are in need of preventative interventions. The SSL is an effective evidence based programme that can help reduce emotional problems and build the emotional resilience of the children and adolescents in RCIs. Collectively, the findings of this thesis have important implications regarding the prevalence and prevention of youth emotional problems in Mauritius. The outcomes and findings of the studies, a first of its kind, were reviewed with recommendations for future research of a similar nature.

There are approximately 10,000 lateral ankle sprains (LAS) occurring a day worldwide, with a significant impact on economy, workforce and individuals, with medical costs in the UK ranging from £940-£1,314 per injury. Long term issues have been reported in 70% of individuals, including pain and instability. A risk factor for LAS that has been identified is lateral centre of pressure (COP) during walking and running, however this is time consuming and costly to establish. One key aetiology of LAS, is incorrect landing with the foot in a more supinated position causing the COP to be lateral. The first study in the thesis (Chapter 3) is titled "Screening for laterally deviated plantar pressure during stance using the Cumberland ankle instability tool and anthropometric measures". The Objective was to identify a novel method in which individuals with a lateral COP during running could be easily identified. 32 healthy males aged 18-45 years had foot pressure data collected whilst running on a treadmill for 2 minutes using a pressure insole system for classifying the participants as medial or lateral strikers. Data including height and body mass, lower limb anthropometrics (ankle range of movement (ROM), Knee ROM, calf circumference, foot length and width and arch height) was collected, the Cumberland Ankle Instability Tool (CAIT) and the Tegner activity level was also used. As a result of the study a model was created using binary logistic regression with the collected data, the model had a sensitivity of 71.4% and a specificity of 54.5% when identifying medial and lateral strikers. A validation trial was also done, comprising of 15 healthy active Asian males recruited by The Chinese University of Hong Kong it reported a 73.3% accuracy. The study concluded that it is possible to identify individuals with a lateral COP using basic anthropometric measures and the CAIT. The second study (Chapter 4) is titled "Effect of 8-week treadmill running with peroneal muscle functional electrical stimulation on laterally deviated centre of plantar pressure position and star excursion balance test performance". This study follows on from the previous study using participants that were identified as having a laterally deviated COP. The Objective was to establish the effect that an 8-week training protocol using FES has on both COP position and SEBT performance. A group of 14 healthy males with a laterally deviated COP during running were recruited from study 1 they were single blinded into a control or intervention group. Participants in the intervention group were allocated a level of FES stimulation to their peroneal muscles based upon comfort. Participants ran on a treadmill for 15 minutes at a comfortable place twice a week for 8 weeks. As part of data collection COP position data were collected at 3 time points (immediate, post intervention, 4 week follow up). SEBT was also assessed pre and post intervention. On analysis there was a significant difference in the results post intervention at max pressure for intervention M=0.7(±0.7) and control M=-6.0 (±4.6) conditions; t(6)=-2.9, p < 0.05. At the conclusion of the study FES was found to have an effect, moving COP position from lateral to medial. SEBT has also been found to improve in posterior, posterior-medial and posterior-lateral directions. A third study (Chapter 5) is titled "Functional electrical stimulation of peroneal muscles on balance in healthy females: a cohort study". This study focused on balance and FES, impaired balance is linked with lateral ankle sprain risk and has been associated with peroneal strength and reaction times. The objective was to assess the effect of FES on balance using total COP excursion length. Fifteen healthy females performed single and double-leg standing balance tests with eyes open and closed on a force plate, before and after 15-minute FES intervention during treadmill running. The total excursion of COP in single and double-leg stance with eyes open reduced significantly after FES intervention by 14.7% (p < 0.001) and 5.9% (p = 0.031) respectively. The eyes closed condition exhibited a 12.7% (p = 0.002) reduction in single-leg stance but did not significantly change in double-leg stance (p > 0.05). In conclusion the study identified a positive impact from the programme with an increase in balance for both single and double leg stance. Overall, these studies have identified a potential tool to detect individuals with a lateral COP in a clinical setting and use FES to both change COP position and improve balance.

Collings, R. Insoles to ease plantar pressure in people with diabetes and peripheral neuropathy: a feasibility randomised controlled study with embedded qualitative component. Background: Diabetic foot ulceration is a devastating complication of diabetic foot disease. Therapeutic footwear and insoles are one preventative strategy to reduce elevated plantar pressures associated with foot ulcer risk. However, their effectiveness is variable, difficult to predict and evaluated by the high-risk strategy of observing foot health and tissue integrity over time. Aim: To develop and test, in a feasibility randomised controlled trial (fRCT), an insole prescription and fabrication intervention appropriate for chairside delivery to reduce plantar foot pressures and consequent foot ulceration risk in people with diabetes. Methods: The Medical Research Council's framework for developing and evaluating complex interventions was adopted. The first phase developed the novel optimised insole intervention, informed by stakeholder and patient/public involvement and a systematic review with three meta-analyses. The second phase involved conducting a double-blinded multicentre fRCT with an embedded qualitative study. In addition to usual care, participants were randomised to either an optimised insole group or an active control group. Participants were assessed at baseline and then again at 3, 6 and 12 months with clinical outcomes of mean peak plantar pressure (MPPP) reduction for identified regions-of-interest and ulcer incidence. The embedded qualitative study involved semi-structured interviews with 12 study participants and three podiatrists to explore their experiences of the intervention and trial procedures. Data were analysed using descriptive statistics (quantitative data) and thematic analysis (qualitative data). Results: The systematic review identified the best footwear and insole design features for offloading the plantar surface of the foot to prevent foot ulceration in people with diabetic peripheral neuropathy. The review involved 54 studies, with random-effects modelling finding plantar pressure reductions with an arch profile (37kPa), metatarsal addition (36kPa) and with pressure informed design (75kPa). An optimised insole algorithm based on real-time temporal load and pressure profiles was created to underpin the optimised insole intervention. The fRCT screened 142 participants from which 61 participants were recruited; 30 randomised to the optimised insole group and 31 to the active control insole group. Forty-two participants completed the study and at 12-months, 69% of patient-reported questionnaires were returned and 68% of clinical outcomes were collected. There were seven incidences of foot ulceration in the active control group and 10 in the optimised insole group. Mean difference in MPPP between the optimised insole and active control insole for all regions-of-interest combined favoured the optimised insole, with increases from 87kPa at postrandomisation to 255kPa at 12-months. Thematic analysis revealed three themes; accepting the study, behaviour and support during study procedures, and impact from study participation. Conclusion: An optimised insole intervention has been developed to reduce the risk of foot ulceration in people with diabetic peripheral neuropathy. The feasibility study results suggest that the optimised insole holds promise as an intervention and that a full RCT to evaluate the clinical and cost-effectiveness of this intervention is feasible and warranted for people with diabetic peripheral neuropathy.

Background: A Stop Smoking in Schools Trial (ASSIST) is a social network intervention designed to disseminate non-smoking messages among secondary school children via student selected peer supporters. Message diffusion is restricted to the school year, with limited understanding of the extent and context of message diffusion in peer supporters' wider social networks. The aim of this thesis was to address this gap by examining whether ASSIST had the potential to influence smoking behaviour, attitudes, and knowledge of smoking related harm, beyond the school year. Method: Two literature reviews and a systematic review were conducted to inform the empirical data collection phase, which employed a qualitative social network design using a mixed methods analytical approach. A novel research method to collect data from young people (egocentric sociograms using coloured dots and post-it notes to prompt further discussion) and recruitment approach were piloted with 16 peer supporters from two secondary schools. Network data was quantitatively analysed using Excel and qualitative data from the interviews was analysed thematically using NVivo and Framework. Results: The potential reach of message diffusion among the 16 peer supporter networks was large, with the combined number of people nominated being 151. The actual number of reported conversations was 103. Two-fifths (41%) of these conversations were with school friends and three-fifths (59%) with peer supporter family and friends outside of school. Thematic analysis of reported conversation content revealed three main types of conversation: protecting non-smokers from starting to smoke; encouraging smokers to stop; and protecting people from secondhand smoke in wider social networks. Peer supporters perceived impact with 37 people from their social networks, with examples of both positive and negative impact, focusing on the dynamics of a child speaking to an adult. Conclusions: Smoking prevention message diffusion was not limited to the school year, reaching into the wider networks of peer supporters. Future interventions using the ASSIST model should consider changing the guidance that message diffusion should be limited to students in their year group only, as this may reduce the extent of message diffusion. Peer supporters should be better supported to think about whom they could speak to in their social network and the associated potential risks and ethical implications carefully considered.

