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Section A is a review of the current literature on sports involvement with respect to people with learning disabilities. It begins by describing the health status of people with learning disabilities and provides a context of sport and wellbeing in the general population. It continues by describing four reviews of the literature exploring people with learning disabilities with respect to sports involvement. This section ends with a description of the Special Olympics research and suggests future research needs in this area. Section B describes a quantitative cross-sectional study comparing two groups of sports active and non-active people with learning disabilities using several psychological measures. Objectives. There is evidence that people with learning disabilities have poorer mental and physical wellbeing compared with that of the wider population. The aim of this study was to explore whether a group of people with learning disabilities involved in sport differed in terms of psychological well-being compared with a group not involved in sport. Design. A cross sectional design was employed comparing two groups, sports active and non-active on the variables: Self-esteem, quality of life, stress levels and social networks. Methods. Seventy four participants were recruited across South East England. They completed a number of psychological measures. Results. Analysis revealed that self-esteem, quality of life, social networks and stress were all significantly correlated with Special Olympics involvement. A logistic regression analysis was used to explore whether scores on these variables were able to predict sport membership. Self-esteem was found to be a high predictor of group membership, those in the Special Olympics having higher self-esteem. Conclusions. The findings provide further evidence of a positive association between sport involvement and increased psychological wellbeing. The implications of these findings for theory and future research into the relationship between sport and psychological wellbeing within the learning disabled population is considered. Section C is a critical appraisal of the quantitative study that considers four aspects: research skills; amendments to the study if it were replicated; how the study may have influenced clinical practice; and finally, further research and methods relating to this area.

Background: Women in sub-Saharan Africa carry a disproportionate burden and risk of HIV. In this context, women at high HIV risk are not a discrete group, rather on a spectrum of risk caused by a multitude of behavioural, economic, structural, cultural and geographic factors. Pre-exposure prophylaxis (PrEP) is a promising new HIV prevention method, effective at reducing HIV risk when adhered to. However, the results of PrEP trials and implementation studies to date reveal challenges in women’s programme retention and drug adherence. There are also concerns that behavioural disinhibition (reductions in condom use) following the introduction of PrEP may further limit its ability to avert infections. In the context of HIV resource limitations and decreasing donor budgets, this thesis seeks to use mathematical modelling to assess strategies for PrEP scale-up for women across a spectrum of risk in sub-Saharan Africa, accounting for heterogeneities in HIV risk factors and PrEP programme outcomes. Considering the challenges faced by policy makers in using mathematical models to guide decision making, often considered to be complex ‘black boxes’, this thesis also sets out to assess the contexts in which simple models are sufficient to guide policy making around the introduction of a new HIV prevention intervention. Methods: This thesis adopts mathematical modelling approaches to inform HIV policy making. First, a simple static model of HIV risk to female sex workers is developed and used to assess the impact of behavioural disinhibition on PrEP’s ability to avert HIV infections. The static model formulation is then evolved to incorporate dynamic effects to account for the downstream effects of population interactions. The models account for heterogeneities in women’s HIV risk factors and PrEP programme outcomes, and the low levels of PrEP programme retention and adherence reported in studies. The outcomes of the static and dynamic model formulation are compared over different time horizons and epidemic contexts, to contribute to understanding around the importance of modelling complexity to inform HIV policy. Finally, the static model is refined to represent women across a more broadly defined spectrum of risk: women 15-24 years, 25-34 years, 35-49 years and female sex workers. The models are parameterised to case study countries spanning a range of high HIV burden contexts in sub-Saharan Africa: South Africa, Zimbabwe and Kenya, and used to assess strategies for PrEP scale-up in each country, considering cost-effectiveness and population-level impact. Conclusions: PrEP is likely to be of benefit in reducing HIV risk in women across a spectrum of HIV-risk in sub-Saharan Africa, even if reductions in condom use occur. PrEP will be most cost-effective for individuals at great HIV risk, such as female sex workers. However, PrEP has potential to significantly reduce the number of new infections at population-level if made widely available beyond those at highest individual risk, including to women in the general population. Strategies for PrEP scale-up will need to weigh the potential cost-effectiveness and population-level impact of PrEP with the potential for PrEP integration into a wide range of national services and at community level, in order to significantly bring down the costs and improve cost-effectiveness in resource-constrained environments. Static models can be sufficiently robust to inform policy making around the introduction of new HIV prevention interventions in high HIV-burden settings over short-medium time horizon of up to 5 years, where underlying HIV epidemics have reached equilibrium. Over longer timeframes, and in contexts where the underlying HIV epidemics are still evolving (other than over short time horizons of less than a year), static models may under-emphasize situations of programmatic importance and dynamic models will be more appropriate to guide decision making.

