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Stroke is the second largest cause of death in Thailand and many stroke survivors suffer from disability after their stroke. The ministry of public health (MOPH) Thailand published a service plan strategy for improvement in service delivery and has endorsed new rehabilitation guidelines and policy in 2019, which recommended to provide an intensive inpatient-based rehabilitation programme to eligible stroke patients. However, there is currently limited evidence at national level regarding service provision, patients' health outcomes, as well as cost-effectiveness and value of implementation of the new rehabilitation policy. Heath technology assessment (HTA) has received increased attention in the policy decision making process in the past decades in Thailand for assisting policy makers to enhance the allocation of resources. Economic evaluation and value of implementation of new interventions are useful tools to inform evidence-based decision making to maximise the use of cost-effective technology into real-world practice. This study aims to assess the current situation, impact on stroke service delivery, and to evaluate the implications of the endorsement of the new policy of rehabilitation services and estimate cost-effectiveness and value of implementation of this new rehabilitation strategy. A multi-methods approach was utilised, including primary data collection in the form of a hospital survey, the analysis of routinely collected real-world data, a systematic literature review, and an economic evaluation and value of implementation analyses. It is essential to consider a provider's capacity and service delivery in relation to the new service plan strategy. In Chapter 2, this thesis assessed the availability of stroke services and hospital facilities at different hospital levels in Thailand. In Chapter 3, national administrative stroke data, covering about 75% of the Thai population, were analysed to examine the extent to which the stroke service plan improvement affects health resource utilisation, costs, and health outcomes of stroke patients. Chapter 2 presents results from a hospital survey of tertiary hospitals across Thailand, which are categorised into advanced-level, standard-level and mid-level hospitals. Findings confirm that hospitals at all levels are likely to have shown improvement in service delivery, achieving the goals set by the service plan strategy in terms of setting up stroke units with essential supportive features for acute stroke treatment. However, some challenges remain in order to improve quality of care. These include establishing health information systems to record clinical measurements and health outcome measures, e.g. the Barthel index score, during the post-acute phase. This should be done to ensure continuity of care between hospitals, health regions and at national level. Using national administrative stroke data, stroke services were evaluated in terms of resource utilisation, costs and health outcomes in Chapter 3. Resource use was measured and costs estimated using a two-part model to address issues of zero-cost observations. Parametric survival analysis was used to assess health outcomes, namely all-cause mortality and recurrent stroke events. Though the Thai MOPH attempted to enhance the quality of stroke care by improving treatment during the acute phase, treatment and services during the post acute phase still present challenges. Findings revealed a low proportion of stroke survivors accessed rehabilitation services. But patients who received rehabilitation incurred lower mean annual medical cost and had a 15% decrease in the risk of mortality. A systematic review of economic evaluations of rehabilitation interventions was performed in Chapter 4 to review and assess existing economic models of rehabilitation services to identify an appropriate rehabilitation model for a Thai context. The findings showed that the majority of new rehabilitation interventions/services were likely to be cost-saving or cost-effective. However, these studies were moderately heterogeneous in their economic evaluation components. Most importantly, only direct-medical costs, especially costs related to the new intervention, were considered, while costs due to lost productivity, including informal care costs, were rarely considered. Based on results from the systematic review, an economic evaluation and value of implementation analysis of the new rehabilitation policy were performed to assess whether this initiative presents value for money for the Thai MOPH. Findings showed that inpatient rehabilitation was cost-saving from a provider perspective. It was not cost-effective when adopting a societal perspective. Only when direct non-medical costs were reduced by 20% in sensitivity analyses, the intervention was found to be cost-effective at a willingness to pay threshold of 160,000 Baht. At the current level of rehabilitation implementation, the benefits of new the rehabilitation policy is of value to The Thai MOPH which means it is worth implementing. The expected value of perfect implementation, as net monetary benefit (NMB), is approximately 23,359 Baht per person or 7.9 billion Baht over five years from a provider perspective. From a societal perspective, if non-medical costs were reduced by 25%, the rehabilitation programme would be worth implementing. Further, at the current cost of rehabilitation implementation, the actual level of implementation that would need to be achieved should be at least 69% of eligible patients over five years, so that the NMB to the Thai MOPH would be greater than the implementation costs. Finally, healthcare intervention that have been shown to be cost-effective will be beneficial to patients and the wider healthcare system if these are offered and used in clinical practice. This thesis shows the potential of how evidence generated from real-world data can complement existing evidence from the literature to generate new knowledge to support Thai decision makers in designing the implementation strategies to ensure continuity in stroke care along the stroke care pathway.

This doctoral thesis is a collection of three papers that study topics related to Non-Communicable Diseases (NCDs) - the key cause of death globally, challenging health systems and economies. First, we analyse the dietary changes, a major risk factor of NCDs in Low and Middle-Income Countries (LMICs) and examine the role of education as a mechanism to improve healthy food demand. We use the food consumption data of Sri Lanka. Using the demand elasticities estimated from the Almost Ideal Demand System (AIDS), we prove that the enhancement of the living standards of the people has led them towards a rather unhealthy diet. This adds economic evidence to the literature on the occurrence of nutritional transition leading to the growth of NCDs in LMICs. Further, the study fills the dearth of evidence in the literature on the role of education in dietary choices in LMICs. We show that education plays a significant role in enhancing healthy food demand, however, it does not help to discourage the demand for unhealthy food. Yet, education helps to improve diet quality when individuals have diet-related diseases, i.e. diabetes. We show the possibility of effective use of price policies to encourage healthy consumption and discourage unhealthy consumption in LMICs. Second, we investigate the household consumption impact of out-of-pocket healthcare expenditures arising from chronic NCDs (C-NCDs) and how it changes according to the shifts in public health expenses. We use a matching method to estimate the crowding-out effect and a Matched Difference-in-Difference (MDID) method to identify the changes in the crowding-out effect according to changes in public healthcare expenses. We use the data of Sri Lanka, an LMIC, and show that the out-of-pocket healthcare expenses arising from C-NCDs have grown faster than such expenses of other health conditions during the last two decades. We show that public healthcare provision plays a significant role in C-NCD care, and a reduction in public spending leads to a further increase in the household burden of the treatment cost. The increasing out-of-pocket expenses due to C-NCDs are crowded-out on households' basic needs, such as food and clothing, particularly in low and middle- income households. Accordingly, the study highlights that the lessening of public spending and the absence of health insurance to cover healthcare costs of C-NCDs care generate adverse impacts on household welfare. Third, we provide novel evidence on how the livelihood of people with NCDs was affected by COVID-19. We explore the impact of COVID-19 on the labour market outcomes of individuals with NCDs using the data from the Understanding Society COVID-19 Study in the UK. The difference-in-difference estimates reveal that the pandemic negatively affected the likelihood of engaging in work and the work duration of people with NCDs. We show that their probability of engaging in work negatively relates to the severity of the pandemic, whereas the amount of work hours gradually decreases throughout the pandemic resulting in a significant gap between the pre and post-Covid work amount. The work loss is higher for the upper age group of the workforce and the individuals with riskier health conditions to Covid-19. Although the pandemic did not cause it to deteriorate further, the low mental and physical health of individuals with NCDs may lead them to exit the labour market, raising concerns about their welfare during the post-covid period.

Rabies is a viral zoonotic disease causing horrific neurological symptoms inevitably leading to death without prompt administration of post-exposure prophylaxis (PEP) to prevent infection. While any mammal can be infected by and transmit rabies, almost 99% of the estimated 59,000 human deaths per year are due to bites from rabid dogs, with the vast majority occurring in Asia and Africa. Through mass dog vaccinations starting in the 1920s, rabies has been successfully eliminated from domestic dog populations in practically all high-income countries. Yet, many lowand middle-income countries (LMICs) are still endemic and face extensive challenges controlling rabies and achieving elimination. Strengthening surveillance through integrated intersectoral methods has been an important component of the Zero by 30 global strategy to eliminate human deaths from dog-mediated rabies by 2030. Similar to other neglected tropical diseases, only a small percentage of human and animal rabies cases are captured in surveillance at the local level, then go on to be reported in official national and international statistics. This lack of detection and underreporting has resulted in suboptimal data quality that conceals the true magnitude of the burden of rabies, leading to a cycle of neglect by reducing advocacy, funding, and stakeholder engagement. Hence, surveillance must be sufficiently enhanced to monitor, evaluate, and inform rabies control efforts to support LMICs to achieve elimination. This thesis aims to critically review and evaluate the One Health approach, Integrated Bite Case Management (IBCM), as a cost-effective method to enhance rabies surveillance and guide control and elimination programs in LMICs, with a particular focus on a case study of IBCM implementation in the Philippines. The thesis is presented in a series of five chapters, starting with a general introduction (Chapter 1), followed by three standalone data chapters (Chapters 2, 3 & 4), and concluding with a general discussion (Chapter 5). IBCM is a current gold standard surveillance method advocated by WHO and other international organizations. Yet, as a relatively novel One Health approach, there is still little understood about the implementation of IBCM in practice. In Chapter 2, I examined how IBCM is conceptualized by experts in the field, exploring variation in its operationalization in different epidemiological and geographical contexts. Findings from this study highlighted the diversity of how IBCM can be organized within existing government systems/sectors and demonstrated it is not a one-sizefits-all approach. Contextual features of each location influenced the success of delivery and the potential impact of IBCM, with the issue of sustainability identified as one of the greatest challenges. For successful development and implementation of IBCM programs, this study recommends that more guidance is provided for health workers receiving bite patients on assessing rabies-risk, and for stakeholders and practitioners on how to tailor IBCM to fit the local context. In Chapter 3, I explored this topic in more depth through the evaluation of a threeyear (January 2020 to December 2022) implementation study of IBCM in Oriental Mindoro province, Philippines. Using a mixed methods process evaluation, I assessed the feasibility and fidelity of effective delivery of IBCM, and how protocols were adapted to the context over the course of the study. The evaluation showed that the initial protocols envisioning trained government staff would uptake IBCM activities were not feasible due to implementation barriers. However, following adaptations made by the project team and participants, including adjustments for the COVID-19 pandemic, IBCM was delivering more effectively in 2021 and 2022. The findings concluded that, if implemented effectively, IBCM showed great promise as a strategy to enhance rabies surveillance in the Philippines, with evidence from the study providing key lessons for the adaptation and scale-up of IBCM to additional provinces in the Philippines. In Chapter 4, I used data collected from enhanced IBCM surveillance in Oriental Mindoro province from the implementation study discussed in Chapter 3. This quantitative data was used to develop an adapted probabilistic decision tree model used to estimate the burden of rabies, evaluate surveillance performance, and assess the impact of current rabies prevention practices. Results from this study estimated a high incidence of bite patient presentations to health facilities (1,160/100,000 persons/year), with < 2% deemed high-risk for rabies exposures (<25/100,000 persons/year) and an average of 71.4% of probable rabies-exposed patients seeking PEP. Routine surveillance confirmed < 1% of circulating animal cases, whereas IBCM resulted in a fivefold increase in detection. The model estimated that between 275 to 838 dogs developed rabies; 18 to 28 deaths were averted by PEP; and total costs of over $535,385 USD per year, i.e. $16,730-38,240 USD per death averted, in Oriental Mindoro province. These findings highlight that current PEP practices in the Philippines are not cost-effective without concurrent strengthened risk-based surveillance to reduce the indiscriminate use of PEP. The study concludes that integrating IBCM into national policy has the potential to guide PEP administration to reduce unnecessary expenditure on PEP and inform rabies control measures. Overall, this thesis exemplifies the value of enhancing rabies surveillance using a One Health approach to achieve Zero by 30 rabies elimination goals. Yet, the development and implementation of IBCM must be carefully considered and planned to ensure the effective delivery of IBCM activities leading to desired outputs and outcomes. With more guidance provided by international organizations to streamline protocols and procedures, the IBCM approach has the potential to be a key component of national strategies to monitor and evaluate the progress of rabies control efforts, verify elimination, and promptly detect incursion events.

Leishmaniasis is a neglected tropical disease, which is estimated to produce approximately 1.3 million new cases annually. As yet, no vaccines are available and current effective chemotherapeutic strategies are lacking, due to drug toxicity, resistance, and social and economic barriers affecting availability. Pivotal in the discovery of new interventions for infectious diseases is the understanding of the fundamental biology of the pathogen and its role in infection. Here, the application of single cell RNA sequencing (scRNA-seq) was employed to investigate the fundamental biology behind transcriptomic changes as the parasite progresses through life cycle stages, from promastigote to metacyclic forms before differentiating into amastigotes. The transcriptomic dynamics underpinning these multifarious developmental transitions through life cycle stages are yet to be fully described. To investigate these changes, we employed scRNA-seq over five time-points as Leishmania mexicana (L. mexicana) differentiated from promastigotes to axenicamastigotes in vitro. With clustering and marker analysis of over 16,500 parasites across three experiments, revealing thousands of stage specific markers. Of note during gene marker analysis was the discovery of a transitional cluster placed between promastigote and amastigote stages. This cluster, named here Trans A, displayed overlap between both promastigote and amastigote markers, and potentially representing a new intermediate life cycle stage, defined transcriptionally. Additionally in these data was the identification of over 1,500 differentially expressed markers for a metacyclic like cluster. To examine the timing and the patterns of gene expression over the life and cell cycle, pseudotime analysis was used for the first time in Leishmania, so that we may further explain the order of these transitional events and any potential stage specific patterns in gene expression, providing an unprecedented understanding of the life cycle transitions. Analysis indicated the development between promastigote and amastigote stages was possible by progression through this Trans A cluster, circumventing the infective metacyclic form. Thus, potentially revealing a new developmental strategy for life cycle progression. Furthermore, cell cycle labelling analysis was performed using phase marker orthologues, also revealing new cell cycle phase specific markers. When combined with promastigote stage marker orthologues, a striking overlap between promastigote life stages and cell cycle stages was found, potentially providing further evidence that promastigote morphologies are intrinsically linked with cell cycle stages. To validated how transient gene expression changes may be represented at the protein level, 96 fluorescently tagged cell lines were produced using a highthroughput CRISPR-Cas9 system. Of the 96 cell lines produced, 91 were hypothetical proteins identified as having transient expression patterns for developmental trajectories drawn over promastigote to metacyclic and axenic amastigote stages. Initial assessments by fluorescent microscopy revealed 80 out of the 96 tagged proteins matched overall pseudotime expression profiles, indicating that dynamics of RNA levels detected by scRNA-seq could reflect changes in protein levels. Furthermore, these 91 cell lines of tagged hypothetical proteins provide the opportunity for further research into new biology. So that this transitional gene progression may be explored in broader contexts, scRNA-seq of L. mexicana-infected human macrophages was undertaken. Allowing the comparison of the RNA populations found in differentiation to axenic amastigotes in vitro, to those of the amastigote forms infecting a host cell. This crucial life-cycle development stage of Leishmania within the macrophage revealed infection response associated genes, linked with parasite removal strategies. This project aimed to provide an example of investigating fundamental Leishmania biology by applying scRNA-seq for the study of life and cell cycle transitions, with the application of pseudotime analysis for the first time. Results of differential gene expression analysis revealed new biology not previously described in previous methods. Thereby demonstrating how the application of scRNA-seq may further disseminate parasite biology and infection dynamics.