Background: Anxiety disorders are amongst the most common mental health disorders in children and are becoming more prevalent. As such, it is essential that interventions are timely and effective. Schools are being recognised as fertile ground for fostering positive mental health and for implementing preventative programmes. Method: Systematic database searching yielded 1113 studies with 52 duplicated papers. 1044 studies were excluded against eligibility criteria for various reasons: age group was too high, delivery of programme was not actually universal. Twelve studies from the remaining seventeen were selected for this review after critical appraisal. All twelve were randomised control trials with large enough sample sizes ranging from one whole school population to forty schools' population. Results: The majority of the universal programmes in this review reported significant effects on the reduction of anxiety symptomology with some reporting sustained improvements over time. Areas of specific impact included: reduction of oppositional coping strategies; reduction in behaviour difficulties; increase in social and emotional competence and improved social skills and ability to cope. One study reported improved social climate and less bullying in the classroom. Where parents or carers were involved in a programme, they reported significant gains in their children's coping skills and emotional and behavioural competence, reductions in their own stress and more positive perceptions of their children's behaviour. Conclusions: Universal anxiety prevention programmes delivered at primary school level show promising outcomes for children. Implications for teacher training, engagement with delivery and parental involvement are discussed.

The improvement of children's mental health has been a governmental priority over recent years (DH & NHS, 2015; DHSC & DfE, 2017;2018), with increasing numbers of children and young people experiencing mental health difficulties (Sadler et al., 2018, PHE, 2016; WHO, 2014). Guidance positions schools as providing a key platform for the improvement of children's mental health, through approaches the seek to identify and prevent problems, provide quicker access to support and promote resilience. Despite parents being in a prime position to promote children's resilience and support mental health, evidence suggests that there are challenges in the way that the parent role is currently conceptualised within the agenda to improve children's mental health. Research indicates that parents are one of the most likely persons to refer their child to a professional for support with their mental health (Crenna-Jennings & Hutchinson, 2019; Frith, 2017), this in light of rising referrals to child and adolescent mental health services (CAMHs), stretched services and increased waiting times points towards the need to explore and consider how the parent role might be supported within this context. This research adopted a constructivist grounded theory (Charmaz, 2014) approach to explore collaboratively with 11 parents of primary school aged children, how they understood their role in the promotion of their children's positive mental health and in preventing possible mental health problems. The findings indicated that the parents saw themselves as holding the responsibility for their children's mental health and were motivated to work alongside school in order to fulfil this role. In implementing actions to promote and support their children's mental health, the parents experienced empowerment, disempowerment and uncertainty, drawing attention towards the need for parentally inclusive approaches that recognise and empower them within their role. The research finds implications for schools and for Educational Psychologists (EPs) in light of their unique and distinctive role working with schools, children and parents (Beaver, 2011; Cameron, 2005).

The uninterrupted spread of malaria, besides its seasonal uncertainty, is due to the lack of suitable planning and intervention mechanisms and tools. Several studies have been carried out to understand the factors that affect the development and transmission of malaria, but these efforts have been largely limited to piecemeal specific methods, hence they do not offer comprehensive solutions to predict disease outbreaks. This thesis introduces a 'holistic' approach to understand the relationship between climate parameters and the occurrence of malaria using both mathematical and computational methods. In this respect, we develop new climate-based models using mathematical, agent-based and data-driven modelling techniques. A malaria model is developed using mathematical modelling to investigate the impact of temperature-dependent delays. Although this method is widely applicable, but it is limited to the study of homogeneous populations. An agent-based technique is employed to address this limitation, where the spatial and temporal variability of agents involved in the transmission of malaria are taken into account. Moreover, whilst the mathematical and agent-based approaches allow for temperature and precipitation in the modelling process, they do not capture other dynamics that might potentially affect malaria. Hence, to accommodate the climatic predictors of malaria, an intelligent predictive model is developed using machine-learning algorithms, which supports predictions of endemics in certain geographical areas by monitoring the risk factors, e.g., temperature and humidity. The thesis not only synthesises mathematical and computational methods to better understand the disease dynamics and its transmission, but also provides healthcare providers and policy makers with better planning and intervention tools.

This thesis aims to inform strategies to improve care for mothers after a pregnancy affected by gestational diabetes (GD) in relation to risk of type 2 diabetes (T2D) after delivery. Through a systematic review (including 129 studies of 310,214 women with GD, Study 1) and study-level meta-regression, I highlighted that a third of women developed T2D within 15 years of GD a pregnancy. Progression was higher in non-White European populations compared to other populations, and in those with higher BMI at follow-up. These findings emphasised the need for both sustained follow-up after GD through screening, and interventions to reduce modifiable risk factors. Currently, screening for T2D is recommended at six to 13 weeks after a GD pregnancy, then subsequently at regular intervals. Consistent with other studies, I identified that 25.4% patients (n=556) did not undergo a postpartum test at a local hospital between 2014 and 2017 (Study 2). It is also known that many mothers find it challenging to maintain a healthy lifestyle after a GD pregnancy, and do not make changes to their diet or activity levels to reduce their risk. To explore reasons for this, I conducted two qualitative systematic reviews and developed 30 recommendations to promote screening attendance, healthy diet and physical activity based on the findings (Studies 3 and 4). I then elicited an evaluation of these recommendations from 20 mothers with previous GD (Study 5), in addition to their own ideas for improving postpartum support. Lifestyle advice amid a busy schedule and tips for sustaining changes, along with flexibility in screening appointments and invitations, were welcomed. I have highlighted that women with GD are an easily-identifiable group at high risk of T2D, and there is a need for interventions to manage this risk. I have provided evidence to support and inform such interventions during pregnancy and postpartum, which could include feasible adaptation to current practice, to improve care.

Alcohol use is considered as one of the risk factors that contribute to social and physical harm and disease development globally. Alcohol use onset usually takes place long before adulthood and the surrounding environment has a central role in the development of alcohol use behaviour among children. Thus, targeting parents in prevention programmes has become more common in the past 20 years. This thesis aimed to investigate the relationship between parental attitudes towards children’s alcohol use and their children’s alcohol use and to evaluate a universal parent-oriented alcohol use prevention programme. A systematic review and meta-analysis (k=29 studies) of observational and experimental studies was conducted to assess the former. The findings showed that children whose parents had less restrictive attitudes towards children’s alcohol use had 1.45 (95% CI=1.17–1.80) times higher odds of initiating alcohol use, 1.52 (95% CI=1.24–1.86) times higher odds of drinking alcohol frequently, and 1.58 (95% CI=1.35–1.85) times higher odds of getting drunk. A similar relationship was present between perceived parental attitudes and children’s alcohol use frequency (OR=1.76, 95% CI=1.29–2.40), but no evidence was found for a relationship between perceived attitudes and alcohol use initiation (OR=1.65, 95% CI=0.93–2.94). When data from the Effekt trial was included, the change in pooled effect sizes was mostly marginal. The only exception involved the relationship between perceived parental attitudes and children’s alcohol use initiation, which became statistically significant (OR=1.55, 95% CI=1.14–2.11). Parental attitudes were only weakly positively correlated with perceived parental attitudes (r=0.27, p≤0.001). These findings confirmed and extended the earlier findings presented by Swedish researchers 20 years ago who developed a prevention programme (ÖPP, later called Effekt) to delay and reduce alcohol use among 13–16-year-old children by targeting parental attitudes. The programme was adapted and implemented in Estonia in 2012–2015 among the parents of 11–13-year-old children. The format (i.e. two meetings and two newsletters twice a year, agreements between parents) and the main messages focusing on parental attitudes, alcohol supply and communication were kept unchanged; but more emphasis was put on authoritative parenting, other risk behaviours besides alcohol use and active communication with parents. A matched-pair cluster-randomised controlled trial was carried out among children (n=985) and their parents (n=790) in 66 schools (34 intervention, 32 control) in 2012–2015. While no evidence for an intervention effect was found for students’ alcohol use initiation, past year use or drunkenness, the parents in the intervention group had double the odds (OR=1.92, 95% CI=1.31–2.83) of having restrictive attitudes by the end of the programme than the parents in the control group. A qualitative study at the end of the programme with the facilitators (n=8; focus group), teachers (n=12; individual interviews) and parents (n=24; individual interviews) indicated that the participants perceived the programme to have a possible effect on parents’ attitudes and behaviour, but were unsure as to whether this would have an impact on children’s drinking behaviour. One of the main perceived reasons behind reduced effectiveness was the issue of low participation rates at the meetings throughout the programme. Suggested reasons behind that included the general practice of not attending meetings in higher grades, the parents’ perception of the importance of their role decreasing as children get older, having enough knowledge on the topic, having minimal information about the programme before it started, perceiving that their parenting skills were questioned and having liberal views on the matter. In general, participants supported the idea of the long-term continuation of the programme; although they recommended changes in the content (e.g. reducing the repetitive content, including additional relevant topics, more practical examples, tailored content) and format (e.g. more emphasis on engaging teachers, including children). The findings of the thesis will provide valuable insights for the development of family-based programmes that target substance use prevention by focusing on a broader set of factors that influence behaviour and by conducting qualitative assessment in parallel with quantitative to better understand potential values and weaknesses and participants’ experiences and attitudes towards the programmes.