Introduction: Mathematical models of HIV transmission have played an important role in helping to understand the drivers of the HIV epidemic, and shape the global HIV response. The underlying approaches, assumptions and structures used in HIV modelling have the potential to fundamentally influence the conclusions of any modelling analyses. For this reason, it is important that approaches to modelling HIV transmission in different contexts carefully consider how best to ‘characterise’ a populations distribution of risk and networks of sexual interaction based on data, and the implications of incorporating different levels of epidemiological complexity into their modelling. Across West Africa there are substantial variations in population HIV prevalence - ranging from 0.5-6%. To date, there has been limited exploration of the potential factors influencing this population variation. This PhD aims to inform our understanding of the determinants of population variations in HIV prevalence across West Africa, using a combination of ecological analysis of population data, and both simple and more complex epidemiological modelling. The findings are used both to explore the determinants of HIV transmission across West Africa, and to discuss the implications for future modelling and epidemic appraisal approaches. Methods: A range of modelling and epidemiological analytical approaches were used. Firstly, an existing policy model, The Modes of Transmission (MoT) model, designed to predict patterns of HIV incidence, was revised and re-parameterised using data from Nigeria, to explore the effect on overall conclusions of adding additional heterogeneity into the model, and considering more explicitly how to model HIV risk amongst lower-risk subgroups. Secondly, population data from 13 West African countries were compiled. Linear regression analyses were used to assess potential relationships between HIV prevalence in high-risk groups and population HIV prevalence and the size of high-risk population subgroups and HIV prevalence in the general population. Based on the findings from the MoT and ecological analysis, a dynamic deterministic model was developed to explore the variations in HIV prevalence across West Africa. The population model not only included sex work, client and general population sub-groups, but also included a category of adolescent females (15-24) and a category of males with multiple sexual partners, with a mixing formulation being used to vary the degree the adolescent females form partnerships with clients of female sex workers and the subgroup of males who have multiple partnerships Input parameters were sampled from ranges relevant for West Africa, using Latin Hypercube sampling. The model was fitted to equilibrium prevalence in the general population. Results: A critique and revisions to the MoT, identified high levels of infections in previously unrecognised subgroups. These included 16% of new infections occurring in young females engaging in transactional sex. Findings from the ecological analysis, showed that across West Africa HIV prevalence in FSWs and their clients is not associated with higher HIV prevalence in the general population. Instead, the size of groups of males and females with multiple partners is correlated with higher HIV prevalence levels. The deterministic model generated 11000 fits. Grouping fits, based on epidemic size (with 1% incremental increases from 0-6%), the findings revealed that population sizes of key subgroups is the predominant driver of the epidemic. For epidemics where prevalence is less than 3%, FSW population size is the most important determinant of HIV prevalence. For epidemics above 3%, it is the size of the group of adolescent females with multiple partners and their level of interaction with clients of FSWs that is the most significant variable related to higher HIV prevalence. When the limiting effects on HIV transmission of male circumcision are removed from the model, the findings are less clear, with both sex work and the role of adolescent females with multiple partners being important determinants of the epidemic. Circumcision is however shown to significantly limit the magnitude of an epidemic and epidemic categorisation should account for these variations accordingly. Conclusions: Behavioural heterogeneity has long been recognised as an important component of model development. The results from this thesis show the importance of carefully considering how to compartmentalise population HIV models. Even for simple static models, the inclusion of additional subgroups change model conclusions and suggests different intervention priorities. The use of results and findings from ecological analyses, whilst unable to provide strong evidence of causality, can provide useful insights into the relationship between population level factors or behavioural variables and HIV prevalence in the general population. These findings may then be used to inform model development. Deterministic dynamic modelling used in this thesis demonstrates that the size and sexual networks of vulnerable subgroups in the population may be of key importance in determining levels of HIV epidemics in West Africa. In-particular, adolescent females engaging in noncommercial multiple partnerships, often associated with transactional exchange are an important determinant of the HIV epidemic in West Africa. An improved understanding of this group, their size and motivations for engaging in multiple partnerships, through the use of epidemic mapping techniques and social research, will be important to future HIV intervention activities.