Behavioural weight management programmes are effective in helping some, but not all, patients living with obesity to lose weight. With the emerging pharmacological options for weight loss, and a range of dietary interventions available, it may be advantageous to be able to predict successful short and medium term weight loss, so patients can be moved to other therapies at an earlier stage while they are still engaged. The overall aim of this thesis was therefore to identify factors at the baseline level to predict short and medium terms successful weight loss. In chapter 2, a hypothesis-driven questionnaire was developed after conducting a literature review to test baseline behavioural and psychological factors ability to predict successful short-term weight loss in individuals undertaking behavioural weight management programmes (in NHS GG&C region). This prospective study was not started due to the COVID-19 pandemic, but the questionnaire and study are ready to be implemented in the future. In chapter 3, a prospective study investigated baseline clinical, sociodemographic and process factors association with weight loss (>5%) in individuals undertaking behavioural weight management programmes (in NHS GG&C region). The only variable that predicted short (16 weeks) and medium-term successful weight loss (3 years) is the early weight loss (4 weeks) in the programme. Weight loss of 0.5% at 4 weeks had sensitivity 90.4%, specificity 53.6%, PPV 32.9%, NPV 95.7% in the short term and sensitivity 89.9%, specificity 49.5%, PPV 19.6%, NPV 97.3% in the medium term. In chapter 4, a prospective study tested behavioural and psychological factors ability to predict successful medium-term weight loss in using data from the LookAHEAD trial. Moderate predictive utility was obtained from; age, sex, randomised treatment , baseline weight, bodily pain score, diabetes medication and LDL cholesterol (AUC-ROC= 0.649) In chapter 5, an external validation study was conducted (using the WRAP trial) to validate predictors of successful weight loss identified in Chapters 3 and 4. Strong evidence was seen that early weight loss in the programme is a strong predictor of medium-term successful weight loss (consistent with chapter 3). In contrast, only baseline weight and age were validated as predictors of successful weight loss. In chapter 6, UK Biobank was used to test predictors of weight loss over the medium term in a general population with overweight and obesity. A large proportion (19.7%) of people with overweight or obesity lost a significant amount of weight (≥ 5%) over ~4 years even without known dietary interventions. Moderate predictive utility was obtained from sex, age, initial BMI, diastolic blood pressure, triglycerides, and time spent driving (AUC-ROC= 0.618). In conclusion, socio-demographic, clinical, process, behavioural and psychological variables do not yield sufficient discrimination to allow prediction of successful weight loss, either in a structured weight management programme, or in the general population. However, early weight loss in the first few weeks of starting an intervention is strongly associated with short and medium term successful weight loss. A threshold of failing to achieve 0.5% body weight loss in the first 4 weeks can identify participants who are unlikely to succeed in the programme (>95% of these will not be successful completers). This approach may allow early identification of patients who might benefit more from other interventions while they are still engaged.

This thesis has made several unique contributions to the challenge of incorporating implementation within the economic evaluation of health technologies. My literature reviews have shown that many of the tools we need to consider implementation are already available. However, they are infrequently and inconsistently used in practice. I have described the purpose for which these methods were developed, how these methods differ from one another, and where gaps still remain. The conceptual model developed from my review of current methods suggested where in the HTA process these methods may be most applicable. Both of my case studies highlighted the limitations of traditional methods for costeffectiveness analysis, based on the cost-per-QALY approach, in the context of complex interventions. This is because complex interventions typically require us to consider how a technology will be implemented in routine clinical practice. In my first case study, I worked closely with stroke clinicians and stakeholders to understand the challenges of implementing mechanical thrombectomy in routine practice. This allowed me to incorporate additional costs not captured within the trial setting, ensuring that my research was addressing questions relevant to stakeholders and decision-makers in this area. Furthermore, I showed that the QALY benefit to the eligible population from mechanical thrombectomy was likely to exceed the cost of implementation if we can achieve at least 30% implementation across the UK. This additional evidence means that decision-makers were better able to plan for the resource requirements necessary to implement this technology in their own setting. It also demonstrated that it was not necessary to achieve full implementation to realise the benefits of mechanical thrombectomy. In my second case study, I recognised that, in the context of a complex intervention, involving multiple outcomes and stakeholders, the applicability of the cost-per-QALY framework may have been limited in capturing the full value of a venous access device. For this reason, I undertook a cost-consequence analysis to evaluate a range of clinical and economic outcomes relevant to patients and decision-makers. This allowed patients and decision-makers to consider the importance they place on each of these outcomes when choosing an appropriate device. Recognising the heterogeneity in service delivery and cost within the CAVA trial, I worked alongside radiologists and nurses to develop a plausible scenario for the delivery of a PORT service in routine practice. I used the Value of Implementation framework to estimate the total expected Value of Implementation. I also then used this framework to answer additional questions related to implementation, such what is the value of delivering a PORT to just 50% of patients requiring a VAD? What is the minimum willingness to pay for infections avoided for the benefits of PORT to exceed the cost of implementation? My case studies allowed me to demonstrate how current methods can be used to incorporate implementation within the economic evaluation of a health technology. They also allowed me to identify gaps in our current approach. For example, implementation is too often considered retrospectively, and on an ad hoc basis. Additional methods which explicitly incorporate implementation and economic evaluation alongside one another may be required. However, we already have sufficient methods to make progress in this area. What is missing is practical and consistent guidance on where, when, and how available methods can be incorporated in the development, evaluation, and implementation of a health technology. Both the Department for Health and Social Care and the NHS have identified the implementation of clinically effective and cost-effective health technologies as a key priority for the healthcare system. Therefore, the time is apt for funders, reimbursement agencies, decision-makers, and researchers to work together to develop guidance demonstrating how implementation can be incorporated within the economic evaluation of a health technology. Health research funders should consider whether implementation ought to play a greater role within the evaluation of complex interventions. Reimbursement agencies should consider if we need to develop formal process by which the issue of implementation can be considered alongside the more traditional mechanisms for assessing health technologies.

Diabetes is a non-communicable disease that requires continuous care and a knowledgeable healthcare workforce. The prevalence of diabetes has increased and is known to affect both the quality of life and finances of patients in countries without universal healthcare provision. Thailand is a developing country and has experienced the health care shortage for many years. In contrast, the number of people who need the health service is increasing day by day. It is challenging for the country to manage their population health within the limited budget and availability of the healthcare staff. For many decades, the HVs have been recognised and involved in several community health projects in Thailand. Employing HVs to work in the community is seen as a means of increasing service provision without increasing expenditure. Currently it is approximately one million HVs are active in Thailand. A HV is a lay person who is recruited by the community. The HV received the trainings from the healthcare staff, then delivered multiple health services for the community. They were also assigned to take care of 10-15 households in their community. As the HV is a voluntary job the HV is not required to work full time. The HV works only once a week or four times a month. Initially the HV was not given the monetary incentive; however, currently the HV earned monthly compensation from the government for doing service every month. In Thailand, the Health Volunteer (HV) plays an important role in providing care for diabetic patients in the community. However, the knowledge levels and learning experience of this workforce are key to the provision of high-quality patient care. Yet little is known about these phenomena. This study employed an explanatory sequential mixed methods design to explore the HVs' knowledge of diabetes and their learning experiences. The study was undertaken in two phases. The first phase included amending, cross culturally adapting and translating, testing and administrating a diabetes knowledge questionnaire. This modified questionnaire was found to be valid (CVI=0.875-1) and reliable (KR= 0.830) and was therefore administered to 390 HVs in Thailand. The results of the study enabled the researcher to identify those with differing knowledge levels, a factor that was included in the purposive sampling framework for the second phase of the study where 15 HVs participated in a semi-structured interview. The findings of the first phase highlighted that 73.3% of the HVs lacked knowledge of diabetes with greater knowledge being noted in the management of diabetes and lower knowledge recorded in areas focussed on the prevention of the disease. HVs who possessed high knowledge levels were likely to be motivated to learn whereas the converse was true in those with lower knowledge levels, underlining the importance of motivation to learning. Classroom training was the main learning resource available for the HVs. HVs who attended the training were likely to have higher knowledge levels compared to those who did not attend class; however, findings from the second phase of the study found that the training was not prioritised due to financial pressures and family commitments. Although the classroom lecture-based training was deemed to be beneficial for the HVs, the high number of classroom attendees and the didactic teaching methods presented a number of barriers to learning including, noise, peer pressure and unfavourable teaching methods. In addition, poor memory, limited prior knowledge and a perception of a theory-practice gap inhibited the HVs' effective learning. Although there were several online diabetes learning resources available, these were rarely accessed, the reason for which was unclear but may have been related to internet access. Conclusion: The study findings indicate that the current diabetes knowledge of the HVs may not be enough to provide holistic care for the population they serve, as the HVs possess knowledge gaps in several areas. The study findings also highlight that the large class teaching, inadequate relevance to practice, competing priorities and limited focus on the prevention of the complications of diabetes, contributed to a lack of knowledge among the HVs. It is necessary to eliminate many of the barriers to learning that have been identified in this thesis and reshape the educational provision to enable the HVs to play a more productive role in the management of people with diabetes in the local community.

Obtaining a greater understanding of the meanings and motivations for the consumption of drugs is an important part of targeting drug-prevention and harm reduction strategies, particularly when considering why people continue to use drugs after initial experimentation, or where there may be a high probability of harm. By exploring the concept of identity in people who use drugs (PWUD) and how this affects their substance-related decision making, it may be possible to broaden understandings of use and develop more relevant and responsive interventions. This programme of PhD research explored the development and expression of drug-related identity in young adults, and sought to understand how drug use and the associated lifestyles and practices featured as part of a young adult's general identity. The research investigated how PWUD negotiate potential problems and risks associated with drug-identity related behaviour, and explored belongingness and capital in the formation and expression of identities. The design was multi-phase and used mixed methods. In the first phase, participants completed an online survey. Multivariate statistical analyses were used to identify three latent profiles of PWUD who differed on their responses to key questions concerning identity and drug use, specifically, drug-related cultural capital, differentiated normalisation to recreational drug use, and belongingness to a drug culture. The largest class consisted of those with a 'salient drug user identity', while belonging to the other two classes indicated either a 'moderate' or 'non-salient' drug user identity. For the next phase of research, purposeful sampling techniques were used to recruit young adults who use drugs for individual interviews. Interpretative Phenomenological Analysis was used to examine the concept of 'drug user identity' in more detail. Findings generated three overarching themes, which present a framework for understanding how drug use and the associated lifestyles and practices feature as part of the identities of PWUD, and developed a concept of 'drug user identity', that is established, maintained, and negotiated within a broader sense of self. The project offers novel insights for understanding belongingness and capital between PWUD that can help inform targeted harm reduction strategies for different profiles of PWUD, without reinforcing stigma associated with drug use, or further marginalising other groups of people who use drugs; these include approaches to drug use in higher education settings and harm reduction approaches that consider the gendered use of recreational drugs.

This thesis considers the roles currently set out for patient and public involvement on antimicrobial resistance (AMR) and clinical care in the UK. Taking the example of uncomplicated community - acquired UTI in people treated under clinical guidelines written for women, I conceptualise what alternative roles there might be for different publics and patients. Uncomplicated UTI has long been identified by both patients and health care practitioners (HCPs) as an area of poor patient care and mo re recently has become a target of antimicrobial stewardship policy mobilisations. The condition has largely been neglected outside of biomedical and policy - orientated literature. This thesis makes a contribution informed by feminist theory by keeping marg inalised experiences central. The thesis argues that public health efforts to engage the public on AMR and clinical efforts to care for people with urinary symptoms largely adopt depressed outlooks. With empirical work based on 29 semi-structured online object - based interviews with participants in the role of patients, 18 supplementary interviews with diverse HCPs, researchers and advocates, and grey literature such as clinical guidelines and engagement materials, I examine how the problem of AMR and UTI i s enacted, considering how evidence could be assembled differently in order to enact the problem in a more caring way. Working with Annemarie Mol's concept of ontological multiplicity, I follow the argument that good care for urinary symptoms can be found in clinical experimentation due to the way it works with multiplicity. However, I depart from Mol's work in finding such experimentation not in the practices of HCPs, which I find to be organized around rather singular antibiotic care practices. Instead, I point out a wealth of expertise in the practices of patients who care for their bladders outside of standard uses of antibiotics. Finding pessimism and depression in efforts to conserve antibiotics through compliance, the thesis offers bountiful ways to a pproach difference.