This research work presents the design and implementation of a host-based Intrusion Detection and Prevention System (IDPS) called HIDROID (Host-based Intrusion Detection and protection system for andROID) for Android smartphones. It runs completely on the mobile device, with a minimal computation burden. It collects data in real-time, periodically sampling features that reflect the overall utilisation of scarce resources of a mobile device (e.g. CPU, memory, battery, bandwidth, etc.). The Detection Engine of HIDROID adopts an anomaly-based approach by exploiting statistical and machine learning algorithms. That is, it builds a data-driven model for benign behaviour and looks for the outliers considered as suspicious activities. Any observation failing to match this model triggers an alert and the preventive agent takes proper countermeasure(s) to minimise the risk. The key novel characteristic of the Detection Engine of HIDROID is the fact that it requires no malicious data for training or tuning. In fact, the Detection Engine implements the following two anomaly detection algorithms: a variation of K-Means algorithm with only one cluster and the univariate Gaussian algorithm. Experimental test results on a real device show that HIDROID is well able to learn and discriminate normal from anomalous behaviour, demonstrating a very promising detection accuracy of up to 0.91, while maintaining false positive rate below 0.03. Finally, it is noteworthy to mention that to the best of our knowledge, publicly available datasets representing benign and abnormal behaviour of Android smartphones do not exist. Thus, in the context of this research work, two new datasets were generated in order to evaluate HIDROID.

Background: It has been consistently reported in the literature that adolescent dancers have a high injury prevalence. Most injuries are reported as overuse onset and the most affected body region is the lower limb. Growth and maturation have been reported as non-modifiable whereas poor motor performance in power and strength as modifiable risk factors. Methods: A systematic review was conducted to evaluate the association of growth, maturation and overuse injuries in aesthetic sports/disciplines. This was followed by a prospective cross­ sectional study to assess the relationship of injury incidence and primarily countermovement­ jump (CMJ), a valid indicator of motor performance, and secondarily gender differences and maturity status. Three randomized controlled trials (RCT) were conducted to assess 1) the feasibility of a trial in a vocational environment, 2) to conduct power and sample calculation and 3) to assess the effects a neuromuscular injury prevention intervention on countermovement-jump, reactive strength-index (RSI), isometric mid-thigh pull (IMTP) and inter-limb asymmetry (ASYM) in adolescent ballet dancers. Results: The results from the systematic review were inconclusive, due to the heterogeneity of the studies, the research design, and sample size. The cross-sectional study revealed no association between injury incidence and CMJ; and there was no statistically significant gender or maturity status differences in injury incidence. The RCT results demonstrated no statistically significant between-group differences in the mean scores of all the measured parameters. Both groups revealed potentially clinically meaningful difference, between pre and post intervention scores in CMJ and IMTP. No harm was observed, however, less injuries were reported for the intervention group during the duration of the trial. Conclusion: The results of this investigation indicate no association of CMJ and injury incidence, and no gender or maturity status differences in injury incidence were observed. The RCT results indicate no significant between-group post intervention differences in all the assessed parameters. The observations about the potentially clinically meaningful results in power and strength, may warrant further investigation in this area of study. Research in injuries and dance is particularly important, given the high prevalence, suggesting that more work is needed in this field to ameliorate the detrimental effects of injury in this population.

Since the 1920s, medical professionals and researchers have been significant concerned with traumatic brain injuries sustained through sporting participation. Indeed, research has shown that subconcussive, concussive and repetitive trauma to the head can lead to a range of neurological, physiological, psychological and social issues and deficiencies. Yet, despite these concern, limited precautions and social progress has been forthcoming in regard to preventing or even reducing injuries within many team sport contexts (soccer and rugby being two examples). Of particular worry is that many sports, that have a high-risk of injury and brain injury for the youth population, also are delivered as part of the secondary school physical education curriculum. As such, this interdisciplinary thesis was concerned with exploring if tackling should be banned within the secondary school physical education environment. Firstly, through an analysis of how government and sporting institutions responded to the call to remove tackling from school sport, I found that officials and representatives used common discursive strategies to justify not taking preventative action. Secondly, in an exploration of the governance relationships between the Rugby Football Union, young people and school sport, it was recognised that there is limited opportunity for young people to directly input and influence decision-making in rugby union. Finally, through a national survey, it is apparent that rugby union is widely delivered in schools and most often a compulsory part of the secondary school physical education curriculum. This is in spite of being identified by most schools as their highest risk activity. It, therefore, is evident that the social provision is not appropriate for contact rugby, based upon the injury level, the lack of informed decision-making and limited preventative measures to remove the risks associated with traumatic brain injuries.