Background: ‘Transactional sex’, is generally defined as a sexual relationship in which money or material goods are exchanged for sex. As this may entail sex with older or multiple partners, it is likely to be associated with young women’s increased vulnerability to HIV or HSV-2 infection. Existing research illustrates that the motivations for young women’s engagement in transactional sex are complex. This PhD study explores the socio-demographic factors that motivate young women to engage in transactional sex and the relationship with HIV or HSV-2 infection. Methods: This thesis uses a combination of quantitative and qualitative methods. The quantitative analysis uses baseline data from HPTN 068, an ongoing randomised controlled trial (RCT) in rural Mpumalanga province, South Africa. Using both descriptive statistics and multivariable logistic regression analysis, I have quantitatively explored the relationship between household socio-economic status and socio-demographics, young women’s self- reported engagement in transactional sex, specific characteristics of her consumption patterns and the relationship between transactional sex and HIV and HSV-2 infection. I have also used qualitative methods to explore the strategies young women deploy for accessing money or gifts, the role that transactional sex plays in meeting these aspirations and the agency she exhibits in these encounters. Results: Multivariable analysis shows that young women from low socio-economic status households who engage in transactional sex have higher odds of consuming a combination of both high cost essential items (such as school fees, transport to school and food and groceries) and entertainment related items (such as beer/alcohol, movie tickets and birth control/condoms) compared to young women who do not engage in transactional sex. In addition, after adjusting for age and household level socio-demographics, young women who report engaging in transactional sex had significantly increased odds of being HIV seropositive. No association with HSV-2 infection was seen. The association between transactional sex and HIV does not appear to be mediated by any of the other dimensions of HIV risk that might ordinarily overlap with transactional sex. Qualitative findings suggest that belongingness, peer acceptance and status were all factors that motivated young women to aspire for items considered needs or wants. In-depth interviews also showed how young women have a deep-seated need to feel financially independent and have aspirations for lucrative job opportunities in the future, which they hope to achieve through education. But, given their current context where economic opportunities are circumscribed, young women use the money received from transactional sex to fill gaps in their needs and wants. Most of them appear to be in “love” with their boyfriends and have romantic notions of what they want from the relationship, but underlying it all very clearly is the need to be provided for by the man, in the form of money. Thus, the balance between the emotional and transactional elements in a relationship is blurred. Young women appear to express considerable agency when it comes to partner choice, but not necessarily after the choice of partner is made; as within the relationship they invariably submit to male authority within unequal gendered power structures. Discussion: Findings suggest that there is not a clear dichotomy between the survival sex of the passive victim and the consumption sex of the active sexual agent; rather, these distinctions are far more nuanced. Engagement in transactional sex seems to be driven by poverty and economic need, but also by aspirations within the context of a globalising emerging economy like South Africa. In addition, these findings also indicate the subtle position that transactional sex or sexual exchange occupies within a continuum of adolescent sexual relationships in South Africa where sexual exchange occurs within the context of loving peer relationships. This potentially weakens the negotiating or bargaining position of young women if they are receiving money or items, thus having implications on HIV prevention and programming.