Dental caries in primary teeth affects over 530 million children globally, and outcomes are significantly associated with social circumstances. Scotland's national child oral health improvement programme Childsmile has in part been responsible for improvements in oral health over the past decade, but inequality based on socioeconomic factors persists. Community Linking/Social Prescribing aims to reduce inequality through addressing the social determinants of health by engaging patients with community services/third-sector support. The Childsmile programme employs Dental Health Support Workers who provide targeted and tailored interventions to families most in need. Part of the role of Dental Health Support Workers is to link families experiencing wider social and economic problems to external community services/resources where tailored support can be offered. This thesis describes research which aims to optimise Childsmile's Community Linking/Social Prescribing pathway for families of young children to improve oral health and tackle the social determinants of health to reduce inequalities. Methodology: A mixed methods approach was employed, and three studies were conducted. Study one used secondary analysis of population-wide individuallevel linked routine administrative data and health data to investigate Community Linking practice within Childsmile. The second study was a Systematic Overview of systematic reviews and guidelines to assess best practices for Community Linking, drawing from literature across Primary Care health services and using the Consolidated Framework for Implementation Research (CFIR) model to guide analysis and reporting. The third study was an online national survey of Dental Health Support Workers to assess the feasibility and acceptability of Community Linking. The first and the second study informed the survey content, and again the CFIR guided survey design. IBM SPSS v26 was used to describe quantitative data, and QRS NVivo v12 was used for qualitative thematic analysis. Results: Secondary analysis of linked data showed just over a fifth of families were referred to a Dental Health Support Worker for additional support over the study years, reflecting the targeted nature of this Childsmile intervention. Among these families, the percentages who were linked to external community services/resources increased from 1.8% (219/12169) in 2011 to 21.0% (1227/5833) in 2015, with the main support services being related to nutrition/diet and parent/baby support groups. Families living in the most deprived areas of Scotland and those determined by their Health Visitor to have greater support needs were more likely to be linked to wider community services by Dental Health Support Workers; however, there was significant variation in linking rates. The Systematic Overview key findings highlight several programme delivery aspects associated with best practice, such as basing programmes on high-quality evidence, obtaining resources, and being flexible in approach, developing trust among partners and assessing participants' needs to provide a tailored pathway. An optimum level of training, mentoring, and feedback is required for Community Health Workers. The Community Health Workers' characteristics should be such that they are perceived as leaders in the community and are respected. The services should be accessible and perceived by the participants as beneficial. Inter-sectoral working is also key. Partners should have enough time to develop understanding, communicate, network, and implement and evaluate the Community Linking implementation. The Systematic Overview showed a need for a multilevel pragmatic approach. The Online Survey of Dental Health Support Workers had a response rate of 58% (59/102) from 13/14 geographical health boards. Results demonstrated high awareness of Community Linking: 88% (52/59) of respondents agreed that this is a good way to improve child oral health, and 72% (42/59) had some experience of Community Linking in their current role. Feedback from community services and families was lacking. More than three quarters, 85% (50/59), said they would be able to identify appropriate community organisations for Community Linking. Thematic illustrations of open-ended responses showed: workload and time barriers when working with families; the importance of collaborative working, for example, with social services and education; training of staff to overcome these barriers, such as local area knowledge; the importance of building trust with families; and the importance of actively facilitating and supporting access to services. Conclusion: Community Linking is a relatively new concept in dental public health. It is implemented within the Childsmile programme via Dental Health Support Workers and is considered a route to help families in need of support and address socio-economic inequalities in oral health. According to our findings, future implementation work in Childsmile is broadly supported by moderate quality evidence and perceptions on acceptability and feasibility. Programme theory is articulated in Chapter 7, which shows the need to tailor links to need and foster integrated working, with clear communication routes between referrers and community organisations, including those for monitoring and evaluation. Staff are supportive of this as a route to a range of positive health outcomes. Nevertheless, workload/resource barriers need to be considered, and support and training are required in terms of available community resources and building sustainable links.

In this dissertation I present developments in statistical methodologies that deal with interdependent data, i.e. data in which the units of observation are connected to each other resulting in a network of interdependence between them. Data considered interdependent poses a challenge to traditional statistical methodologies that assume units of observation to be independent and identically distributed. I focus on networks, and in particular social networks, as a tool to characterise these units of observation, called nodes, their observable attributes, and the connections between them. The developments in this dissertation are used to try to answer questions about the causal relationship between the observed variables, conditional on the network structure. In chapter 3 I present a causal analysis of the the Sexually Transmitted infections And Sexual Health (STASH) intervention and find that it had a positive effect of treatment (direct effect), but no effect of interference (effect of treatment spilling over to other individuals). I consider the methodology developed by Forastiere et al. (2020), as well as a flexible regression approach, to model the potential outcomes of the intervention for different levels of treatment and spillover, conditional on the joint propensity to be treated, directly and indirectly. Using a simulation study, I find that the proposed flexible approach has similar performance in terms of bias and uncertainty to the approach by Forastiere et al. (2020) when estimating the effect of the intervention, without the need for full information on the outcome model. In addition, our simulations suggest that regardless of methodology, estimation using a small sample produces larger uncertainty bounds. In chapter 4 I present a methodology to identify social influence and separate it from the effect of prior similarity in bipartite event cascades, when analysed using the relational event model (REM). The REM can be used to analyse the interdependent nature of data where the behaviour by an actor can be caused by the recent behaviour of similar actors (social influence). Homophily statistics can test for such contagion, given one or more actor attributes or network relations. However, social influence along the cascade, and independent but similar behaviour as a consequence of shared attributes, are generally confounded. Using Monte Carlo simulations, I show the limits of a randomisation test as a tool to distinguish from these two competing mechanisms (influence and prior similarities). The simulations, as well as an empirical example in political science, delineate the scope conditions of the randomisation inference test used and demonstrate its efficacy under different mixture regimes of influence and similarity. Chapter 5 presents a Bayesian methodology to estimate parameters for social networks using the exponential family of distributions via a network sampler that produces candidates in which both the connections between the nodes and their attributes are considered endogenous. Parameter estimation for networks with the exponential family is based on sampling networks candidates conditional on a fixed value of the parameter. Traditional estimation produces networks where only the connections between the nodes are switched to produce viable candidates. Fellows and Handcock (2012) developed a sampler that produces networks where both the connections and some nodal attributes are switched (toggled, as it is referred to in the literature) in order to generate viable samples. I propose using a Bayesian estimation routine with a sampler that also toggles node attributes and network connections, based on Caimo and Friel (2011)'s approach, to replace estimation using maximum likelihood, and produce samples from the posterior distribution for the parameter. This results in an estimating methodology that considers a data generating process in which networks are generated by changing edges and node attributes, and conditional on having a proper model, is less prone to produce degenerate results.

Antimicrobial resistance (AMR) has emerged as one of the most significant threats to population health of recent times. It is estimated that its associated mortality could reach 10 million by 2050. Availability of effective antimicrobial prophylaxis is essential to allow many routine surgical and obstetric procedures to be performed safely. Reducing unnecessary antimicrobial use is integral to controlling the spread of AMR. As awareness of the need for judicious antimicrobial prescribing has grown, so has recognition of the importance of early diagnosis and management of sepsis, with high profile media reporting of selected cases, often involving children. Early administration of antibiotics to improve outcomes from sepsis conflicts, in part, with a drive to reduce antimicrobial prescribing. Previous research has suggested that AMR is often perceived as a distant and theoretical threat that has little personal impact, which may in part be related to how it is framed in news media. There is no evidence about how reporting of sepsis in children impacts on public understandings about antibiotic use. This PhD aims to better understand how the risks of antimicrobial resistance and sepsis are constructed in the popular news and how these impact on the attitudes and behaviour of the public, as parents and carers. Content analysis of 616 articles from 6 national newspapers published between 1988 and 2018 demonstrated key differences in the way AMR and sepsis are framed. AMR is framed predominantly according to its potential impact on future global health. Its causes and solutions are presented as complex and dependent on co-ordinated actions between policymakers and the healthcare, farming and pharmaceutical industries. In contrast, sepsis is framed as an issue whose drivers lie predominantly within the healthcare sector and whose main solution is better awareness. The use of personalised narratives about individuals affected by sepsis increases its relevance and accessibility for the public. Thematic analysis of a subset of articles demonstrated that failings in the health service were portrayed as the cause of avoidable deaths in children, often through failure to prescribe timely antibiotics, with parents positioned as advocates for their children. Exploration of these themes in 20 focus groups with 84 parents, carers and individuals with lived experience of sepsis demonstrated that decisions about when to seek health advice had to be balanced against a perceived moral duty to avoid placing excessive demands on healthcare resources. Health professionals were frequently perceived to be ambivalent about the need for antibiotics, with parent preference often influencing decisions. Few participants had direct experience of AMR, which was widely perceived to be a risk confined to individuals who use antibiotics inappropriately. There is a need to align messages about the complex interplay between AMR, sepsis and antimicrobial use. Personal narratives about individuals affected by AMR, similar to those used in sepsis awareness campaigns, may increase accessibility of public health messaging about preserving the efficacy of antibiotics.

Background: Older people are who use prescription opioids are living longer in the UK and the USA, and contribute to a steadily growing rate of illicit opioid and polysubstance misuse among people over 50. Anecdotal evidence suggests older people with problematic long-term opioid use issues face difficulties in accessing physical and mental health services, entering drug treatment services, maintaining safe housing, participating in employment and staying out of prison. Evidence also suggests that older people with opioid use problems remain uniquely at risk for multiple and complex health issues which combine problematic opioid use with issues of imprisonment, discrimination, housing instability, overdose, poverty, social exclusion, stigmatization and victimization. Further, there is evidence of older people with problematic long-term opioid use issues related to decades-long methadone prescriptions as stand-alone opioid treatment strategies in the UK. Opioid dependent people in the USA who would benefit from Opioid Substitution Treatment remain largely unable to access methadone and buprenorphine as treatment strategies for a range of reasons. Additional evidence suggests older people with problematic longterm opioid use issues in the UK and USA are stigmatized and denied access to healthcare and drug treatment services. Currently there exists a lack of published research exploring older people's perspectives and experiences with problematic opioid use, obstacles to treatment and pathways to sobriety. Older long-term drug users remain an under-researched population in both the UK and USA. Aim: To explore the perspectives and experiences of older people with longterm opioid use problems and to identify the social, cultural and environmental conditions that contribute to both use and sobriety in Liverpool, UK and New Haven, Connecticut USA using visual methods. Design and Setting: A visual ethnographic study using participant-generated photography and photo-elicitation interviews among older people aged 50+, with 10+ years of experience using opioids including heroin from Liverpool, UK and New Haven, Connecticut, USA. Method: Participant-generated photo-elicitation and photo-documentation methods were used alongside participant-researcher interviews in the field over a five-week period. Participant-generated photographs and participant interviews were analyzed using a novel Modified Interpretive Engagement Framework to support both narrative and visual findings. Capitol Themes and Capitol Works, which constitute the narrative and visual findings, together articulate the similarities and differences between the two international communities. Results: A total of twenty-six people were recruited. Participants offered perspectives based on their personal photographs and lived experiences. Twenty-five participants completed exit interviews and reported a wide range of conditions that contributed to the development of long-term problematic opioid use, relapse and recovery. Thematic analysis revealed four major themes of interest: 1) adverse childhood experiences and adult traumas, 2) cyclical arrest and imprisonment, 3) housing and homelessness and 4) broken kin relationships. Themes were found to be overlapping and enmeshed issues of physical and mental health, which complicates solutions for long-term problematic opioid use in both communities. Differences between health treatment pathways, accessibility to health care services and right to health issues in Liverpool and New Haven were identified and found to result from a complex mix of long-standing policies, historical political divisions and freemarket vs universal-coverage healthcare systems.

COPD is increasingly recognized as a heterogeneous and multidimensional disease. Multicomponent prognostic scores account for this by measuring components beyond FEV1. This thesis used data from large cohort studies and routine health data from general practice to answer research questions under four themes: 1) demonstrate the burden of exacerbation occurence; 2) provide evidence on the external validity of prognostic scores in accurately predicting risk in various clinical settings; 3) examine the potential for extending the use of these scores to detect disease worsening; 4) further our understanding of some components that comprise prognostic scores. Severe COPD exacerbations present a significant burden to patients as they increase hospitalisation and mortality. We found that the incidence rates of severe COPD shows signs of an increase from year-to-year which highlights the importance in accurately predicting these events. We demonstrate the external discriminative validity of the BLISS and ADO scores in predicting exacerbations and mortality, respectively. However, these scores may need to be recalibrated before predicting outcomes in different time horizons or healthcare settings. Serial measurements of the ADO score may help to update prognostic risk in people with COPD. Among people screened for COPD with respiratory symptoms, we found that symptom burden over time and prognosis of persistent moderate-to-severe respiratory symptoms was similar in those with normal FEV1, compared to those with airway obstruction. Finally, weight loss due to continuous smoking is accelerated if a person has COPD, and quitting results in an accelerated weight gain compared to those without COPD.

Time spent in sedentary behaviours, particularly prolonged sitting, has been identified as an independent risk factor for cardiovascular disease (CVD). However, the physiological mechanisms by which prolonged sitting contributes to CVD burden and what can be done to offset that burden remains unclear. Whilst a working model currently exists, further work is needed. In order to progress the working model, it is first necessary to consolidate the existing literature to identify the likely effect of prolonged sitting on the cardiovascular system. Identifying the impact of prolonged sitting is complicated by the fact that this behaviour is likely to cluster with other modifiable lifestyle behaviours, the most prominent of which are fat consumption, habitual physical activity, and cardiorespiratory fitness. Understanding into how these modifiable lifestyle factors may impact the cardiovascular system in conjunction with prolonged sitting is vital for the development of a robust biologically plausible model. As such, this thesis has two overarching aims: 1) to consolidate the existing evidence related to prolonged sitting, with and without interruption, and certain markers of cardiovascular health and function using systematic review and meta-analytic practices, and 2) to conduct experimental studies to investigate the interactions of prominent modifiable lifestyle factors on cardiovascular responses to bouts of prolonged sitting. This thesis demonstrated that: 1) acute bouts of prolonged uninterrupted sitting negatively impact cardiovascular function, but regularly interrupting bouts of prolonged sitting, particularly with aerobic activities, may offset these negative effects, and, 2) whilst cardiorespiratory fitness and habitual physical activity do not impact the cardiovascular responses to an acute sitting bout, the combined deleterious effects of prolonged sitting and consumption of a high-fat meal can be offset using regular interruptions. Collectively, this thesis identified a robust mechanism by which prolonged sitting contributes to cardiovascular burden, and further, this thesis offers insight into strategies to mitigate cardiovascular dysfunction. Finally, this thesis identified several methodological practices within the research area which should be improved.