Background: In Northern Ireland (N.I) the overall prevalence rates of mental ill health are approximately 25% higher than other parts of the U.K (Bamford., 2006). Research suggests approximately 45,000 adolescents in N.I suffer with mental ill health at any one time (Betts & Thompson., 2017). Despite this, the current available evidence on the prevalence of mental ill health in adolescent in N.I and in the Republic of Ireland (R.O.I) is scarce (Betts & Thompson., 2017; Dooley, Fitzgerald & Giollabhui., 2015; Harley et al., 2015). The lack of existing prevalence data within N.I for mental health disorders in adolescence is particularly concerning due to the rising rates of self-reported poor emotional wellbeing, higher rates of antidepressant prescribing among young people and increasing rates of self-harm (SH) and completed suicide among young people in N.I (PHA., 2014; O'Neill, Corry, McFeeters, Murphy & Bunting., 2015). Unfortunately, the lack of existing prevalence data for mental health disorders in adolescence means that our understanding of mental health problems in N.I remains largely elusive. Anxiety and mood disorders are the most prevalent disorders among young people in today’s society and as such are considered a major public health concern (Stockings et al., 2015). Developing either of these disorders in the younger years is associated with increased risk of suicide, future psychopathology and a range of psychosocial issues. (Balazs et al., 2013; Yap et al., 2018). Furthermore, it is well documented that a substantial degree of comorbidity exists between anxiety and mood disorders in adolescence. In fact a solid empirical evidence base suggests that when it comes to depression and AD’s, comorbidity is the rule rather than the exception (Essau et al., 2017). Research has suggested that the clinical outcomes of co-occurring anxiety and depression are significantly more impairing than for either disorder alone (Garber & Weersing., 2010; Zhou et al., 2017). Moreover, recent research has also demonstrated the presence of co-occurring symptoms of depression and anxiety in subclinical forms among adolescents within the general population (van Lang, Ferdinand, Ormel & Verhulst., 2006; Wadsworth, Hudziak, Heath & Achenbach., 2001). Despite the fact that these sub clinical symptoms of depression and anxiety do not meet diagnostic thresholds, they have been found to contribute to high levels of distress for those who experience them and greatly increase the risk of future psychopathology and suicidality (Balázs et al., 2013; Jinnin et al., 2017; Løvaas et al., 2018; Mullarkey et al., 2019). However, despite the clear clinical relevance of sub threshold symptoms of anxiety and depression in adolescence, it remains a largely understudied area (Jinnin et al., 2017). This, coupled with lack of consensus regarding how best to distinguish anxiety and depression during childhood and adolescence, with some researchers suggesting there is little to separate anxiety and depression in the younger years and therefore may take the form of an unidimensional construct (Garber & Weersing., 2010; McElroy, Fearon, Belsky, Fonagy & Patalay., 2018; Rouquette et al., 2018), creates a key gap within the current literature to understand how depression and anxiety symptoms are expressed among adolescents within the general population. Overall, issues such as high rates of comorbidity, heterogeneity of symptoms and the limited evidence supporting depression and anxiety disorders as discrete diagnostic entities (Beard et al., 2016; Fried., 2015), has challenged researchers to begin to study the complexity of these constructs in a unique way. Specifically Fried and colleagues suggested that “this calls for more transdiagnostic work” (p. 6, Fried et al., 2017). With this in mind, exploring a factor demonstrated to play a transdiagnostic role in the onset and maintenance of both anxiety and depression symptoms would therefore be a fruitful avenue of exploration. One such factor identified in the literature is emotional regulation (ER; Schäfer et al., 2017). Therefore, this thesis aims to explore self-reported symptoms of anxiety and depression, specifically generalised anxiety disorder (GAD) and major depressive disorder (MDD) based symptoms among adolescent females within the general population through the lens of ER. Aims: This thesis is concerned with three key lines of enquiry; (1) how common symptoms of GAD and MDD are among school aged females in the general population, (2) how are these symptoms expressed among school aged females, (3) what role does ER ability play in relation to GAD and MDD symptom interplay and expression among school aged females. Methods: This study utilised data from a cross sectional school-based study. A total of 615 adolescent females (M = 13.32; SD = 2.02) were recruited from two post primary schools in the north-west region of N.I. Participants completed measures assessing demographic information, deficits in ER, major depressive disorder (MDD) and generalised anxiety disorder (GAD) symptomatology, self-harm (SH) and thoughts of SH and peer victimisation. A series of advanced statistical models including factor analysis, latent variable modelling and network analysis (NA) were employed to test the research questions. Firstly, confirmatory factor analysis (CFA) and latent class analysis (LCA) were utilised to (i) identify the dimensional structure of MDD and GAD in a school based sample of adolescent females and (ii) explore the potential heterogeneity of MDD and GAD symptoms among adolescent females. Next, exploratory factor analysis (EFA), CFA and latent profile analysis (LPA) were employed to (i) identify the dimensional structure of ER ability in a school-based sample of adolescent females and (ii) explore the potential heterogeneity of ER ability among adolescent females. A series of regression based analyse were then used to explore the differences between the ER classes using a range of risk variables and mental health outcomes. Finally, network analysis (NA) was used to examine the structure of MDD and GAD based symptoms in the sample and examine the distinctions that emerge in the network structure of anxiety-depression between adolescents with varying degrees of ER ability. Results: In this sample 10.9% met the criteria for self-reported MDD symptoms and 16.9% met the criteria for self-reported GAD symptoms. Lifetime prevalence of SH and thoughts of SH across the entire sample was 11.7% and 10.2% respectively. The structure of GAD and MDD was successfully modelled as i) four homogenous sub-populations characterised by different patterns of comorbidity, no distinct groups with ‘pure’ GAD or ‘pure’ MDD occurred, and ii) a network of causally associated symptoms, with no evidence of modularity regarding the distinct domains of GAD and MDD. Regarding ER, CFA confirmed a six-factor solution was the most parsimonious model. LPA revealed the presence of three distinct profiles, each with varying degrees of deficits in ER ability. The dysregulated class (characterised by higher levels across all six factors), exhibited greater risk and were significantly more likely to experience several mental health outcomes. The structure of three separate GAD-MDD networks was compared using the three ER ability profiles generated from the LPA. The ‘low ER ability’ network as predicted, contained the most positive associations, with a network structure consistent with previous similar studies which have used psychiatric adult samples. However, no evidence of modularity was demonstrated. Symptom connectivity for the ‘low ER’ group was significantly greater compared to the ’high ER’ group. The findings tentatively suggest the significance of the ‘transdiagnostic quality’ of ER in GAD and MDD symptoms in adolescence from both a common cause and casual systems perspective, highlighting the potential implications when ER processes are compromised. Conclusions: The current thesis is novel in nature for two key reasons i) contributing to and updating the empirical evidence base surrounding the prevalence of common mental health problems in the younger years in N.I. and, ii) offering a unique contribution to the examination of the role of protective factors i.e. ER in the study of symptoms of adolescent MDD and GAD from both a common cause and network perspective.

There is a great deal of importance placed upon the conceptual strategies of diversion and early intervention in the field of contemporary youth justice. Despite the centrality of these concepts, comparatively little attention has been paid to critically exploring how they are interpreted and enacted by professionals at the front line. This thesis investigates the meaning of the highly contested rationales of diversion and early intervention in relation to the current policy context of enacting a 'Whole System Approach' (WSA) to prevent youth crime in Scotland. Utilising a qualitative case study design, the field work involved: analysis of questionnaires following a scoping study, documentary analysis of protocols and guidance documents, multiple observations of meetings and events across three case study areas, and forty-two interviews with a range of youth justice professionals. This thesis makes a valuable contribution that is relevant for both professional and academic audiences. Firstly, the research brings considerable insight into the many intricacies and challenges involved for professionals working to prevent crime through early intervention and diversion. The research found that these strategies are conceptualised differently in practice, leading to ambiguity and variability in relation to local application. The thesis also considers the key implications arising from these differing conceptualisations, which raise some problematic issues of relevance to wider critical debates in youth justice. In particular, this thesis contributes to the academic literature through critically exploring the problems associated with responding to welfare concerns within a youth justice context, upholding children's rights within a pre-statutory context, and the implications of allowing ample discretion and local experimentation in youth justice policy implementation. Lastly, the research also found some evidence of neo-liberal influence in the implementation of the WSA, serving as a reminder that multiple and complex discourses are consistently at play within the contemporary youth justice sphere.

BACKGROUND. Unhealthy lifestyle behaviours such as physical inactivity are global risk factors for chronic disease. Despite this, a substantial proportion of the UK population fail to achieve the recommended levels of physical activity. This may partly be because the health messages presently disseminated are not sufficiently potent to evoke behaviour change. There has been an exponential growth in the availability of digital health technologies within the consumer marketplace. This influx of technology has allowed people to self-monitor a plethora of health indices, such as their physical activity, in real-time. However, changing movement behaviours is difficult and often predicated on the assumption that individuals are willing to change their lifestyles today to reduce the risk of developing disease years or even decades later. One approach that may help overcome this challenge is to present physiological feedback in parallel with physical activity feedback. In combination, this approach may help people to observe the acute health benefits of being more physically active and subsequently translate that insight into a more physically active lifestyle. AIMS. Study One aimed to review existing studies employing fMRI to examine neurological responses to health messages pertaining to physical activity, sedentary behaviour, smoking, diet and alcohol consumption to assess the capacity for fMRI to assist in evaluating health behaviours. Study Two aimed to use fMRI to evaluate physical activity, sedentary behaviour and glucose feedback obtained through wearable digital health technologies and to explore associations between activated brain regions and subsequent changes in behaviour. Study Three aimed to explore engagement of people at risk of type 2 diabetes using digital health technologies to monitor physical activity and glucose levels. METHODS. Study One was a systematic review of published studies investigating health messages relating to physical activity, sedentary behaviour, diet, smoking or alcohol consumption using fMRI. Study Two asked adults aged 30-60 years to undergo fMRI whilst presented personalised feedback on their physical activity, sedentary behaviour and glucose levels, following a 14-day wear protocol of an accelerometer, inclinometer and flash glucose monitor. Study Three was a six-week, three-armed randomised feasibility trial for individuals at moderate-to-high risk of developing type 2 diabetes. The study used commercially available wearable physical activity (Fitbit Charge 2) and flash glucose (Freestyle Libre) technologies. Group 1 were offered glucose feedback for 4 weeks followed by glucose plus physical activity feedback for 2 weeks (G4GPA2). Group 2 were offered physical activity feedback for 4 weeks followed by glucose plus physical activity feedback for 2 weeks (PA4GPA2). Group 3 were offered glucose plus physical activity feedback for six weeks (GPA6). The primary outcome for the study was engagement, measured objectively by time spent on the Fitbit app, LibreLink app (companion app for the Freestyle Libre) as well as the frequency of scanning the Freestyle Libre and syncing the Fitbit. RESULTS. For Study One, 18 studies were included in the systematic review and of those, 15 examined neurological responses to smoking related health messages. The remaining three studies examined health messages about diet (k=2) and physical activity (k=1). Areas of the prefrontal cortex and amygdala were most commonly activated with increased activation of the ventromedial prefrontal cortex predicting subsequent behaviour (e.g. smoking cessation). Study Two identified that presenting people with personalised feedback relating to interstitial glucose levels resulted in significantly more brain activation when compared with feedback on personalised movement behaviours (P < .001). Activations within regions of the prefrontal cortex were significantly greater for glucose feedback compared with feedback on personalised movement behaviours. Activation in the subgyral area was correlated with moderate-to-vigorous physical activity at follow-up (r=.392, P=.043). In Study Three, time spent on the LibreLink app significantly reduced for G4GPA2 and GPA6 (week 1: 20.2±20 versus week 6: 9.4±14.6min/day, p=.007) and significantly fewer glucose scans were recorded (week 1: 9.2±5.1 versus week 6: 5.9±3.4 scans/day, p=.016). Similarly, Fitbit app usage significantly reduced (week 1: 7.1±3.8 versus week 6: 3.8±2.9min/day p=.003). The number of Fitbit syncs did not change significantly (week 1: 6.9±7.8 versus week 6: 6.5±10.2 syncs/day, p=.752). CONCLUSIONS. Study One highlighted the fact that thus far the field has focused on examining neurological responses to health messages using fMRI for smoking with important knowledge gaps in the neurological evaluation of health messages for other lifestyle behaviours. The prefrontal cortex and amygdala were most commonly activated in response to health messages. Using fMRI, Study Two was able to contribute to the knowledge gaps identified in Study One, with personalised glucose feedback resulting in a greater neurological response than personalised feedback on physical activity and sedentary behaviour. From this, Study Three found that individuals at risk of developing type 2 diabetes were able to engage with digital health technologies offering real-time feedback on behaviour and physiology, with engagement diminishing over time. Overall, this thesis demonstrates the potential for digital health technologies to play a key role in feedback paradigms relating to chronic disease prevention.