Sociological and economic bargaining theories have different predictions on how women's economic status - primarily women's employment - affects their risk of partner violence. These competing predictions were mirrored in a systematic review of published evidence from low and middle income countries. Increasingly researchers from North America and Europe are highlighting that there exists different forms of partner violence, and that the relationship with women's economic status may not be the same depending on the form. Currently there is limited in-depth exploration of the forms of partner violence and their relationship with women's economic status in sub-Saharan Africa. This thesis fills this gap in knowledge by exploring this relationship in two contrasting Tanzania settings: Dar es Salaam and Mbeya. An existing household survey data and primary qualitative interviews with women market traders were analysed. This study found that partner violence broadly divided into three groups that did not differ by study setting: moderate physical violence; sexual dominance; and severe abuse. Women who experienced severe abuse were most likely to have experienced high intensity emotional aggression, controlling behaviour, poorer health outcomes, and to have sought help. While there was no compelling evidence on the relationship between women's economic status and partner violence in Mbeya, there was suggestive evidence of an increased risk in Dar es Salaam. In both sites, partners' 'refusal to give their wives money' was the single most predictive risk factor of partner violence. Qualitative interviews found that men's insufficient financial provision for the household was a strong motive for women to enter into paid employment, and in doing so, mitigated one major source of conflict in the household - negotiating over money. This thesis also sheds light on the limitations of current sociological and economic bargaining theories, suggests future research priorities, and discusses the implications for women's economic empowerment programmes.

Vaginal microbicides are pharmaceutical products in development that are designed to reduce the sexual transmission of HIV in women. They are commonly known as a `woman-controlled technology' and tool for women's empowerment, and form part of a burgeoning field of clinical research into new biotechnologies for HIV prevention. Little work has critically examined how such research and new technologies are produced, and how they in turn contribute to the construction, maintenance or deconstruction of gender relations. Adopting a Foucauldian understanding of power and discourse, and using theoretical insights from science and technology studies (STS), this research explores the coproduction of gender and technology through the case study of vaginal microbicides. 'T'his account of the relations between science, society and technology draws on empirical research conducted in the UK and Zambia with the pharmaceutical industry, trialists, trial participants and trial communities. It interrogates the techniques of power through which transnational scientific networks are mobilised to test new products, such as microbicides, and how these affect scientific practices, knowledges and identities across socio-geographic boundaries. It attends to the potential multiplicity of interventions in diverse contexts, calling into question the presumed stability and singularity of both the randomized controlled trial and vaginal microbicides. This research makes an empirical contribution to knowledge about new biomedical technologies for HIV prevention, detailing the transformation that may occur when technologies travel from their site of development to their site of use. It provides a detailed analysis of the interaction between gender performativity and science in action, challenging the sense of `gendered' technologies for a `feminized' epidemic. Theoretically, it contributes to debates about the role of social theory in public health research and reconstructivist agendas in STS, concluding with a model for greater collaboration between health technology designers, evaluators, critics, and users.

Background: NHS Regulations were amended in 2004, restricting access to secondary healthcare for refused asylum applicants. In recent years there have been substantial numbers of unsuccessful asylum applications from Zimbabwean nationals. HIV-positive Zimbabweans with insecure immigration status in the UK occupy a precarious medico-legal position, especially since HAART is not available to most in Zimbabwe. There has been little research on these policies or their effects on the lives of Zimbabwean HIV-positive women in the UK. Objectives: This thesis examines the development and implementation of UK policy relating to access to HIV-related services by Zimbabwean HIV-positive women with insecure immigration status, and explores how these policies influence women's healthcare. Methods: Three separate strategies were used for data collection. Policy analysis scrutinised 35 publicly available documents and additional material obtained through Freedom of Information (FOI) requests. Data for policy analysis were also collected through semistructured interviews with 24 HIV/immigration key informants. Further qualitative data were collected through semi-structured interviews with 13 Zimbabwean HIV-positive women with insecure immigration status. These different approaches allowed for data 'triangulation'. Results: Policy restricting access to healthcare for migrants is situated within three immigration control strategies of deterrence, internal control, and 'enforced discomfort'. Implementation of the policy has been limited by staff who interpret it to suit their own agendas. Access to HIV-care for Zimbabwean women seems to bear little relation to these policies, but their access to other health services and their wellbeing was influenced by a number of other socio-structural barriers associated with their immigration status. Conclusions: These results offer new evidence and theoretical models on the politics of immigration policy, the role of street-level bureaucrats as mediators of the gap between policy and practice, and on access to healthcare for migrants. There is a disjuncture between policy on entitlement and clinical practice, which may reflect a conflict between clinicians' duty of care and UK policy. Zimbabwean women's HIV- and migrant-status places them in a periphery, reducing the resources available to them that could mitigate some of the barriers they face.