The changing landscape of aging population, increasing incidence of critical illness and more constrained national budgets mean physicians, policy makes, and hospital administrators must consider more efficient ways to organise critical care services. In general, policymakers have embraced the idea of centralising services and increased specialisation to improve efficiency in health care. This thesis explores these policies in the context of critical care services in the UK. Evidence of the productivity of critical care services and in particular volume-outcome relationship in critical care and the underlying mechanism by which this relationship operates is scarce. I consider several aspects of these issues. In the first study I investigate the volume-outcome relationship for sepsis using data from the Intensive Care National Audit and Research Centre which covers all ICUs in the England, Wales, and Northern Ireland. In this cohort study, sepsis case volume in an ICU was significantly associated with hospital mortality from sepsis, and a volume lower threshold of 215 patients per year was associated with an improvement in mortality. The second study explores the underlying mechanism of the volume-outcome relationship. Two possible mechanisms proposed are dynamic learning-by-doing and static scale economies. If the volume-outcome relationship operates through the learning-by-doing mechanism, then patient outcomes would improve by the volume of patients treated over time, making system-wide centralisation unnecessary. This study supports the idea that the underlying mechanism by which volume leads to improved outcomes is through learning-by-doing. ICUs tend to improve by caring for a large volume patients distributed over time. Patients may, therefore, be better served by ICUs organised to achieve minimum volume 5 standards without centralisation. The third study examines the related role of ICU specialisation in improving mortality. This study found that ICU specialisation do not have significantly lower hospital mortality for critically ill patients in the UK after adjusting for patient characteristics and caseload volume. Across the three studies I argue that a minimum volume threshold may be effective in improving patient outcomes. Centralisation may not fully leverage the benefits of the learning-by-doing mechanism. Lastly, accounting for volume, there is no compelling evidence of any added value from ICUs specialisation.

Cardiovascular complications are common in people with type 2 diabetes. In the United Kingdom, cardiovascular disease accounts for approximately 32.1% of mortality in people with type 2 diabetes. One way to tackle this is through providing eligible type 2 diabetes patients with therapeutic interventions such as lipid lowering or antihypertensive drugs to reduce the risk of cardiovascular events. Previous research reported suboptimal prescribing of such drugs in eligible patients. This thesis explored initiation of lipid lowering and antihypertensive drugs for primary prevention. Firstly, a qualitative systematic review was conducted, using thematic analysis to understand both healthcare professionals' and patients' attitudes and perspectives towards drugs for primary prevention of cardiovascular disease. Themes relating to patients' attitudes towards preventive drugs included questioning preventive drugs, perceived benefits and risks, patient preferences, trust in health professionals' judgement and family, friends and media influences. Themes relating to health professional attitudes included addressing patient concerns and information, duty as a health professional to prescribe, uncertainty about preventive drug prescribing, recognising consequences of prescribing and personalised treatment. Secondly, factors predictive of drug initiation were investigated in a cohort study using a national longitudinal database of United Kingdom primary care records, the IQVIA Medical Research Database (IMRD). The study revealed a number of factors that influenced drug initiation including age, deprivation score and ethnicity. Lastly, statistically significant predictors from the retrospective cohort analysis were investigated in an experimental study using clinical vignette-based survey to elucidate which factors influence healthcare professionals to initiate preventive treatment. The survey responses revealed improvements in healthcare professionals prescribing of statins and antihypertensives in vignettes where initiation was recommended by guidelines.

Background: There is a strong research focus on the identification of individuals at risk of RA, to facilitate preventive interventions. To inform the development of effective predictive and preventive approaches for RA, it is important to gain a thorough understanding of the views of those who may affected by these approaches. Therefore, this thesis aimed to explore stakeholder's perspectives towards predictive and preventive approaches for RA, including RA patients, their first degree relatives (FDRs) and healthcare professionals (HCPs). Method: Due to the limited existing literature within the field of RA, a mixed-methods systematic literature review was conducted to examine the acceptability of predictive testing for ischemic heart disease (IHD) in those with a family history, to gain insights that may be relevant in the context of RA. Two cross-sectional surveys were conducted to assess the views of patients with RA and their FDRs regarding predictive testing. FDRs' surveys assessed their interest in predictive testing, and potential predictors of interest. Patients' surveys assessed their likelihood of communicating RA risk information to their FDRs, and potential predictors of this likelihood. Finally, one-to-one qualitative interviews were conducted on rheumatologists, rheumatology nurse specialists and GPs to assess their views on predictive and preventive approaches. Results: The systematic review examined five quantitative and two qualitative studies. Surveys were completed by 396 FDRs and 482 patients, and interviews were conducted with 16 HCPs. Those with a family history of RA (and IHD) were interested in taking a predictive test for the disease. Patients were willing to communicate information about RA risk to their FDRs, and HCPs were willing to provide predictive and preventive approaches to those at-risk. Several factors influencing stakeholders' perceptions towards these approaches, including the introduction of these approaches, were identified. These included demographic characteristics, perceived risk of developing RA, understanding of prediction and prevention, the need for patient autonomy, and the potential for tests to cause psychological harm. Conclusion: Stakeholders were generally interested in predictive and preventive approaches for RA, and reported various factors influencing their perceptions that could be used to inform the development of effective strategies to support the implementation of such approaches into clinical practice.

Cooking with solid biomass fuel is a global public health concern, presenting significant morbidity and mortality due to exposure to household air pollution (HAP). The HAP burden in urban Rwanda is high because of ongoing reliance upon solid biomass usage and rapid population growth. This thesis aims to inform the future development of effective public health interventions to address HAP in urban Rwanda, using a convergent mixed-methods approach. A systematic review, secondary data analyses of a population-based dataset and primary quantitative (semi-structured survey) and qualitative (in-depth interviews) data collection and analysis have been undertaken. Results of these activities have been interpreted and integrated using the development phase of the Medical Research Council's (MRC) complex intervention framework. Health risk assessments showed reduced risks of acute respiratory infections for children under five years associated with outdoor compared to indoor biomass fuel cooking, which may inform development of a health behaviour focussed intervention. In addition, biomass fuel use was not protective against risk of malaria infection, of relevance for a health educational intervention. Transition from charcoal to wood fuel (as observed during the COVID-19 pandemic) may be associated with increased risks of acute respiratory infection; of importance for future unintended consequences arising from fuel restriction policies, including a proposed charcoal ban in Rwanda. Qualitative investigation identified that cleaner fuels were the desired cooking fuel of choice, but structural and cultural barriers remain to access, uptake and concerns persist regarding outdoor cooking practices. The evidence from this thesis has enabled identification of potential health behavioural change interventions to mitigate HAP harms in urban Rwanda. Findings highlight the importance of early user involvement and co-production to ensure cultural suitability and sustained uptake. Interventions may be supported by appropriate policy initiatives, which must identify and mitigate potential unintended consequences at a policy formulation stage.

Overweight/obesity is increasing rapidly in low-and middle-income countries (LMICs), where forms of undernutrition remain high. Women of reproductive age and children living in LMICs are largely affected by anaemia, which is one of the 2025 global nutrition targets; however, its prevalence has remained stagnant over the past decades. As a result, different forms of malnutrition coexist at different levels: the double burden of malnutrition (DBM). Yet, the coexistence of overweight/obesity and anaemia had not being comprehensively investigated to date. Therefore, this thesis aimed to understand the epidemiology of the double burden of overweight/obesity and anaemia among adult women, adolescent girls and children living in LMICs. Data from the Demographic and Health Surveys (DHS) were employed for the analyses. Firstly, prevalence estimates were calculated at the population, household, and individual levels. Secondly, stratified analyses of the intra-individual and intrahousehold DBM were performed by household wealth, education level, area of residence, and sex. Lastly, trends were documented for the magnitude and inequalities of the intra-individual DBM among adult women. Overall, the intraindividual DBM was common among adult women and low among children; whereas among adolescent girls the overall pooled prevalence was 1/3 than that of adult women. At the household level, the DBM was high, primarily driven by maternal overweight/obesity and childhood anaemia. Important differences were identified by sociodemographic characteristics for the intra-individual DBM among adult women and adolescent girls, and maternal overweight/obesity and childhood anaemia; with higher prevalence estimates among those in the wealthiest groups, higher education levels and in urban areas. The trend analyses yielded a modest increase in the intraindividual DBM among adult women over the past two decades, which occurred in parallel with an overall rise in overweight/obesity and a decrease in anaemia. Due to the high heterogeneity of results obtained for the different LMICs, recommendations to address the DBM should be context-specific. The findings presented in this thesis can be used by policy makers to inform double-duty actions and accelerate progress towards the 2025 global nutrition targets.

Evaluating hospital care quality using case-note reviews is mandated in the United Kingdom and is endorsed by many high-income countries. This thesis separately addresses both the validity of case-note reviews and the use of case-note reviews for care quality improvement. On case-note reviewing validity, there are moderate-to-high levels of disagreement (variability) between multiple clinician case-note reviewers when evaluating the overall care quality of the same case-note. The sources of this disagreement (variability) are unknown. On case-note review use, the potential factors which affect case-note reviewing in hospitals has not been well-studied in relation to their contribution to hospital care quality improvement. This thesis presents the findings of three original studies and seeks to both identify the sources for this reviewer variability and the organizational factors which influence case-note review's likely contribution to hospital quality improvement. The introduction discusses the policy context and offers a critique of hospital mortality statistics with the prospective use of case-note reviews as an alternative approach for detecting care quality issues. Chapter 1 involved a systematic review of preventable mortality rates and a characterization of their measurement properties for evaluating care quality and subsequent hospital ranking. Findings concluded that a limitation of studies not accounting for variation between different hospitals, assuming equal variance, in the ranking process. Case-note reviews are presented as a workable alternative, to which this thesis is devoted to investigating. Chapter 2 presents the findings of an original systematic review which identified cognitive biases and heuristics related to case-note review care quality judgements. Cognitive biases and heuristics, sourced from two systematic reviews, are investigated with their plausible influence upon case-note reviewer care quality judgments using clinical scenarios derived using a systematic literature search and informed by a panel consensus. Findings indicate the plausible influence of cognitive biases and heuristics. Chapter 3 investigates the influence of reviewer attitudes; their demographics and patient case-note review characteristics upon case-note reviewer care quality judgements. Selected attitudes did not significantly influence care quality judgements and a significant proportion of care quality judgement variability is unexplained by the included independent variables. Chapter 4 describes case study fieldwork in an acute NHS Trust which explored the organizational processes around case-note review including its embedding, information flow and its perceived quality improvement contribution. We found that case-note reviews were well-embedded, with there being limited information flow from ward-to-board. Chapter 5 is a critical reflection of the research process and the assumptions made in this thesis. Chapter 6 summarizes the thesis, discusses practical implications, and identifies opportunities for future research for quality improvement from case-note reviews.

There is a high prevalence of sexual transmitted infections (STIs) within Organisation for Economic Co-operation and Development (OECD) settings particularly among ethnic minorities and marginalized groups which contributes significantly to the overall burden of disease. STIs have direct cost implications and impact on the overall wellbeing of patients, in part due to the strong stigma associated with contracting a STI. The thesis aimed to highlight the various aspects of sexual health services considered most important by patients while accessing care to inform healthcare decision-making for evaluation and planning (designing or re-designing) of services to ensure they are patient centred. A systematic review, qualitative synthesis and meta-ethnography, and primary research (qualitative) were conducted to establish themes pertaining to various aspects of services considered most important by patients and potential clients. This was further substantiated by generating an evidence-based discussion (based on existing theories in health economics and patient reported outcome measure (PROM) development processes) to justify the need for the development of a preference-based PROM specifically for sexual health services. Analysis of existing theories in health economics suggested that an Extra-Welfarist approach (expanding the evaluative space within quality adjusted life year (QALY) measurement) as more appropriate for measuring and valuing outcomes in this area. The findings of the systematic review highlighted important structural and methodological limitations in the existing assessment tools whereas the qualitative synthesis and meta-ethnography reported that patients had expectations which were far more than being tested and treated for STIs and receiving advice on contraception. Nine main themes were identified in the primary qualitative research: involvement in decision-making; clear and comprehensive diagnosis and treatment; being seen and getting results quickly; having a choice of appointment type; feeling respected and put at ease; non-judgemental and friendly staff; feeling reassured about confidentiality; having support with partner notification & being able to find & get to services. The findings of the thesis suggest that a standalone or de-novo sexual health services specific preference-based measure would better allow particular focus on the dimensions which are important to patients, with increased ability to detect meaningful changes in the status of patients.

Introduction: Pulmonary Rehabilitation (PR) is an essential non-pharmacological intervention for patients with chronic obstructive pulmonary disease (COPD), yet rates of referral across the UK are persistently low. There is little research on the perspectives of health care referrers which could highlight avenues for interventions that could improve referral rates. Methods: Drawing on the principles of implementation science and including psychological theory offered by the Theoretical Domains Framework (TDF) and the Capability Opportunity Motivation and Behaviour model (COM-B), a multiphase mixed methods approach has been used. This commenced with a systematic review to identify previously tested PR referral uptake and adherence enhancing interventions. Then an inductive qualitative research study was carried out, followed by a second deductive approach where the TDF was applied to the original qualitative findings. This supported the generation of belief statements which informed a survey for distribution amongst a wider primary health care professional population. This sought to test the generalisability of the qualitative findings and used a sequential exploratory mixed methods approach. The findings from all individual approaches were then integrated to highlight key practice based referral barriers and enablers and inform intervention development, which utilised COM-B and its associative Behaviour Change Wheel (BCW). Results: The systematic review showed there is a paucity of controlled studies that have evaluated referral, uptake and adherence interventions. Patient held COPD scorecards and training respiratory healthcare professionals in motivational interviewing alongside personalised care planning may be effective referral enhancing strategies. The combined Primary Health Care Practitioners (PHCP) qualitative and quantitative investigations showed referral to PR is complex. There are multiple barriers and very few enablers, which relate to three populations: patients, PHCPs and PR providers, individually and collectively. Key findings highlight that PR knowledge and awareness is important, but intrinsic and extrinsic factors pertinent to patients, systems and providers affect subsequent referral behaviours, both positively and negatively. However, PHCPs with respiratory qualifications report having greater confidence in answering patient's questions and to refer more frequently than those without. Intervention design using COM-B and the BCW is time consuming and challenging. However, its use highlighted PHCPs 'unconscious beliefs (termed 'automatic motivation') around a number of perceived patient factors affected referral behaviours. Nevertheless, PHCPs consider PR beneficial for patients with COPD and describe wanting to refer more patients. Conclusion: PHCPs decisions to refer patients with COPD to PR are influenced by many factors before and during the physical PR referral process. Interventions need to consider how to enhance collaborative working across patients, PHCPs and PR providers in order to increase PR awareness, uptake and completion. It must also consider intervention fidelity. Adopting targeted strategies to increase PR awareness that address patients and PHCPs motivations and enhancing PR provider engagement are likely to help. Testing these interventions within a cluster RCT are recommended next steps.