Background: People with gestational diabetes mellitus (GDM) and impaired glucose regulation (IGR) are at increased risk of developing type 2 diabetes but lifestyle change can help to delay or prevent type 2 diabetes in these groups. Aims: This thesis comprises five publications which inform the development of lifestyle interventions for people with IGR and GDM by describing the epidemiology, progression to type 2 diabetes, and patient views and perceptions associated with these conditions. Methods: Publications one and two used systematic review and meta-analysis methods to describe the prevalence of IGR and GDM in Europe. A retrospective cohort design utilising routinely collected health care data from one region in Scotland was used in publications three and four to describe the incidence of IGR, and the progression from GDM and IGR to type 2 diabetes. Publication five explored women's perceptions and experiences of GDM using semi-structured interviews informed by behaviour change theory. Results: Mean prevalence of IGR and GDM in developed Europe was 22.3% and 5.4% respectively. Rates of progression to type 2 diabetes were 9% in a mean time of 34 months for IGR and 25% in a mean time of eight years for GDM. Older people with IGR living in deprived areas and women with GDM who were overweight and with higher fasting plasma glucose levels were at most risk of developing type 2 diabetes. Publication five highlighted how perceptions about the consequences of GDM and timeline and consequences of type 2 diabetes may be linked to the lifestyle change women make after diagnosis of GDM and their lack of success in maintaining these changes postnatally. Conclusions: This thesis provides a clear understanding of the prevalence of IGR and GDM, rates of progression to type 2 diabetes, and patient views and perceptions on which to base intervention planning and health care delivery.

This thesis explores the use of universal, prevention programmes in primary schools. A systematic literature review examined the effectiveness of universally targeted, schoolbased body-image programmes in children under 12. The review highlighted that approximately half of programmes were successful in reducing body dissatisfaction or improving body satisfaction. Improvements in other associated risk factors were also found. Not all results were maintained at follow-up and the longer-term impact of such programmes was not clear. There were also several methodological concerns that must be considered. An empirical study investigated the use of a bullying programme, KiVa, in Welsh primary schools and the school-level factors that predict outcomes. A mixed-methods approach was used with analysis of pupil survey data and interviews with school staff. KiVa was found to have a positive impact on bullying behaviour which continued as years progressed. School level free-school meal percentage as a proxy for socio-economic deprivation and additional learning needs were found to be predictive of KiVa outcome. Teachers also discussed several within school-factors that they felt affected implementation. The final chapter discusses the implication of the findings for future research and clinical application in relation to other research. Recommendations are made for how schoolbased programmes may be successful implemented within primary schools. Finally, a personal reflection of the research process is considered.

Provisional Question for the thesis to address: Indicated and selective prevention of common mental health problems in later life: Is there a theoretical rationale for an Acceptance and Commitment Therapy approach? Background The burden of late life depression and anxiety is significant. Even subthreshold symptoms result in great individual, community, economic and societal cost. However, common mental health problems in later life are under‐recognised and under‐treated despite evidence in support of pharmacological and psychological intervention. Previous research regarding psychological therapy for late life mental health problems has been dominated by cognitive behavioural therapy. However, the effectiveness of this approach has been questioned, leading researchers to explore alternative approaches. Acceptance and Commitment Therapy has received increasing attention from researchers keen to explore an alternative and some have argued that this approach is particularly suited to older people. In the context of demographic change and a significant increase in the proportion of community dwelling elderly there is a need to provide evidence to support the use of alternative management strategies for late life mental health problems, for example, focusing on prevention. Methods A systematic review will evaluate the current evidence for the use of ‘indicated’ and ‘selective’ prevention interventions for older people at risk of developing a major depressive or anxiety disorder due to the experience of subsyndromal symptoms or the presence of significant physical, socioeconomic, and psychosocial risk factors. This paper will be followed by an empirical article in which the relationship between psychological processes and ageing will be explored. Specifically, this study will explore psychological flexibility, the use of Selection, Optimisation and Compensation strategies, and the presence of psychopathology in a non clinical sample of community dwelling older people. Results Findings of the systematic review provide preliminary evidence for indicated and selective prevention of late life depression, however there is no clear evidence of benefits of these interventions in late life anxiety. The relationships between variables in the empirical study were explored using descriptive statistics, correlation analysis, and conditional process modelling. Although the study did not find age to be a specific predictor of variance in psychological variables explored, the study did provide empirical support for the potential to use Acceptance and Commitment Therapy with older people. Discussion The systematic review article provided preliminary evidence for the efficacy of selective and indicated prevention interventions for late life depression. However, further research is required to consolidate these findings. The empirical paper found significant relationships between the perception of positive health, reduced psychopathology and theoretical variables including cognitive fusion, engagement in valued living, and the use of Selection, Optimisation, and Compensation strategies. Cognitive fusion was found to mediate these relationships and as such, findings provide support for the use of an Acceptance and Commitment Therapy approach with older people. The theoretical and clinical implications of these findings are discussed in detail.

The six research papers and journal articles that form this submission all focus on the nature of and response to young people and young adults who have experienced relationship violence and non-partner sexual violence in New York City (NYC). These six empirical papers are based on three primary research studies in which I was the Principal Investigator spanning four years of research work: • A quantitative study of 1,312 young people in NYC high schools, • A survey of 65 survivors of sexual violence about their experiences with services (hospital, counselling, police and criminal justice) in NYC, and • A comprehensive survey of 39 emergency departments in NYC about acute care provision for sexual assault patients. These studies are innovative in that all three are ‘firsts’ in the field of violence prevention and response: ‘Partners and Peers’ was the first study of its kind to explore the prevalence of sexual and dating violence in NYC amongst high school students. This study found that 16.2% or more than 1 in 6 students surveyed reported experiencing sexual violence at some point in their lives. Of these youth, 10.1% reported experiencing non-partner sexual violence (sexual abuse or forced sex), and 14.1% reported experiencing sexual violence from a dating partner. The survey was available in both Spanish and English (both versions translated and back-translated). Passive parental consent and student assent were obtained with parental consent letters available in English, Spanish and Chinese. Three ethical review boards, including the NYC Department of Education, approved this study. ‘A Room of Our Own’ was the first study to explore from survivors’ own perspectives their satisfaction with the care and support they received post-assault in NYC with the majority of respondents having experienced a sexual assault under the age of 25 (study was approved by eight Ethics Review Boards), and ‘How Safe is NYC’ was the first study to comprehensively map protocols, procedures and services offered across Emergency Departments in NYC including how adolescent patients are treated. All three of these studies garnering significant media coverage which appeared in the New York Sun, The Washington Post, the New York Post, The New York Daily News, El Diario and on CBS news (TV) and WBAI radio. Three of the six submitted publications have already been ranked internally as part of the Moray House School of Education’s REF submission (my 4th REF submission was another journal article on a different area of child protection) and they have all been recognised as internationally excellent in terms of originality, significance and rigour. This body of work has had and continues to have significant implications for practice as highlighted in this thesis. The study of survivors’ perspectives and acute care responses in emergency departments led directly to a change in New York State Law for ambulance destination designation and a commitment from the NYC Mayor for Sexual Assault Forensic Services in all public NYC hospitals. The school-based study findings also directly led the NYC Chancellor to change the disciplinary regulations in all New York City high schools in relation to adolescent relationship violence. This research highlights the need for practitioners, policymakers and researchers to better understand the nature of relationship violence and non-partner sexual violence among adolescents and young adults in New York City in order to develop evidence-informed programmes and policies for prevention and response.