Background. The trafficking of women and adolescents into exploitative and forced labour is a growing crime and a severe form of violence against women. Little theory or research-based evidence currently exists on the health risks and consequences associated with trafficking. Objectives. This thesis presents conceptual models and describes systematically collected data on the health risks and consequences of trafficked women and adolescents, and considers methodological implications of research with this vulnerable group. Methods. Two studies, one qualitative and one quantitative, were conducted with women trafficked predominantly for sexual exploitation. The formative research exploring trafficking-related health risks was carried out in five European states with a total of 28 women. The quantitative survey was conducted with a cohort of 207 attending post-trafficking services in seven European States. Semi-structured interviews were carried out over three time periods (0-14 days, 28-56 days and 90+ days) to document reported pre-trafficking and trafficking-related risk exposures and post-trafficking physical, sexual, reproductive and mental health symptoms. Results. Risk exposures included high levels of pre-departure and in-trafficking violence (physical and/or sexual). Perceived physical health symptoms were prevalent, especially at the first interview, with neurological symptoms (e.g., headaches) being the most prevalent and persistent. Most physical symptoms reduced between the first and second interviews. Symptoms suggestive of post-traumatic stress disorder were reported over the three interviews by 56%,12% and 7% of women, respectively. Depression levels remained extremely high throughout the study. Anxiety and hostility levels were also high, but decreased more than depression. Conclusions. These descriptive analyses offer theoretical models and new evidence on risk and health symptom patterns. Findings suggest the need for urgent and longterm comprehensive health care services, an adequate legal period of recovery and reflection, and research methods sensitive to the risks associated with studying this vulnerable population.

Young women migrate from rural to urban areas for a multitude of reasons. As girls are encouraged to migrate into the city to find work, many are lured or tricked into selling sex to earn money. This study investigates the factors pushing a young woman from her village, pulling her to the city and the facilitating factors that enable her exploitation through migration and sex work. This thesis discusses the current literature on migration and sexual exploitation and addresses the gaps in information from literature and from previous studies conducted in Viet Nam and regionally. The conceptual framework for this study illustrates that young women's migration and sexual exploitation in Viet Nam is influenced and then facilitated by numerous factors acting at national, communal, familial and individual levels. It also discusses the implications of the research findings for interventions and policies that aim to reduce levels of exploitation of young women through migration and sex work. In-depth interviews took place with 20 randomly selected female migrants currently working as sex workers in northern Viet Nam. In-depth interviews were also conducted with 23 families in rural areas known to have children working in a city to help support the family. Additionally, key informant interviews were conducted with provincial and community leaders in both the rural and urban areas of this study. This thesis describes and analyses a qualitative study, which explores the decisionmaking for youth migration, the communication processes between a child and parent and the facilitating factors that influence a daughters exploitation through migration and sex work. In addition, the thesis explores the affects of migration and sex work on a young women.