This thesis examines portrayals of homes and gardens in magazines, advice books, public health discourse and government propaganda in mid-twentieth-century Britain, analysing representations of healthy domesticity inside and outside the home, and in transition between the two. Taking an environmental perspective, it explores the implications of the association of housewives with hygiene and care for choices in shopping, the home and the garden. Vegetables were regarded as essential to health yet might still have soil on them. Waste, when converted into compost, was seen as a component of healthy soil, yet whilst in the process of decay had associations with risk to health. This thesis explores the tensions between two different understandings relating to health, namely that fresh vegetables grown in soil were nutritious, and that germs might hide unseen in dirty soil and might pose a risk if ingested. It attends to alternative voices advocating a cyclical and local approach to waste management and vegetable production but argues that they did not significantly impact the dominant cultural association between housewives, the indoors, and hygiene. Chapter one demonstrates how considering soil in the domestic space connects perspectives from multiple disciplines. Chapter two explores the construction of boundaries in the domestic space, between the indoors and the outdoors, the clean and the dirty. Chapter three focuses on the procurement of vegetables, analysing choices that were made between different purchasing options, and domestic growing in the garden or on the allotment, assessing how far concepts of protection from germs influenced these choices. Chapter four explores waste, both as rubbish and as sewage, and the ways in which practices were influenced by the construct of the ideal hygienic home. This thesis thus makes a significant contribution to histories of domesticity, gender and the environment that can inform current debates relating to climate breakdown.

This thesis aims to understand how methodological and conceptual approaches to complexity in quantitative analysis can improve evidence and decision-making, specifically for schistosomiasis control in Uganda and more broadly within global health. Engaging directly with the complexity through methodological choices provided new insights into policies and practices in global health. In Paper 1, I provided an overview of actors and power dynamics in global health, by describing the changing landscape of global health actors as it relates to relative shifts in power over time. This is accomplished by capturing the emergent, dynamic network structure of development aid for health in the period encompassing the 'MDG era', between 1990 and 2015. This paper was published in the Journal of Health Policy and Planning (https://doi.org/10.1093/heapol/czac025). Paper 2 aimed to develop evidence for decision-making in response to the needs of policymakers and practitioners, with a focus on schistosomiasis transmission and control activities in Uganda. This was accomplished by (1) capturing the perspectives of national and sub-national decision-makers on schistosomiasis transmission using participatory modelling, and (2) using the participatory modelling outputs to inform mathematical model simulations in response to the evidence needs. The implementation of this approach challenged the balance of power between international and domestic actors in the development of evidence and decisions regarding the delivery of global health interventions. This paper was published in BMJ Global Health (http://dx.doi.org/10.1136/bmjgh-2021-007113). Paper 3 used the outcomes of the participatory systems mapping workshops and individual-based simulations to guide the scope and content of economic evaluations of schistosomiasis interventions. The results indicated that the most cost-effective scenario is a system of implementation reliant on volunteers from within communities and donated drugs. As anticipated, when all else is held equal, including these costs result in lower cost-effectiveness ratios relative to other interventions. Further, the results bring into question the purpose of continuing interventions which are not predicted to achieve the desired targets within the 30-year time horizon. This paper highlighted potential opportunities for schistosomiasis intervention design and implementation which is more aligned with the aims of equitable, country-led sustainable development. Paper 4 shifted the focus within the discussion of evidence for decision-making in global health to consider one particular type, peer-reviewed publications, which is most often considered as 'best practice' in evidence-based decision-making. A systematic review captured the network of authors who had published on MDA. These results constituted the sampling frame for a remote survey to elucidate perspectives on their roles in policy and practice related to MDA. The findings highlighted the ongoing structural disparities in research leadership and found broad concern about opportunities and about disconnects that limit engagement between researchers and decision-makers for use of primary research in policy and decision-making processes. Paper 4 was published in the Journal of Public Health Policy (https://doi.org/10.1057/s41271-021-00294-x). Broadly speaking, the papers in this thesis have shown that while reductionist, linear perspectives may be part of the reason for the continuation of ineffectual policies and practices, the confluence of politics, power relations, and economies in the context of a complex system of actors and processes also plays a significant role with regards to policy and practice decision making. This was observed in relation to schistosomiasis in Uganda and more broadly in global health at the system level. This thesis uses language and methods common in health sciences to communicate critiques in a way that can be engaged with by health policy-makers, practitioners, and many public health researchers. Finally, this thesis showed the possibilities for using network-based and computational models for understanding complexity within the global health 'system'.

The neglected tropical disease visceral leishmaniasis (VL) has greatly burdened vulnerable populations in the Indian subcontinent. The analyses in this thesis are motivated by observations from VL field epidemiology that cases cluster in space & time. Using a household-level dataset from a highly-endemic Bangladeshi village covering the years 2002-2010, I investigate spatiotemporal clustering using the tau statistic to estimate the magnitude & spatial range of clustering of cases to inform control interventions and to validate a recent mechanistic model result. Then, for Vaishali district, India, I employ a spatiotemporal statistical model to assess if an intensified intervention pilot during 2015-2017 was successful and how many cases may have been averted while accounting for district-level clustering of incidence. To deliver high-quality insights, several novel advances in methodologies were made. A literature review of the tau statistic was performed that detailed its existing uses & methods of inference to assess the presence of spatiotemporal clustering and estimate the range of clustering around cases. This prompted corrections & improvements in inference methods leading to higher precision in clustering estimates than a previous baseline analysis on a measles dataset. A new rate estimator for the tau statistic was created to account for variable person-time at risk in the Bangladeshi study. Finally, customisations in the use of the surveillance & hhh4addon R packages were made to perform an interrupted time series analysis for the Vaishali study. The findings of this thesis contribute to the current VL discourse by quantifying spatiotemporal clustering around cases, partially validating a recent result on clustering and giving a rigorous evaluation of a control pilot that may be required if incidence recrudesces. For spatiotemporal statistics, improvements in the tau statistic and the new applications of these R packages offer valuable examples in methodology & code for other infectious diseases. I summarise the findings of this thesis and list further research opportunities in VL, which I hope to explore as my career in infectious disease modelling progresses.

Background: Little is known about the prevalence, determinants, and treatment needs of people who reside in the slums of Nigeria, and information on slum dwellers' experiences about oral health care is scarce. Such information is needed to plan appropriate interventions to improve the oral health and well-being of Nigeria's growing slum population, hence this study. Methods: This thesis was mixed methods parallel convergent in design and was approached by conducting three research works: 1) a systematic review on oral health in slum and nonslum urban settings of the Low and Middle-Income Countries (LMICs); 2) a community oral health survey on the prevalence of oral health conditions, the determinants and treatment needs among slum residents in comparison with non-slum residents in Ibadan; 3) qualitative research exploring the perspectives of slum dwellers about their dental health experience. Results: Combined findings suggest bleeding gum, periodontal pocket, and dental caries as prevalent oral diseases in the slum. Oral health outcomes were worse when compared to the non-slum counterpart and this is comparable to findings from the LMICs in terms of high prevalence. Verified normative needs confirmed the slum residents' felt treatment needs and identified 35% that required the "prompt and urgent" levels of treatment. Dental visits were generally low, mostly problem-driven, often as last resort, and worse in the slum. Wide practice of alternative dental care remedy options that generally preceded professional healthcare seeking abound. Oral health needs include improved access to more comprehensive dental treatments at reduced costs as well as increased oral health literacy. Conclusions: The slum residents had high oral disease burden with worse outcomes relative to their non-slum counterparts. Potentially harmful oral self‐care remedy options abound among them and these generally precede professional healthcare seeking. They could benefit from targeted oral health education and improved access to professional dental care.

Introduction: The prevention of maternal infection and sepsis are essential to reduce maternal mortality and morbidity worldwide. Internationally, childbirth in healthcare facilities is actively encouraged to reduce maternal mortality; however, it can increase the risk of healthcare associated infections if infection prevention and control standards are not met. By adhering to World Health Organization (WHO) guidelines for health facilities, incidence of maternal infection can be reduced. The relevant WHO guidelines include those on: 'water, sanitation and hygiene'; 'hand hygiene'; and 'recommendations for the prevention and treatment of maternal peripartum infection'. This PhD research investigated the feasibility of implementing these in maternity care, focussing on low resource settings. Methods: Three separate studies were undertaken as part of this PhD research. (1) The UK hospital inpatient cases (n = 455) of maternal infection and sepsis during the GLOSS 1-week inception cohort study were reviewed. The aetiology, causative organisms and risk factors for severe infection were explored using descriptive statistical analysis. (2) An explanatory sequential mixed methods feasibility study entitled 'Preventing Maternal Sepsis in Low Resource Settings' was designed and conducted in three low resource maternity settings in Malawi. Aligned with Proctor's implementation framework, this study investigated the feasibility of introducing the WHO guidelines using ward infrastructure surveys at 4 time points, observed hand hygiene opportunities (n=7472), patient record reviews (n=858), qualitative semi-structured interviews (n=33) and six member validation events with healthcare professionals. (3) The WHO 'hand hygiene reminders for the work place' were examined using a convergent mixed methods approach, investigating their acceptability in maternity settings using a survey (n=342) qualitative semi-structured interviews (n=12) and a focus group. Data collection and analysis aligned with Sekhon's acceptability framework. Results: Study 1: the incidence of maternal infection in inpatients in the UK was 32 cases per 1000 live births; lower than the global incidence. Most cases were endometritis or chorioamnionitis where the source was identified, in keeping with the global findings. Study 2: all sites lacked reliable access to running water. The biggest improvement to hand hygiene adherence was seen with the introduction of alcohol-based handrub; to 81%, from 8% at baseline. A significant improvement in antibiotic prophylaxis (75% at baseline to 94% after intervention (P < 0.001)) and vaginal cleansing at caesarean section (0% at baseline to 58% after intervention (P<0.001)) was seen. However, long courses of antibiotic prophylaxis continued to be given against WHO guidance. Two themes (a) study context and (b) characteristics of the intervention were interpreted from the qualitative data to understand these findings and draw recommendations for randomised controlled study (RCT) scale up. Study 3: WHO hand hygiene reminders for the workplace were found to have high acceptability for use in maternity settings but did require some adaptions. Participants from high income settings reported overfamiliarity with the reminders, whereas following the guidance was an issue in low and middle income countries due to resource availability. Conclusion: This PhD research demonstrated that it is feasible to improve the prevention of maternal infection in low resource settings. Adapting guidance and implementation strategies to the local context improved acceptability and uptake. The results are being used in an RCT assessing clinical outcomes. Additionally, the research findings have influenced development of new WHO posters and training materials, aiming to reduce global maternal mortality and morbidity from infection.

Background: Ramadan fasting, in which Muslims abstain from food and drinks from dawn to sun-set, is one of the five Pillars of Islam. Millions of Muslims observe this month every year. Howev-er, little is known on the effect of Ramadan fasting on health. There is a lack of research investi-gating the effect of Ramadan on health. Ramadan fasting is associated with sudden changes in lifestyle including changes in mealtime and sleeping pattern. These changes lead to circadian misalignment that could lead to cardiometabolic dysfunction and cardiovascular disease. Moreo-ver, dehydration resulting from the prolonged fasting is claimed to increase the risk of infection in Ramadan. The aims of this thesis are (1) to assess the impact of Ramadan fasting on different aspects of health (2) to strengthen the available evidence on the effect of Ramadan fasting on health using a robust method that have not previously been employed in Ramadan research. Methods: The overall methods (1) using The Health Improvement Network (THIN) database for a retrospective cohort design to explore the cardiometabolic profile of a predominate Muslim popu-lation in the UK, (2) systematic review to summarise the available evidence on the effect of Ram-adan fasting on cardiovascular disease (CVD) and risk factors for CVD in patients with diabetes (3) controlled interrupted time series using THIN database and hospital data to explore (a) infection (all infections), using antibiotics prescriptions as a proxy measure and (b) ischemic heart disease (IHD) risks in a predominant South Asian Muslim population in the UK to a predominantly non-Muslim white ethnic population as a control group. Results: The retrospective cohort study showed that compared to white population, South Asian (SA) are at higher risk of diabetes, hypertension and IHD with some variations between SA sub-groups. Systematic review showed that there is insufficient evidence suggesting that Ramadan fasting is associated with increased risk of CVD events in patients with diabetes. The interrupted time series studies show that there is no evidence that Ramadan fasting is associated with in-creased risk of infection or IHD. Conclusion: Up to date there is no evidence that Ramadan fasting is associated with detrimental effect on health. However, more well conducted studies are needed to validate the findings.