This thesis will assess the United Kingdom’s implementation of the United Nations Convention Against Torture and other Cruel Inhuman and Degrading Treatment or Punishment. It will first focus on a contextual analysis of the problem of torture, examining the circumstances in which it has historically been used, philosophical and theoretical perspectives on the practice and the political aspects of torture, including its effect on international relations. This will illustrate the circumstances in which torture is used, the motivation behind it and the way in which it affects its victims. The argument will then be made that, in view of the uniquely grave nature of the practice of torture, it is insufficient for States to merely criminalise it and punish the offenders. They must actively seek to eradicate it from society and ultimately prevent it from occurring. It is against this aim that the thesis will examine the compliance of the United Kingdom with its obligations under the Convention. This examination will look first at the international regime for the prevention of torture, focusing on the work of the United Nations Committee Against Torture. The engagement of the United Kingdom with this body will be explored in detail and the argument made that more needs to be done in order to ensure that the Committee’s recommendations are put into effect and that treatment contrary to the Convention is prevented from taking place. The final part of the thesis will assess the United Kingdom’s State practice with a focus on key institutions of the State including the courts and the legislature. This part of the thesis will seek to explore the extent to which the practices of these institutions is consistent with an overall aim of preventing torture and the extent to which they show awareness of the Convention and its requirements of the Convention in the discharge of their functions. The conclusion will be drawn that, while the Human Rights Act has gone some way towards improving compliance, more needs to be done to insure a complete implementation by the United Kingdom of its obligations under the Convention and full prevention of torture. The State must actively engage with the Committee and the organs of the State must consider the Convention Against Torture in the discharge of all of their functions to ensure that these aims are achieved.

Purpose: Postnatal depression has significant negative outcomes for both mother and baby. Cognitive-behavioural interventions have proven promising in its treatment, but there are a number of barriers, specific to the postnatal period, which lead to low take-up of treatment. Online interventions may circumvent some of these barriers. However, evidence of long-term follow-up is sparse, in spite of the importance of knowing how such treatments work over the longer-term. Methods: Long-term follow-up of postnatal women participating in a feasibility randomised controlled trial of NetmumsHWD, an online behavioural activation treatment with telephone support. Results: Retention rates of over 70 percent were obtained. There were small but non-significant effects of treatment on depressive symptomology and behavioural activation scores at 16 months post-randomisation. Baseline depression and behavioural activation scores predicted attrition prior to the implementation of outreach strategies for data collection; these systematic differences in attrition disappeared post-implementation. Measures of treatment adherence were not related to outcome. Conclusions: Collection of long-term follow-up data from postnatal women appears feasible. The findings demonstrate the importance of outreach in maximising retention, especially in relation to the generalizability of results. Future research should consider ways to assess treatment engagement and its relationship with outcome.

Mindfulness-based interventions reduce depressive symptoms and rumination, and enhance mindfulness in adults; this non-randomised controlled feasibility study aimed to determine whether these conclusions apply to young people, and whether mindfulness and rumination mediate the effect on depressive symptoms. Participants aged 12-16 received a nine-week universal mindfulness intervention in schools delivered by trained teachers (intervention group, N = 256) or their regular school curriculum (control group, N = 266). Intervention schools were matched to control schools on key variables (publicly-funded versus private, mainstream versus special needs). Young people who received the intervention reported fewer depressive symptoms post-intervention relative to controls, which was maintained at three-month follow-up. Mindfulness and rumination were unchanged immediately after the intervention, however by follow-up, intervention participants were significantly more mindful and less likely to ruminate than controls. The extent to which young people practiced mindfulness was negatively correlated with depressive symptoms at post-intervention and follow-up, positively correlated with mindfulness at post-intervention and follow-up, and positively correlated with rumination at follow-up. This universal mindfulness intervention shows promise for reducing depressive symptoms, reducing rumination and increasing mindfulness in young people, however further research is warranted, particularly regarding the mechanisms of change.

Vascular disease is the leading cause of death and disability worldwide. Incidence, risk factors, and outcome of coronary artery disease have been extensively studied, but there are fewer data on other forms of arterial disease, including carotid, aortic, visceral, and peripheral arterial disease. Although the burden of these diseases may be increasing due to the ageing population, we lack the most basic epidemiological data on which to base clinical decisions on individual patients (short and long-term prognosis); local service provision (current incidence and projected future burden); public health / screening initiatives (age and sex-specific incidence, risk factors, and outcome); and with which to assess current levels of primary prevention (pre-morbid risk factor control). Indeed, it is this lack of data, rather than a lack of treatments that is the greatest barrier to effective prevention. I have contributed to, cleaned, and analysed data from the Oxford Vascular Study, a prospective, population-based study (n=92,728) of all acute vascular events (2002-2012), and the Oxford Plaque Study, a carotid atherosclerosis biobank of over 1000 carotid plaques, in order to study these conditions. For acute aortic disease, I aimed to assess the risk factors associated with acute abdominal aortic aneurysms (AAA) and the population impact of the current UK AAA screening programme; and the incidence, risk factors, outcome, and projected future burden of acute aortic dissection. For acute peripheral arterial disease, I assessed the risk factors associated with premature onset and poor outcome, together with current levels of primary prevention. For symptomatic carotid artery disease, I studied the timing and benefits of surgical intervention in the current era; and went on to assess whether underlying carotid plaque morphology can be used to improve stroke risk stratification and help explain why ocular and cerebral stroke types have vast differences in future ipsilateral stroke risk. I found that compared with the current UK AAA screening strategy (one-off scan for men aged 65), screening of male smokers at 65 and all men at 75 would prevent nearly four-times as many deaths and three-times as many life-years lost with 21% fewer annual scans. I have also shown that incidence of acute aortic dissection is higher than previous estimates, a third of cases are out-of-hospital deaths, and uncontrolled hypertension is the most significant treatable risk factor for this condition. For acute peripheral arterial disease, the presence of multiple atherosclerotic risk factors are associated with premature onset, and severity of ischaemia, pre-morbid renal dysfunction, cardiac failure, and diabetes mellitus are predictive of future limb loss and survival. A significant proportion of acute peripheral events are AF-related in high risk patients who were not pre-morbidly anticoagulated despite having no contraindications and being at low risk of bleeding. Symptomatic carotid artery disease currently accounts for <10% of incident cerebrovascular events, and only 40% of these patients undergo surgical intervention. Due to improvements in medical therapy and on-going delays to intervention, little benefit is currently obtained from intervening in patients with <70% stenosis. Ipsilateral stroke risk is correlated with several carotid plaque features in a time-dependent manner, confirming the potential utility of plaque morphology in risk stratification. In addition, plaques from patients with cerebral events were significantly more unstable and inflammatory than from those with ocular events, helping explain differences in stroke risk between these groups. My findings advance the understanding of these conditions that form the backbone of modern vascular surgical practice, and I hope will improve prevention, clinical management, and outcome for patients with vascular disease.

The objective of this thesis is to examine which socio-economic, structural and cultural factors may influence Indian women’s propensity to contract HIV and later their ability to access the relevant healthcare services for their condition. The research draws on two theoretical frameworks, the first being Barnett and Whiteside’s (2002) concept of social structural factors of disease transmission. Second, Anderson and Aday’s (1981) model of access examines how a variety of structural and resource-based factors, e.g. area of residence, can influence usage of healthcare facilities. Two stages of data analysis were undertaken, the first being secondary statistical analysis of the National Family Health Survey III. The survey provided state level estimates on the HIV sero-status of the general population in India and data on demographic and socio-economic determinants for family planning, nutrition, utilization of healthcare and emerging health issues. The second stage of analysis consisted of a set of qualitative interviews conducted in Andhra Pradesh, India. Thirty-three interviews were conducted with female sero-positive patients and ten with HIV-infected women who were providing social services to others with the same condition. Statistical results on social structural determinants of HIV transmission illustrated that Indian women who were formerly married (OR=5.27, CI=3.07-9.04), lived in higher prevalence states (OR=3.48, CI=2.19-5.54), had a low level of education (OR=2.27, CI=1.40-3.68) and were employed (OR=1.45, CI=0.96-2.18) had significantly (<.05) higher odds of being HIV-positive in comparison to those who were not. Findings in the qualitative phase of analysis were similar but participants’ narratives illustrated that their risk of contracting HIV begun before they even had the opportunity to seek a match as they seemed to live in communities with a high level of HIV prevalence. Many of the participants commented that there were factors outside of their sphere of control, e.g. lack of education, which resulted in them having a narrow choice of potential partners. Additionally, statistical results on female participants’ access to healthcare services indicated the vast majority of HIV-positive respondents were almost certainly not aware of their sero-status as they had not undertaken an HIV test prior to the survey. As the sample of female HIV infected respondents was relatively small, it was difficult to ascertain which social factors had an impact on these participants utilisation of HIV testing services. On the other hand, respondents’ narratives from the qualitative stage of research highlighted on social structural factors which could potentially influence WLHA’s continual utilisation of HIV-related healthcare services. It was found that participants experienced the most barriers to accessing healthcare facilities in the initial phases of their treatment. These barriers were mediated by the structure of healthcare services, culturally sanctioned medical practices (e.g. physicians refusal to inform the patient of their sero-status) and quality of services.