Background objectives: Previous research has documented the substantial household economic impact of a recent HIV/AIDS death. There is limited information about the household economic impact of HIV/AIDS illness or forms of coping strategies used by households with different levels of available care and support services. The study aimed to understand the economic impact of chronic adult HIV morbidity and examine how households cope with the situation. Specifically the study aimed to: 1) explore the coping strategies used by households to reduce the impact of chronic HIV/AIDS, 2) document the levels and forms of utilisation of support and health services by households affected by chronic HIV/AIDS, 3) explore whether the availability of services influences the household economic impact of chronic HIV/AIDS morbidity, and the coping strategies used by households, 4) explore the implications of the findings for policies to mitigate the impact of HIV/AIDS on households and communities. Study design and setting: The study was conducted in Phayao province in Northern Thailand where people of this province were highly affected by HIV illness and death. Two study districts were identified: Mueng had active support services and Pong had less active services. Within each district, 9 villages were randomly selected and within each village a mapping survey of all households was conducted to identify 'case household' (household with chronically ill adult (CIA)) and 'control household' (household where there was no history of chronic illness in the past 6 months or household member aged 15-49 years died from chronic diseases). In each district, 150 case and 150 control households were selected for interview conducted by trained interviewers in Thai. Outcome indicators: The main outcome indicators were: the reported availability and use of support services, medical care expenditure in the past six months, source and level of income, coping mechanism of households e.g. saving and borrowing money, selling of assets and transfer money. The main outcome indicators compared among case households between two districts were the direct and indirect costs associated with having CIAs, the reported loss of income and how care of children and the elderly was affected by chronic illness. Data entry and analysis: The data were entered twice and cleaned before the final analysis was conducted. Descriptive statistics were used to obtain the demographic and household socio-economic profile and estimates of the socio-economic impact. Tabulations, t-test, bivariate and regression analyses were used to identify factors associated with impact and the coping mechanisms of households. Results: The case and control samples were relatively comparable. Support services in the last six months were more available in Mueng than in Pong in either case or control households. Regression results suggest that having a CIA significantly reduced the reported use of all services. A significantly lower percentage of household members aged 15-59 years were employed in case households than in control households in both districts. Case households as well as households in Mueng were less likely to have cash income and among households with a cash income HIV/AIDS morbidity did not impact on the per capita household cash income and this was confirmed from the regression analysis. About one-third of all households reported having savings. Two-thirds of case households in Mueng and half of case households in Pong reported using their savings for health care cost. Case households in both districts had a lower value of assets per capita than control households. About half of all households reported being in debt. Case households reported being in debt less than control households. Case households borrowed for daily consumption and health care while control households borrowed for investment. To cope with HIV illness, case households used their savings, sold their assets, cut their consumption and obtained transfer-in and supports from extended family members for care for children and the elderly. Various strategies were used to maintain family productivity including increasing family members' workload, hiring labours and withdrawal of children (especially girls) from school. The study documented 324 CIAs from 300 case households. Caregivers who took care of CIAs at home were parents, spouses or children of the CIA, with over a quarter of the adult care-givers stopping working and almost three quarters of child caregivers stopping going to school. In the past 6 months, the average health care expenditure in case households was significantly higher than in control households in both districts and the case households in Mueng reported significantly lower health care expenditure than in Pong. The percentage of case households in Mueng that paid health care expenditure by households was half of that in Pong. This was supported by the proportion of health care card usage among the case households in Mueng which was significantly higher than those in Pong. There were 24% and 39% of case households in Mueng and in Pong reported having experienced being discrimination against. Conclusions: This thesis highlights how chronic HIV morbidity impacts on household income, savings and assets. The study has illustrated how chronic HIV/AIDS morbidity impacts substantially on household labour supply and family production. This impact in case households was relatively more than in control households. Our findings suggest that the Free Medical Program for the poor under the Ministry of Public Health did not reach the poorest section of the case households in Pong. It is important that methods to increase coverage to these vulnerable groups are identified. Case households in Mueng appeared to be less affected by consumption reduction than case households in Pong. This might be because the case households in Mueng had, on average, higher incomes, higher value of assets, lower medical care cost and lower income loss than those of case households in Pong. Our study therefore confirms that the poor families with chronic HIV/AIDS morbidity suffer more consumption reduction. The study has important policy implications to ensure that households can support themselves and meet their medical care needs without jeopardising the wellbeing and future of other household members.