Background: Dental caries is reportedly the most prevalent disease worldwide and represents a significant challenge for public health, especially in childhood, with 7.8% of children suffering from untreated caries in their primary teeth worldwide. The Chilean Government is making efforts to gradually improve oral health across the population, with the incorporation of new public health programmes that aim to improve oral health and reduce oral health inequalities, including a community water fluoridation programme; oral health preventive interventions in primary care public clinics, and "Sembrando Sonrisas", a daily supervised toothbrushing and fluoride varnish application programme in state-funded nurseries based on the "Childsmile" national child oral health improvement programme for Scotland. In Chile, there are few published studies that determine the burden of caries in children, and thus far, there has been no formal evaluation of the impact of the national oral health improvement programmes for Chile on child caries outcomes. Aim: The overarching aim of this thesis was to undertake a quantitative outcome evaluation of the national oral health improvement programmes for Chile on oral health outcomes and related inequalities in children. This overarching aim was met by fulfilling the following objectives: (1) To collect, collate and manage data from the national oral health programmes, along with data on child dental caries and sociodemographic characteristics at the national, regional, and municipality level in Chile; and to assess quality and completeness across datasets; (2) To design and develop an area-based ecological longitudinal cohort to assess the trends in dental caries of six-years-old children in Chile at the national, regional, and municipality levels, and to analyse related area-based socioeconomic inequalities and the impact of the sociodemographic characteristics of the municipalities on child caries levels; (3) To assess the impact of the national oral health programmes, including: community fluoridated water, the preventive interventions delivered in primary care public clinics on the caries levels of six-year-old children in the Chilean public health system at the municipality level, and related inequalities; and (4) To evaluate the impact of the Sembrando Sonrisas programme interventions on dental caries outcomes of five-year-old children covered by the programme since its establishment and rollout, and to assess the programme effect over and above community water fluoridation on child dental caries and related inequalities. Methods: National information governance approvals were obtained to access, collect and collate aggregated municipality level data (n=346 municipalities) for each year (2008 to 2019) from datasets on child dental caries outcomes; the national oral health improvement programmes (community water fluoridation; preventive interventions delivered in primary care public clinics; Sembrando Sonrisas); area-based socioeconomic deprivation (Socioeconomic Development Index; Multidimensional Poverty Index) and rurality (Rurality Proportion Index; Rurality Level Index) data indexes. Data quality and completeness checks were performed to assemble the ecological cohort. A novel ecological longitudinal cohort was assembled using the "municipality/years" unit of analysis, along with the design of a continuous variable for the evaluation of child caries outcomes: "Caries Experience", measured as the presence of decay (into dentine), missing (extracted) due to decay, or filled primary teeth, in six-year-old children living in Chile who attend primary care public clinics. Univariate and multivariate weighted linear regression models assessed the trends and the effect of socioeconomic deprivation and rurality on caries experience. The most parsimonious model to evaluate the impact of the national oral health improvement programmes was selected with a forward selection model including significant potential confounders of caries experience. Socioeconomic inequalities in the distribution of caries experience by deprivation category were assessed by summary inequality measures. A detailed description of caries experience and related sociodemographic characteristics was performed at the national, regional, and municipality levels. Univariate and multivariate weighted linear regression models assessed the independent potential effect of the national oral health improvement programmes interventions on caries experience, including community water fluoridation coverage and annual fluoride concentration, along with the oral health preventive interventions performed in the primary care public clinics: individual toothbrushing advice to parents; application of sealants on primary teeth; and fluoride varnish applications. Potential inequalities in the delivery of the programmes interventions where evaluated via weighted linear regression models. To assess the impact of Sembrando Sonrisas interventions on caries outcomes of children covered by the programme another, further, separate area-based longitudinal cohort was assembled by merging the data of the two birth cohorts that had being exposed to the Sembrando Sonrisas interventions since its establishment and rollout in 2015. An outcome variable was used, "Sembrando caries experience" in five-year-old children covered by the programme in 2018 and 2019 and examined in the nurseries covered by the programme. Univariate and multivariate weighted linear regression models assessed the independent potential effect of the Sembrando Sonrisas interventions on "Sembrando caries experience", including the delivery of oral health kits for supervised daily toothbrushing in nurseries (including four toothbrushes and one toothpaste with 1000 ppm of fluoride annually per child) and the application of fluoride varnish in nurseries. Also, multivariate weighted linear regression models assessed the potential impact of those interventions over and above community water fluoridation. Finally, weighted linear regression models evaluated potential inequalities in the delivery of Sembrando Sonrisas interventions. Results: A novel ecological longitudinal cohort was built including dental examination municipality-level data recorded in the primary care public clinics on 1,397,377 six-year-old children available from 3608 municipality/years. Caries experience significantly reduced from 83% in 2008 to 66% in 2019. Those areas with 90% or greater water fluoridation coverage and fluoride concentrations of 0.6 mg/L or higher demonstrated between 7% to 15% lower caries experience than those not exposed to community water fluoridation. A socioeconomic gradient was observed with those municipality from the most socioeconomic deprived category of the Socioeconomic Development Index bearing a 15% higher dental caries burden, while also having a 50% lower water fluoridation coverage when compared to those from the least socioeconomic deprived category of the Socioeconomic Development Index. For the preventive interventions performed at primary care public clinics, a higher rate of these interventions prior to age six was associated with a significantly higher caries experience. Also, a higher rate of these interventions was observed in the most socioeconomic deprived municipalities, in comparison with the least deprived communities. Dental examination municipality-level data recorded in the nurseries covered by the Sembrando Sonrisas programme on 309,360 five-year-old children were available from 637 municipality/years. The delivery of oral health kits for the daily supervised toothbrushing in nurseries to all children participating in the programme was associated with a 5% decrease in caries experience in comparison to those municipality where this was not achieved, even after adjusting for deprivation and the exposure to fluoridated water. The application of fluoride varnish in nurseries covered by the programme was not a significant explanatory variable on the differences in caries experience at the municipality level. Five-year-olds from municipalities with community water fluoridation and where all children received the oral health kits for daily supervised toothbrushing in nurseries showed a caries experience of 52%. In contrast, those from municipalities unexposed to CWF and where not all children received the kits showed a significantly higher caries experience of 65%. Conclusions: A continuing and significant decrease in the caries experience of six-year-old children at the national and municipality level was observed between 2008 and 2019 in Chile. These improvements were shown to be associated with community water fluoridation coverage and annual fluoride concentration. However, by the end of the study period, the high childhood caries levels and inequalities observed remain a public health challenge in Chile.

Background: Cigarette smoking is the leading preventable risk factor of morbidity and mortality in the world. Many studies have examined the association between smoking and health outcomes. Observational, cross-sectional studies can be confounded, and hence the casualty of associations between smoking and health outcomes cannot be established. A genetic epidemiological approach such as Mendelian randomization (MR) can be informative concerning potential causal associations between smoking and health outcomes. MR leverages the availability of genetic data on smoking and health outcomes to estimate confounder-free associations. The current thesis was carried out to investigate the observational and causal associations between smoking behaviour and cardiometabolic diseases, stroke, and lipid biomarkers. Methods: Firstly, detailed reviews of prior research were conducted, highlighting that the majority of previous research was observational in nature. The thesis utilised the relatively large sample of UK Biobank (N=~502k) to conduct observational as well as MR-based analyses. The observational approach was based on self-report for multiple smoking phenotypes (smoking status, smoking intensity, and age at smoking initiation), clinical diagnoses for cardiometabolic diseases (CMDs; coronary heart disease (CHD), hypertension (HTN), and diabetes mellitus (DM)), stroke, and lipid biomarkers (total cholesterol, low-density lipoproteins, triglycerides, and high-density lipoproteins). The genetic analysis was based on 14 single-nucleotide polymorphisms (SNPs) for smoking intensity (cigarettes smoked per day: CperD) and 15 SNPs for smoking history. The genetic analysis was conducted in the UK Biobank sample (one-sample MR) as well as publicly available 'summary statistic' genetic data (two-sample MR). The analyses were conducted using R software and the MR-Base platform. Results: Observationally (analysis: chapter four), current smokers had a higher risk of CHD (odds ratio [OR]: 1.61, P<0.001), stroke (OR: 1.64, P<0.001), and DM (OR: 1.12, P<0.001), and lower risk for HTN (OR=0.89, P<0.001) compared to never smokers. Additionally, as individuals smoke one more cigarette per day on average (smoking intensity), the risk for all CMDs increases (CHD, stroke, and HTN: OR=1.01, DM: 1.02, all P<0.001 per average daily cigarette). Finally, as an individual initiates smoking one year later in life, the risk of all CMDs decreases except for HTN (CHD and stroke: OR = 0.96, P<0.001, DM: OR=0.99, P > 0.05, and HTN: 1.01, P<0.001). For lipid biomarkers (analysis: chapter five), current smokers showed higher levels of cholesterol (β: 0.05 mmol/L, P<0.001), LDL (β: 0.06 mmol/L, P<0.001), and TG (β: 0.09 mmol/L, P<0.001), and lower level of HDL (β=-0.14 mmol/L, P<0.001) compared to never smokers. Similarly, as individuals smoke one more cigarette per day (smoking intensity), the levels of cholesterol, LDL, and TG increase, and the level of HDL decreases (cholesterol: β=0.02 mmol/L, LDL: β=0.03 mmol/L, TG: β=0.02 mmol/L, and HDL: β=-0.04 mmol/L, all P<0.001). Lastly, as an individual starts to smoke one year later in life, the levels of all lipid biomarkers increase except for TG (cholesterol: β=0.01 mmol/L, P=0.026, LDL: β=0.001 mmol/L, P > 0.05, TG: β=-0.01 mmol/L, P<0.001, HDL: β=0.04 mmol/L, P<0.001). In terms of MR-based causal estimates (analysis: chapter four), there was no evidence of any causal relationship between smoking behaviour variables with CHD, stroke, and lipid biomarkers (analysis: chapter five) in the UK Biobank sample (one-sample MR) nor in other samples or approaches (summary-level in MR-Base platform or R). The only significant causal associations were observed in two isolated MR analyses; one between smoking status (ever) and HTN in one sample MR in the UKB sample and the other was between smoking intensity (CperD) and DM in two sample MR in R. Conclusion: The observational findings indicated that cigarette smoking increases the risk of CHD, stroke, DM, and levels of total cholesterol, LDL, and TG observationally, but this was not supported by 'causal' genetic evidence. Smoking behaviour seems to be associated with lower blood pressure (observationally and genetically) and HDL levels (observationally, not genetically). Finally, findings on HTN, cholesterol, LDL, and HDL have varied depending on the smoking variable. These ambiguous findings point toward some of smoking's association with poorer health perhaps being due to poor lifestyle generally and not smoking itself in isolation. Evidence of potentially protective findings of smoking is likely to be driven by instrumentation or attrition bias. More research is needed to meticulously determine the impact of each smoking variable on health outcomes, both observationally and genetically.

Background: Features of the urban environment can support human health as well as harm it. Evidence has accumulated for the links between different place-based characteristics and physical and mental health. However, this evidence stems primarily from highly developed countries. The extent to which it is generalisable to other locations, such as the Middle Eastern Arab region, which has unique political, socio-cultural, and climatic environments, is not clear. Aims and setting: This thesis aims to investigate health in relation to the urban environment in the twin cities of Ramallah and Albireh in the occupied Palestinian territory. Specifically, it will examine the associations between the risk of chronic illness and: a) politically created area disadvantage (refugee camps and 'Area C'); b) urban green space. It will also explore the interaction between these area-level features and age, sex, and household assets in their association with chronic illness. Methods: Area-level variables were linked with individual respondents to the 2017 census using a Geographic Information System. The analytical sample was 54693 individuals living in 228 residential areas. The outcome variable was the presence/absence of chronic illness. The area-level variables were the politically created disadvantage indicated by Refugee camps and political land classification 'Area C' (controlled by Israel); the proportion of mixed trees, crop trees and open space with little/no vegetation; Individual-level variables included twelve demographic and socioeconomic characteristics. Multi-level logistic regression models examined associations and interactions between individual and area-level variables and the probability of chronic illness risk. Results: On the political dimension, living in the context of a refugee camp was associated with greater odds of chronic illness (OR 1.91 CI [1.17-3.09]). This association was attenuated and rendered non-significant when adjusting for green space. The proportions of 'mixed' trees in residential areas had an independent inverse association with chronic illness (OR 0.96 CI [0.95-0.97]). There was no/weak evidence for an association between the context of 'Area C' and the proportion of crop trees and open space with the risk of chronic illness. A statistically significant interaction was found between sex and living in refugee camps. Females living outside refugee camps have a significantly lower risk of chronic illness compared to males but not for those living inside refugee camps; females inside refugee camps had a higher risk of chronic illness compared to males (though not a significant difference). There was no/weak evidence for interactions between the other area characteristics and age, sex, and household assets. Conclusion: This is the first study in the Palestinian context, and among the few from the Arab World, to investigate links between the urban environment and health. As expected, living in the disadvantaged context of refugee camps is associated with a higher likelihood of chronic illness. Not all greenspace types were associated with improved health outcomes, but mixed trees were, and the green environment appeared implicated in the association between refugee camps and poor health. These results from a Middle Eastern Arab setting add to the evidence, largely from Western countries, that mixed trees in urban environments benefit health. Researchers and policymakers interested in reducing health inequalities should give more attention to refugee camps and green typologies, especially to females living in the disadvantaged contexts of refugee camps who may gain greater benefits. Research with a broader scope is needed to investigate the impact of political land classification on health.

Background: Scotland has the highest rate of drug-related deaths in Europe. Since 2008, the concept of 'recovery' has had an important role in Scottish drug policy. Central to this is the proposed development of community resources to help people overcome addictions. This project evaluated the early establishment of a new residential rehabilitation project called River Garden, opened in 2018, which used a training and social enterprise model to support people into abstinent recovery. The project was inspired by the San Patrignano recovery community and was an attempt to transfer the principles of that model to a new international setting. Methods: This longitudinal mixed-methods process evaluation was based on data from residents, staff, and trustees of River Garden, gathered through participant observation, surveys, social network ('egonet') interviews, and theory-testing interviews. Twenty-seven interviews were conducted with seventeen people (nine residents, four staff, and four trustees). Analysis involved the development of programme theories, informed by principles of realist evaluation. Findings: This intervention worked better for some individuals than others, despite exhaustive screening before entry. The work-based challenges of the social enterprise model were less effective for people requiring greater relational support, resulting in high levels of attrition and relapse. The key mechanisms were trust, respect, and motivation (as responses to instrumental and relational resources). The project was adapted in several ways to increase stability, such as restricted intake of new residents and reduced integration with external recovery communities. Differences of opinion about the necessity of adaptions led to significant attrition from the Board of Trustees. Conclusion: The extent to which necessary adaptions to the San Patrignano model for a successful transfer to a new context could be foreseen was limited. After three years River Garden is best considered as a social integration model that can support the next steps of recovery once an individual is sufficiently stable and motivated. It should not be considered as an intervention that could reduce drug-related deaths, because of its limited capacity to manage the highest levels of risk. Whether this limitation is specific to early community formation or fundamental to the model will be a key question as the programme expands.