Advancements in clinical care have led to a growing cohort of preterm-born individuals now entering adulthood. Before birth, such adults were often exposed to a suboptimal intrauterine environment, and after delivery, key developmental stages that would normally occur in utero during the third trimester had to take place under ex utero physiological conditions. Through detailed cardiovascular phenotyping, this thesis investigates the cardiovascular changes in preterm-born young adults, utilising a cohort of individuals with data collection since recruitment at birth. The detailed perinatal information was first used to design nested case-control studies to investigate the effects of early lipid and glucocorticoid exposure on long-term cardiovascular physiology in individuals born preterm. It was demonstrated that intravenous lipid administration leads to an artificial elevation of total cholesterol levels in immediate postnatal life, which is associated with long-term changes in aortic and left ventricular function proportional to the degree of cholesterol elevation. Additionally, exposure to antenatal glucocorticoids relates to a regional increase in aortic arch stiffness in young adulthood, as well as changes in glucose metabolism. It was then shown that young adults born preterm have increased left ventricular mass, out of proportion to blood pressure, and a unique three-dimensional left ventricular geometry, with reduced systolic and diastolic function compared to term-born controls. Similarly, they also show distinct differences in the right ventricle, with increased right ventricular mass and a proportion having clinically impaired right ventricular systolic function. Finally, it was demonstrated that preterm-born individuals have increased circulating levels of antiangiogenic factors in young adulthood, which relate to capillary rarefaction and blood pressure elevation. These findings are of considerable public health relevance given that nearly 10% of births are now preterm. Understanding whether modification of these variations in cardiovascular structure and function prevent the development of cardiovascular disease in this growing subgroup of the population will be of future interest.

Previous literature showed weak and sometimes contradictory evidence regarding the best interventions to prevent pressure ulcers and the best factors that can serve as predictors for ulceration. The aim of this study was to explore effective interventions and associated risk factors in the area of pressure ulcer. A retrospective approach was used to explore such interventions and risk factors in a more natural clinical environment than found in a prospective study. While retrospective studies have their limitations, one problem of prospective studies, the Hawthorn effect, is not present. In order to meet the aims of the study, a matched case-controlled design was employed. A convenience sampling technique was used to select all patients who matched the study criteria. Two groups of patients were selected. The first group developed pressure ulcer during hospitalization, the other did not. In order to have a sound and robust comparison, each patient from the pressure ulcer groups was matched or at least nearly matched with another patient from the non-pressure ulcer group for a number Waterlow sub-scores. Further criteria for selection included a minimum of three days total length of stay in hospital and being initially free of any pressure ulcer on admission for both of the study groups. Electronic medical records for all patients were revised, and multidimensional data were extracted using a data extraction sheet. Data analyses were carried out using univariate analysis (t-test, Mann-Whitney, Chi-square and Fisher’s exact test) and multivariate analysis (binary logistic regression). In univariate analysis for preventive interventions, the following interventions were significantly associated with pressure ulcer prevention (P≤ 0.05): standard hospital bed, seating cushion, static pressure redistributing mattress, re-positioning every four hours and helping the patient to sit regularly in a chair. When the effect of all interventions was adjusted through the multivariate model, the following interventions were independently associated with prevention: draw sheet, re-positioning every four hours and helping patient to sit regularly in chair (odds ratio = 0.24, 0.06 and 0.13 respectively; P≤ 0.05). In univariate analysis for risk factors related to physical activity and mobility, the following factors were significantly associated with developing pressure ulcer (P≤ 0.05): moving in bed with help, the ability to take a bath only in bed, needing two helpers in performing activities of daily living and moving outside bed only by a hoist. When adjusting the effect of all variables related to physical activity and mobility through the multivariate model, only two factors were independently associated with developing pressure ulcer: moving in bed with help and the ability to take a bath only in bed (odds ratio = 7.69 and 3.67 respectively; P≤ 0.05). In univariate analysis for risk factors related to pressure ulcer intrinsic risk factors, the following factors were significantly associated with developing pressure ulcer (P≤ 0.05): presence of three underlying medical conditions, dehydration, depression, having a blood transfusion, serum albumin <32mg/dl, haemoglobin <130 g/l in males or <115 for females and systolic blood pressure <113 mmHg. When adjusting the effect of all variables related to intrinsic risk factors through the multivariate model, the following risk factors were independently associated with pressure ulcer: presence of two underlying medical conditions, presence of three underlying medical conditions, cognitive impairment, serum albumin <32mg/dl and haemoglobin <130 g/l in males or <115 for females (odds ratio = 13.3, 143, 4.3, 0.10 and 0.14 respectively; P≤ 0.05). Findings from this study suggest a number of interventions to be effective in PUs prevention, and a number of risk factors that can predict risk of PUs. Findings were based on statistical association between acquiring PUs and the independent variables (preventive interventions and risk factors). This cannot constitute a cause and effect relationship due to the retrospective nature of data analyzed; it only supports the association between a number of interventions and risk factors in preventing or predicting PUs. This can guide further research to investigate these interventions and risk factors by employing the same approach used, but in a prospective manner.

The term recovery has been recently re-launched within UK drug policy, with focus on individuals' engaging in treatment and achieving change. What constitutes recovery and the process of recovery is misunderstood, due to the term previously being attributed to an individual reaching total abstinence. Within the UK previous research has largely focused on the benefits of pharmacological interventions, rather than on recovery as a concept. To date there have only been two major studies regarding recovery as a process (Mclntosh and McKeganey 2000a; Best et al 2008). However, what these studies did not do was assess the process of recovery in real time. The aim of the thesis was to provide a comprehensive investigation of recovery, to add knowledge to this area regarding the overall process of the concept. The research includes a prospective study (n=45) to assess the lived experience of recovery from those entering treatment, combined with a retrospective study of oral histories (n=12) to evaluate respondents' drug using career using semi-structured interviews. The main finding of the research was in relation to the importance significant life events have on the individual's decision to stop or resume drug use. The results confirm that recovery should not be viewed as an end state, but as a process of change over time, one which may be influenced by factors extraneous to drug use such as relationships, health and employment. These events are a combination of positive and negative experiences which can initiate or impede change. The results suggest that early identification of these factors could enhance change by removing existing potential barriers. Within the study, the terms recovery and desistance were used, with recovery pertaining to change over time and desistance referring to periods of non-drug use. Reviewing the literature coupled with findings from the study suggest that utilising these terms would provide a more clear cut definition of change and allow policy makers, researchers, academics and service users alike to have a sound understanding of what recovery is, whilst acknowledging the process of change over time.

This research, with the main focus on HIV/AIDS, tuberculosis and malaria, was based on data from the literature, and on questionnaire and interview surveys with the main stakeholders: authorities, drug-developers and NGOs/foundations. It revealed the following determinants, which contributed to the occurrence of drug pricing conflicts in Brazil, Thailand and South Africa: governmental constitutional commitments to supply medicines to poor people, the existence of a local pharmaceutical industry capable of producing generic versions of patented medicines and long histories of disease treatment programmes. The research documented the preferred approaches to increase global access to life-saving medicines for the next decade, which were found to be: public-private-partnerships, prevention measures, dedication of >0.5% of GNP to poor countries, and improvement of national healthcare/insurance systems. Those approaches were integrated into a conceptual framework, which could enable country-level organizations to move beyond the conflict mentality via a 'Public-Private-Partnership for gradual Self-Sufficiency and Sustainability Model,' (P3S3). Within this framework, rich countries should invest >0.5% of their GNP to help to alleviate poverty in poor countries. With these funds, national governments should implement programmes to expand implementation of disease prevention measures and improve national - 4 - healthcare/insurance systems and the quality of the medicines involved. Public-private-partnerships should act as 'steering-and-controlling' organizations to guide the process and to minimise corruption. As a positive message to all who currently lack access to these medicines, the thesis author's conclusion is that the use of this model could help to turn the current unsustainable development policies into sustainable ones, and as a consequence, it would contribute to improvements in the quality of life of millions of people in poor countries.