Background: Simulated Presence Therapy (SPT) involves playing an audio and/or visual recording of a caregiver to persons with dementia (PwD) to ameliorate Stressed and Distressed Behaviors (SDB). Aims: This study aimed to determine if SPT, when employed as part of a formulation-driven approach, can ameliorate SDB in PwD. In addition, this study also investigated the usability and acceptability of SPT by healthcare staff. Methods: A multiple baseline across participants single case experimental design was employed. Participants were in the moderate to severe stages of cognitive decline, residing in residential or hospital settings. Participant attachment style data was also gathered. Data was gathered through recordings of the frequency of daily SDB before and after the introduction of SPT and analyzed using visual inspection and Baseline Corrected (BC) Tau. 21 people participated in the study, consisting of patient participants (N= 5), informants (N=4) SPT video recorders (N=7) and professionals (N=5). Three patient participants, all identified as being securely attached, ultimately completed the study. The five professionals completed the user experience questionnaire. Results: Tau-U analysis revealed that one participant demonstrated a significant increase (Tau = 0.588, p < .001) in daily SDB based upon the method utilized to handle missing data, whilst another demonstrated a significant decrease (Tau = 0.377, p = 0.046). No other significant results were shown. The median score on the user experience questionnaire across participants was 45 out of a possible 55, indicating positive views of the technology-based intervention by healthcare staff. Conclusions: The mixed efficacy of SPT used as part of a formulation-based approach indicates that it may be a useful intervention in certain circumstances. Staff responses to the user experience questionnaire indicated that SPT was a usable, acceptable, and helpful intervention. Recommendations for further research are provided.

Background Despite the huge potential universal health coverage (UHC) holds for solving most public health problems, more than half of the global population yet lack access to essential health services (EHS). Low- and middle-income countries (LMICs), especially those in Africa and South Asia share the highest burden of these issues. This thesis aims to examine the determinants, impact and expected improvement in EHS in LMICs Method Eight analytical techniques were applied to explore the objectives of the thesis. The first three (bibliometric analysis; systematic review and ecological analysis) were applied to generate evidence on key topics on UHC research. A series of five other analytical techniques were applied to examine access to EHS in LMICs. Results were presented with tables, maps, and other figures; all the analyses were performed with STATA and R vs 4.6. Results The lack of financial protection in LMICs is high, with more than two-thirds (67%) exhibiting common-cause variation. The prevalence of mother-child pairs with suboptimal access to EHS varies widely in LMICs, from 5.5% in Honduras to 100% in Colombia. 54.6% of the variance in suboptimal access to EHS are attributable to neighbourhood-level factors and maternal education is the strongest determinant at individual levels. The impact of suboptimal access to EHS was strongly associated with under-five mortality across all the LMICs such that interventions aimed at shifting determinants related to sustainable development goals (SDGs) will increase access to EHS by more than 80%. Conclusion This thesis has added to the growing body of evidence on UHC. Findings suggest that LMICs must prioritise new approaches to ensure health insurance schemes are equitable. Policymakers and stakeholders must begin to think beyond quick but unsustainable intervention for UHC in LMICs and increase their focus on contextual issues and other socioeconomic factors that impact on EHS.

Background Informal networks are important for social support for slum residents of Low and Middle-Income Countries (LMICs), where maintaining health is crucial for household income and formal healthcare provision is scarce. Consulting personal or online-based networks (known as lay consultation) during illness can influence personal treatment decisions, but there was scarce evidence from slums. This thesis aimed to (i) examine the use, characteristics and influence of lay consultation networks in slums of Nigeria, and (ii) explore experiences of using the networks. Methods A mixed-methods approach was adopted. A systematic review was initially conducted to synthesize evidence on lay consultation for symptoms and illnesses in slums of LMICs. A cross-sectional survey was conducted among adults in two slums in Nigeria to describe their lay consultation networks. This was followed by interviews to explore experiences of lay consultation in more depth. Key findings Most participants spoke to lay consultants during illness. The lay consultants used per illness episode were few and were mostly close network members. Use of online sources of advice was scarce largely due to poor access to smart devices and poor digital health literacy. Lay consultation was multi-dimensional, involving casual reporting of health concerns as part of daily bonding, exchanging advice and information about health, emotional and practical support. Lay consultation networks significantly influenced participants' choice of health care services. However, lay consultation had negative aspects, including facilitating the transfer of unhelpful advice, discriminating and stigmatizing people with certain characteristics and intruding on a patient's privacy, contributing to worse health outcomes. Participants were strongly agentic in how they selected lay consultants and adopted advice from others. Conclusion This thesis highlights the potential of engaging lay consultation networks in health education interventions and creating a formal health resource as cost-effective means to support treatment decisions in slums.

References to social identity feature prominently in the psychoanalytic canon but generally receive little attention or discussion. This qualitative research study aims to examine the role of social identity in the training of child and adolescent psychoanalytic psychotherapists by exploring how it has been experienced and understood, and how this role relates to therapeutic practice. It investigates this topic via a literature review and 12 interviews with psychotherapist members of the Association of Child Psychotherapy (ACP). The literature shows how the exclusion of critical or reflexive approaches to learning about healing creates tension when encountering social identity references harmful to non-normative or non-conforming people. Of the most prominent of these references, females, 'negroes', 'homosexuals', and the religious are all designated as inferior and labelled 'primitive' - terminology still habitually used in UK psychoanalytic contexts. I draw on Black Feminist Care Ethics, Social Anthropological and Sociological epistemologies attentive to forms of symbolic violence and the need for 'participant objectivation'. This provides a historically contextualised, cross-disciplinary review of the above terminology, its accompanying ideologies and existing research. This explores how individuals make sense of particular aspects of identity, accompanied by psychoanalytically focused studies considering the dynamic between trainees' social identities and the task of developing a professional/psychoanalytic identity. The results of Thematic Analysis represented social identity as holding 3 distinct roles: insufficient, sufficient and ambivalent. The first two roles are opposed, correlating distinctly with the degrees that participants' social identifications were normative and conforming. The ambivalent role involved more complexity in that it was experienced across all participants' trainings. This, highlights variation within identity groups and within individuals' understandings and experiences of navigating training, on account of their social identities. These findings suggest that psychoanalytic training and psychotherapeutic practice would benefit, ethically and epistemically, from an authentic reckoning with the legacy of the very particular relation to social identity that has prevailed until now. Such a 'turn' may foster a new relation, less beholden to the uncritical embrace of normative ideologies and disavowal of vulnerability.

Aim: To examine how 'parental determinism' is understood by mothers, the role of the media in shaping these understandings, and how mothers perceive these understandings to impact on their wellbeing. Background: Two main theories underlay this study. First, 'parental determinism', coined by Frank Furedi, is the concept that children's outcomes are largely shaped by parenting practices, which ultimately shape society (Lee, 2014a). Second, Clive Seale's (2003) argument that people use cultural scripts presented in the media to construct the self. Literature in parenting culture studies suggests intense social and political interest in parenting, which may be stressful for mothers. Scoping reviews of the literature found studies showing media representations of parental determinism, and that endorsement of 'intensive mothering' ideologies were associated with poorer maternal wellbeing (Rizzo et al, 2013). Research questions were formed with the intention of investigating possible links between these elements of key background literature. Research Questions: Three key research questions: 1) What are mothers' understandings of parental determinism and to what extent do they endorse a causal association between their actions and their children's outcomes? 2) What do mothers think are the key sources of their beliefs and attitudes on parenting and what impact do mothers think broadcast and social media representations of parenting have on their parenting identities and behaviours? 3) What impact do mothers think their parenting identities and behaviours and the media have on their wellbeing? There were also two intermediary questions related to RQ2: 2a) What are the main media channels mothers consider they are exposed to? 2b) How do mothers perceive broadcast and social media to represent parenting? Methods: Two main stages of data collection, each preceded by a contextualising stage. The main stages of data collection were: 1) interviews with 23 mothers (aged 20-49 years, living in SIMD areas 1-10, 14 with university degrees, 16 white Scottish, 3 South Asian (born outside Scotland), most (n20) with children aged 3 months- 5 years, 3 mothers of children with Autism); and 2) follow up interviews with eleven previously interviewed mothers. Preceding the first main stage of data collection was a contextualising analysis of content of 47 threads from an online parenting forum (data collection stage 1a); and before the second main stage, a contextualising analysis of content of 49 BBC News items (data collection stage 2a). This order of data collection stages allowed not just for cumulative insights but also 'zooming in' on specific issues. All data were analysed thematically following (with adjustments) Braun and Clarke's (2006) method. Results: RQ1: There was no complete rebuttal of the causality aspect of parental determinism, though there were varying levels of endorsement of it. Some mothers cited other important factors contributing to children's outcomes, and others argued that parental actions are the single most important factor determining children's outcomes. There was higher endorsement of parental determinism among mothers who had experienced poor parenting, and lower endorsement among mothers of children with Autism. RQ2: Reported influences on parenting ranged across the paradigms of expert guided and tacit knowledge and included childhood experiences, instincts, parenting groups, and the media. There were some examples cited by interviewees of behaviours changed because of a media message. Some mothers argued that they may be subject to unconscious influence, and there was also an argument that though they themselves may not be influenced by the media, others (due to lack of education or experience) might be. RQ2a: All of the interviewed mothers used social media of some sort, most Facebook. There were few overlaps in traditional media channels cited, with the exceptions of two sitcoms and the BBC as a news source. Mothers on the online forum frequently referenced the Daily Mail, possibly to prompt debate. RQ2b: Hall (1997) distinguished between studies of media representation concerned with being realistic, and those concerned with media as constituent of reality. Mothers in interviews identified two sitcoms as realistic; both feature themes which could be linked to notions of parental determinism and intensive mothering. Mothers identified sources of power that shaped media representations, in ways aligned to Hall's consideration of representation as constituent of reality. RQ3: Feelings of worry and guilt were reported following reflection on their own parenting practices linked to 'parental determinism' and 'intensive mothering'. The media played a complex role in mothers' social lives, as representation and infrastructure, and had positive and negative impacts on their wellbeing. Implications for Policy and Practice: A discursive shift away from dismissal of media studies towards bringing media literacy into general secondary education may better equip people to critique media messages and avoid harm from negative or unhelpful messages. Health professionals face a tension between providing mother-centred care and professional obligations to unequivocally promote breastfeeding. If major health and care organisations presented a more ambivalent view of breastfeeding, it would enable health professionals to offer more mother-centred care.

Background: Food insecurity has risen across the UK. Explanations for the rise include austerity policies and the rising cost of living in the context of stagnating wages. Food insecurity is associated with poorer physical and mental health outcomes. Within the UK there has been limited research which has focused on the experiences of single men, despite their over representation at food banks. Single men experiencing food insecurity are not a demographic who elicit sympathy among the public, media, or policymakers, and therefore their experiences receive little policy attention. This research seeks to explore the experiences of single men, and how their lived experience may be used to influence the policy making process. Aims: This research had dual aims. The first was to explore single men in Scotland's experiences of food insecurity and their perspectives on the causes of their food insecurity. The second was to explore policy actors' reflections on how lived experience data can influence policy related to the experiences of food insecurity. Methods: Photo-elicitation interviews were undertaken with a sample of 18 men, who did not have or did not live with a partner, and who were experiencing food insecurity, across Aberdeen, Edinburgh and Glasgow. These interviews were analysed using abductive analysis, with the lenses of structural violence and biographical disruption applied to further understanding. Nine policy actors were interviewed remotely, using semi-structured interviews, with elements of photo-elicitation incorporating data generated by single men in Scotland. These interviews were analysed using thematic analysis. Findings: Single men's experiences of food insecurity in Scotland reflect the complex interplay of individual lived experience of extreme hardship and understandings of the structural determinants of that experience. Their experiences were read as a consequence of structural violence - with social security policies alongside organisations which claim to provide support, particular sites of harm. In the lives of the men there was a coalescing of harms, with food insecurity and other intersecting conditions resultant from income insecurity and poverty, contributing to physical and psychological harm. Exploring these experiences through the lens of biographical disruption, food insecurity affected individuals' identities and disrupted participants' relationships with eating and food preparation. Participants mobilised resources to cope with their experiences of food insecurity, however, they often reported little hope of their situations improving due to macro-level drivers of their experiences. Policy actors indicated that the combination of photographs and quotes from lived experience research had the potential to be impactful in advocacy and potentially policy briefing settings. They raised concerns, however, around confidentiality and the potential to contribute to negative stereotypes of people living in poverty. Conclusion: Single men living in Scotland experience needs-based deprivation as a consequence of structural violence, with perceptions of their vulnerability negatively impacting their ability to alleviate their situation in the immediate term through access to support. Lived experience, both directly from affected individuals and through the prism of research, may help to change perceptions, with photographs considered to be particularly impactful.