This research focuses on vulnerable children in Swaziland, the country with the highest level of adult HIV prevalence in the world, where nearly 25 percent of children will be orphaned by 2010. It investigates the experiences of relatively poor urban children growing up in the epidemic and the coping strategies the children and their adult carers adopt. Through the lens of both children and adult carers, it explores the ways sexual knowledge is gained and used by older children in the context of HIV/AIDS as well as the experience of coping with widespread bereavement. In this way, it adds to the literature on childhoods in the 'South' and the increasing recognition of the heterogeneity of children's lived experiences. Rather than being seen as passive, the agency of both vulnerable children and their adult carers emerges as they seek to improve their livelihoods. The way this agency connects with government, NGO and community structures is revealed by showing the opportunities for and constraints on gaining access to education and health-care. The interwoven roles of government, international donors, NGOs and civil society is explored by assessing the relative merits of supporting vulnerable children by either welfare assistance to poor families or new forms of 'community' care structures or institutionalised residential care. The critical importance of relationships and power relations between key actors in different organisations and the effect this has on implementation of interventions for children is discussed as well as the relevance of these findings to vulnerable children in other settings.

The study refers to the issue of cross-cultural transfer of internationally initiated health promotion and tobacco control policies. It explores the process of cross-cultural policy transfer, analyses the difficulties, proposes methods to overcome them, and tests the approach in Bulgaria. Generally focused on international health promotion policies as a broad area of study, the work particularly concentrates on tobacco control policies as a more concrete and specific subject of investigation. Completion of a short piece of cross-national comparative policy transfer research, based on two case studies - the UK as a donor of policy and Bulgaria as a recipient location - is used to assist designing an empirical investigation that develops and tests an approach for strengthening the process of cross-cultural transfer. The Hofstede Model of National Cultures is used as a guiding tool to describe and classify the different cultures of the two countries, and to assess the cultural constraints and possibilities for transfer. The results confirm the hypothesis that through contextual interpretation of international health promotion policy language, and its specification to the cultural patterns of Bulgaria, we can increase the acceptability and assure greater effectiveness in communicating those health promotion messages. The findings indicate the need for culturally specific language interpretation and adaptation of global policies if they are to become understandable and applicable to specific cultural contexts. They help to address the question: "How can the main concepts and issues inherent in western developed health promotion policies be translated into the language of countries having different cultural patterns?" The main theme of this research has not been explored so far in Bulgaria and it is also a rather new topic for international policy research. The findings might assist the process of improving cross-cultural policy formulation and help to overcome the difficulties in cross-cultural policy transfer. The study takes into account the dynamic developments within Bulgaria as it prepares for European integration as a pre-Accession country; and its findings could assist in negotiations within public health policy. The work could also have some major applications on a wider policy basis. It might also be of particular importance for countries not in the western group within Europe and which are socio-culturally different. Some implications can also be considered for the process of accession to the EU. The Union is now expanding and is challenged by great cultural diversity, both across Europe and within the individual states. Accession countries like Bulgaria have to adapt now to international and European policies and principles, which cannot be directly translated into the language of many countries. The methodology developed here should assist the adaptation of international policy items into a language that is culturally specific for the country and the sub-national levels, and thus improve the implementation of European policies in particular localities.

Coronary heart disease (CHD) remains one of this country's leading cause of mortality. This study has concentrated on the development of a functional biscuit, which will reduce selected risk factors for heart disease, in particular elevated serum homocysteine. The developed biscuit contains vitamins Be, Bi 2, and folic acid, all of which have been shown to be important in homocysteine metabolism. There were a number of criteria that had to be met for the author to receive the full support of Burton's Foods: (1) The biscuit must remain commercially viable and be accepted by the consumer. (2) Enzymes should not be used in the preparation of the dough. (3) The jam could not be modified in any way. Without exception, these have been successfully achieved. Jammie Dodgers were selected as the control product for a number of reasons. They are one of the UK's best selling biscuits and are consumed by both children and adults. This makes the target number of consumers very large. In addition, the standard product is high in both fat and sugar, its modification into a health promoting biscuit was therefore technically challenging. The product resulting from this project is commercially viable; it is low in fat and sugar, contains the vitamins that will deliver the full RNI on consumption of just two biscuits daily, and is not significantly different to the control product. The product is also palatable. Clinical trials have demonstrated that following consumption of the product, serum homocysteine, an independent risk factor for coronary heart disease, has been significantly reduced. In addition, there appears to be a relationship with consumption of the modified biscuit and a fall in serum lipoprotein(a). It is possible to reduce selected mutable risk factors associated with heart disease, simply by the daily consumption of a product that is liked and consumed by a great number of people. As far as the author is aware, there has been no other development of this kind prior to this study, i.e. a biscuit that will reduce the risk of coronary heart disease by lowering serum homocysteine. This biscuit is therefore the first of its kind.

Deep Vein Thrombosis (DVT) is a disease of hospitalised patients and is a precursor of Pulmonary Embolism (PE), a potentially fatal complication. DVT and PE are preventable and venous thromboprophylaxis consensus groups recommend that patients be risk assessed and accordingly receive appropriate prophylaxis. The Scope of Professional Practice (UKCC, 1992) enables nurses with appropriate knowledge and clinical competence to explore· new territories, previously the exclusive province of doctors. In the spirit of the position statement of professional practice framework, the Autar DVT scale (1994) was developed to identify patients at risk, so that appropriate venous thromboprophylaxis can be initiated. The scale is composed of seven categories of risk factors derived from Virchow's triad in the genesis of DVT. In this study, the DVT scale was re-validated on 150 patients across three distinct clinical specialities in order to allow for generalisation of the findings. DVT is a continuing problem and for this significant reason, the patients were followed up for a minimum of three months after discharge from hospital. Interestingly, 39 per cent of the patients with DVT (11/28) developed this insidious condition at home. Five reproducibility studies on the orthopaedic, medical and surgical directorates achieved kappa values ranging between 0.88 to 0.95, confirming the consistency of the instrument. A Receiver Operating Characteristic (ROC) curve was constructed to determine the optimal predictive accuracy of the DVT scale and a cutoff score of 11 yielded approximately 70 per cent sensitivity. Data from two patients, who could not be followed up, on account of discharge to no fixed abodes, were excluded for the sensitivity analysis of the DVT scale. Overall, 115 patients out of the 148 (78%) were correctly classified. However, the administration of venous thromboprophylaxis masked the predictive efficiency of the DVT scale in relation to its sensitivity and specificity. A high predictive value of 84 per cent of negative outcome was achieved at the cost of a predictive value of 37 per cent of positive outcome. The DVT scale exhibited good clinical and practical application. Data extrapolation also suggests that although the clinical areas use some venous thromboprophylaxis strategies, in practice they are not consistently applied.

This thesis addresses the development of a methodology to determine primary safety strategy with respect to the choice of appropriate technological solutions to the problem of accidents in cars. In motorised societies in the 1990s, road accidents are a major cause of loss of life, injury and property damage. Motor manufacturers have increasingly been concerned with reducing the effects of accidents and have recently been developing technologies to attempt to reduce the number of accidents on the roads. Traditionally, these technologies have been transferred from other domains into vehicles, (principally from aerospace). Two problems however exist with this approach. Firstly, developing solutions on the basis of what is technologically feasible may ignore the requirements of the drivers in terms of systems that would actually be of benefit whilst driving. In part, this is due to an incomplete understanding of the reasons why drivers have accidents in cars. Secondly, motor manufacturers are faced with an ever increasing number of potential systems that they may develop and eventually implement in cars. Currently, they have no methodology to determine which of these systems, if any, should be researched or developed further. This thesis addresses both of these issues. Firstly, a large scale questionnaire survey was conducted using a population of recently accident involved drivers drawn from the insurance group of a major motor manufacturer. The survey was designed to obtain information from drivers pertaining to the reasons for the occurrence of their accident. This information was more detailed than had previously been gained from drivers after they have been involved in accidents in cars. This data was built upon in the second study of the thesis, which used real life accident data to develop a methodology to determine safety strategy for a motor manufacturer. Focus groups using a variety of employees of the motor manufacturer were employed to correlate accident scenarios with a series of functionally defined accident countermeasures. When combined with quantitative data from the questionnaire survey, assessments of the overall efficacy of the countermeasures could be deduced. From this, an outline strategy for primary safety system development was deduced.