In England, specially-qualified public health practitioners, called Public Health Consultants (CPHs), support the planning and implementation of evidence-based public health improvement policies and programmes, including ensuring they reduce, or do not exacerbate, health inequalities. CPHs are required to deliver evaluations to assess effectiveness of interventions and protect funding provisions, or support policy decisions or recommendations. Despite clear inter-dependencies, the integration of academic research into public health practice continues to be problematic, with tensions remaining and research and evaluation under-utilised as a result. Where research is undertaken, observational research paradigms are usually the most applicable, particularly using existing data sources, often collected for administrative rather than health research per se. The resulting observational research can provide valuable insights into real-world programme impacts, and has the credibility to successfully change policy. This thesis presents seven research works that were published in between 2011 and 2020. The included studies apply appropriate and pragmatic research methods (systematic literature review; regression analysis; cost utility analysis; cross-sectional survey; evidence-based policy creation through consensus) to existing data, thereby demonstrating feasibility of high-quality, generalisable research conducted in a public health service context, and include considerations of inequities - a fundamental consideration of public health practice in England. The papers comprise the following: 1. Systematic evidence review of smoking cessation interventions that are effective among Chronic Obstructive Pulmonary Disease patients, as well as perceived as barriers to quitting (2011); 2. Systematic evidence review of the impact of smoking on the risk of Severe Acute Respiratory Syndrome Coronavirus 2a infection, and risk of severe Coronavirus Disease outcomes (2020); 3. A zero-inflated negative binomial regression analysis to evaluate the public health benefit of the National Bus Pass, a universal social policy permitting free local bus travel for adults ≥60 years in England, using data from the National Travel Survey (2012); 4. A negative binomial regression analysis of a multi-year national dataset, Hospital Episode Statistics (HES), to examine changes in selected 'low value' surgical procedure rates as a result of a National Health Service efficiency savings programme (2015); 5. A cost-utility analysis of hernia surgery using data from three national datasets (Patient Reported Outcome MeasureS; Reference Costs; Hospital Episode Statistics) (2013); 6. A cross-sectional survey of 151 commissioning organisations to evaluate whether they had formal policies in place restricting access to cataract surgery and, if so, whether these were appropriate (2012); 7. Development of national commissioning guidelines for cataract surgery by consensus. Following publication of (6) above, the author of this thesis was invited by the Royal College of Ophthalmologists to join its working group responsible for developing NICE-accredited, national commissioning guidelines for cataract surgery (2016). Together, the papers form a cohesive set of research undertaken alongside public health practice, demonstrating academic methodology applied to a range of real-world public health questions or problems.

Playing-related musculoskeletal disorders are very common in musicians and, depending on their severity, they could potentially endanger their whole career. Understanding the main risk factors leading to their development or relapse is one of the very first milestone for developing useful assessment tools, treatment guidelines or preventive programmes. Although research and clinical practice have evolved considerably and have increased our ability to manage musicians' injuries, there is still a lack of detailed understanding of risk factors leading to potential injuries. The overall purpose of this work was to increase knowledge of injury risk factors predisposing musicians for developing playing-related musculoskeletal disorders in order to better prevent these injuries. The first study aimed to develop a comprehensive theoretical model about the risk factors for developing injuries related to the instrumental practice while being an orchestra musician. This model classified risk factors into nine categories and fifty-five different items to consider when looking after musicians. The main aim of this first step was to provide foundations to then develop tools to better investigate and assess musicians' health, providing useful resources to both healthcare practitioners and musicians (professionals, students, teachers, etc.) to enhance preventive interventions for playing-related musculoskeletal disorders. Based on this model, two separate tools were developed and tested to assess musicians' health: the Injury Risk Factors Questionnaire for Musicians, a self-report survey to screen a large number of risk factors and a comprehensive physical examination. Moreover, based on this risk factor model and on a literature review, the Postural Analysis Tool for Musicians has been described in order to better investigate musicians' posture and playing technique. Among psycho-social factors, pain beliefs are described in the general population as being potentially associated with chronic pain. The third study focused on investigating pain beliefs in musicians, which highlighted the potential need to explain better to musicians, and particularly musicians who report PRMDs, what really are pain mechanisms. Finally, the extraordinary situation we lived through in the past two years has overwhelmed the music industry to a dramatic extent. In order to monitor how the Covid-19 pandemic affected musicians' health, questionnaires were sent to orchestra musicians before and after their return-to-work following the first lockdown. Pain prevalence were lower than those reported in literature, as well as number of playing hours per week which showed a significant reduction. This study highlighted the need to plan the return-to-work in order to avoid an important PRMDs emergence by increasing the musicians' playing load suddenly. These findings provide important knowledge about injury risk factors and expand the possibilities for protecting musicians' health.

Background - Effective self-management plays a role in improving the health and well-being of people living with type 2 diabetes and structured education is vital as a means of preparing people for a lifetime with the disease. However, in recognition of the fact that there is wide diversity in world populations, there is a need for cultural adaptation to ensure relevance in different populations. Aims - The aim of this research was to determine the requirements for developing a culturally sensitive structured diabetes education programme for people living with type 2 diabetes in Saudi Arabia Methodology - A total of four individual studies were carried out to address the aims of the research. First, a systematic review of existing literature to summarise the current status and impact of theory-based, culturally adapted self-management education programmes on type 2 diabetes mellitus. This was followed up by two qualitative research studies involving semi-structured interviews with health care professionals involved in the provision of diabetes care and people living with type 2 diabetes respectively in Saudi Arabia. Finally, a secondary analysis of existing datasets from a hospital in Saudi Arabia highlights the diagnosis and care for people living with type 2 diabetes. Results - Type 2 diabetes self-management education programmes result in significant improvements in people well-being demonstrated by objective measures such as blood glucose and glycated haemoglobin levels. Education served to prepare individuals to embark on the life-long task of lifestyle improvement as a means of improving their glycaemic control and therefore reducing their risk of short-, medium- and long-term complications. Targeted programmes therefore facilitate the achievement of these goals. Culturally relevant self-management education programmes are best provided with dedicated professionals that are familiar with the target culture and who adopt a person-centred approach to the process. The interviews with health professionals and people living with type 2 diabetes in Saudi Arabia demonstrated that while these participants recognised the benefits of self-management for people with type 2 diabetes, they emphasized the importance of tailoring the approach to the needs of people living with type 2 diabetes. Information should be delivered in the native language of the participants and also recognize and respect elements of culture such as religious beliefs, value systems and customs. Tailoring information and support in such a manner can produce positive effects on dietary and physical activity patterns as well as illness and health-related beliefs. This was of particular importance since many people living with type 2 diabetes felt that it was difficult to identify self-management measures that were suited to the Saudi Arabian context. Conclusion - Successful behaviour change in people living with type 2 diabetes is greatly facilitated by well-designed, self-management education programmes. The research demonstrated that there is a need for well-developed, structured self-management education programmes to improve the management of type 2 diabetes in Saudi Arabia. Many of the existing programmes do not demonstrate sensitivity to and recognition of cultural and religious nuances that could have an impact on adherence in the target population. The unique characteristics of Saudi society highlight the need for targeted culturally sensitive education programmes for people living with type 2 diabetes. This highlights the increased tendency to adhere to guidelines and measures that are in line with the social, cultural and religious beliefs of the targeted populations. This is of particular significance in view of the fact that culturally adapted type 2 diabetes self-management education programmes have been shown to be effective in improving short-, medium- and long-term outcomes in minority populations.

This thesis uses five case studies of health centre and hospital development between 1945 and 1974, showing how planners and publics were a productive force in making the National Health Service (NHS) meaningful. During the period, the British state completed new healthcare facilities on a scale which has been largely unmatched since, with a popular attachment to the health services appearing to increase in parallel. I make sense of public attitudes to large-scale welfare state modernisation through an emphasis on place, showing that local knowledge, hierarchies and rituals provided a foundation for agency. In both rural and urban contexts, new healthcare spaces held particular significance to communities looking to renegotiate their relationship with the state. To further unpick these systems of feeling I posit the idea of emotional ecologies, an approach which focuses on how seemingly small conflicts could generate whole-system meaning. This thesis demonstrates that, to many, an affective bond with the health services was defined by built provision's gestures of accommodation, attempts to democratise planning and appeals to local communities of patients. Towards the end of the period, I highlight definite limits to sensitive social democratic planning practice. Atmospheres of neglect could persist despite rebuilding and public confidence could be undermined by evidence of a private dependence on public investment for growth. The contribution of this thesis is therefore twofold: firstly, in challenging technocratic and national optics as inadequate lenses for understanding how NHS expansion was made possible. Secondly, the thesis synthesises a diversity of interlinked emotive processes in order to understand how popular impressions of the wider health service were made. Following a cultural turn in the historiography of the welfare state I add that, beyond opposing and resisting, many publics created their own deep attachments to the NHS through planning.

This thesis explores the factors that influence smoking behaviours amongst Indonesian Pesantren (Islamic Boarding Schools) santri (students) and kyai (Islamic Scholar, Teacher, or Leader). Indonesia is the fourth most populous country in the world and also home to the largest Muslim population in the world. It has the highest male smoking prevalence rates in the world and the highest in Muslim countries. Specifically, it has examined how religious practices, school environments, and personal beliefs affect smoking behaviours. The study adopted an ethnographic approach to data collection in three pesantren; Traditional (Salafiyah), Modern (Khalafiyah) and one that is a combination of both. The thesis documents the findings from semi-structured interviews conducted with 49 participants (students and teachers). Participant observation and documentary analysis are used to provide further insights into smoking behaviours. The findings suggest that the practice of gifting cigarettes to pesantren teachers was common. Positive beliefs about smoking, particularly herbal cigarettes, was another factor that greatly influenced pesantren teachers and students smoking behaviours. They believed that smoking herbal cigarettes could provide health benefits, maintaining health, curing diseases, and reducing addiction. Furthermore, smoking was believed to provide smokers with financial benefits. Religiosity was also found to significantly influence pesantren teachers and santri to smoke. Smoker participants believed that smoking-related diseases and death was mostly determined by Allah, and humans had very passive role to control their health states. In contrast to the previous findings, however, the findings of the current study challenge a theory that states religion can be a protective factor against tobacco use. The thesis suggests there is a need to review smoke-free policies and develop pesantren specific public health campaigns that incorporate culturally specific approaches combined with conventional public health methods. It makes an original contribution to knowledge about the role of gifting, religiosity, and health beliefs on the smoking behaviours of santri (students) and Kyai (Islamic Scholar, Teacher, or Leader) in pesantren.

Background: There is a well-developed body of literature on sex tourism, a phenomenon that is experienced in almost every corner of the world. While extant literature depicts the complexity of sex tourism, it does not acknowledge the extent to which globalisation has irrevocably changed the industry. To date, there is a distinct lack of examination and understanding of the theoretical aspects of sex tourism that effectively conceptualise the intricate phenomenon within a contemporary worldview. For clarity, this thesis defines sex tourism as a phenomenon involving tourists, planned or spontaneously purchasing sexual services or experiences. Aim: Sex tourism is a multifaceted and complex phenomenon. Using existing visual and theoretical frameworks and extensive analyses of literature, a model was created to depict the contemporary realities of those involved in the sex tourism industry. Using the country specific context of Thailand, this research took a public health and social science approach to map out sex tourism by drawing on the situation of sex workers, tourists, healthcare professionals, and community workers, as well as wider global forces such as technology, human rights, law enforcement, sexual health, and healthcare provision. Methodology: The research consisted of four stages. Stage 1 was a critical analysis of extant literature, resulting in the development of an initial, conceptual sex tourism model. Stage 2 was an empirical, pragmatic, qualitative study, using unstructured and then semi-structured interviews with community workers, healthcare professionals, tourists, and sex workers. The interviews explored the unmet needs of stakeholders involved in sex tourism. Following this, the interviews sought to understand increased risky sexual behaviour in the context of globalisation; analyse the impact of technology on relationships between tourists and sex workers in Thailand; and discuss required changes to UK public health and social policy, clinical practice, and sexual health programmes. Stage 3 analysed and compared findings generated from Stages 1 and 2. Stage 4 scrutinised and refined the contemporary sex tourism model based on the combined findings from the previous stages, as well as presenting a sexual health patient pathway for tourists before travel and upon return to the UK. Results and future research: To date, the holistic conceptual model is unique as it was built upon existing bodies of work whilst incorporating distinctive aspects of the industry that have not yet been considered in the field. The model consists of interacting, multi-level associations. Whilst the separate micro, contextual, meso, and macro levels are versatile, decision- makers and practitioners will be equipped to understand sex tourism in its entirety. The model should be used to inform international public health policy, practice and investments in country specific contexts. Following acceptance of the conceptual model, further empirical research should be undertaken to prove the validity and reliability of the model, adapt it where necessary, and expand the scope of the current research.

Background Forced migration has become an issue of great political, economic, and humanitarian importance. It is estimated that there are 30.1 million asylum seekers and refugees globally. Since 2000, Glasgow has been a dispersal city for asylum seekers and refugees and hosts one of the largest numbers of asylum seekers of any local authority in the U.K. Asylum seekers and refugees in Scotland are entitled to universal healthcare at all stages of the asylum process. However, there are known inequalities in access, particularly for women. Asylum seeker and refugee women have poorer health outcomes than economic migrant and host country populations. There is a specific gap in the literature with regards to asylum seeker and refugee women's preventive sexual healthcare needs, out with pregnancy and maternal care. Therefore, this thesis aimed to address this gap. Aim To identify and explore the factors that influence how asylum seeking and refugee women access preventive healthcare, using cervical screening as a case study. This aim was addressed by three research questions: 1) What discourses are constructed in the UK's print media around asylum seekers, refugees, and health? 2) How do these discourses affect asylum seeking and refugee women's and health care workers perceptions of this population's deservingness for preventive healthcare? 3) What are the barriers and facilitators, identified by asylum seeker/refugee women, community workers and primary care healthcare workers, with regards to the identification of candidacy, the assertion of this candidacy and the provision of cervical screening to women who are asylum seekers and refugees? Methods A multiple qualitative approach was taken, with newspaper analysis, focus group and individual interviews. Data collection and analysis were underpinned by the theory of candidacy. Intersectionality was a conceptual lens with which to interpret more fully the data generated. The newspaper analysis covered the years 2008-2013. Newspapers were purposively selected to represent the breadth of the U.K. and Scottish national newspapers, in terms of political alignments and readership demographics. Articles were included if they focussed on asylum seekers or refugees in the U.K. and if >50% of the story focused on health of healthcare. A pro-forma was used to collect data on article tone; migrant group; and themes such as health access and healthcare spending. NVivo 10 software was used to organise the data and it was then analysed using both content and thematic analysis. The second study involved semi-structured individual and focus group interviews. A purposive sampling approach was taken, and interpreter services were used as required. 17 asylum seeking and refugee women, 2 community workers and 7 primary healthcare workers were interviewed. The focus group of asylum seeking and refugee women was recruited through a community group, as were the two community workers. Individual asylum seeker and refugee interviews were recruited through a flyer advertisement placed with the Scottish Refugee Council and through contacts of the focus group. Healthcare workers were recruited by contacting practices who were known to care for asylum seekers and refugees. These interviews were coded using NVivo 10 software and analysis facilitated using the One Sheet of Paper (OSOP) approach. Findings 198 newspaper articles were included. Despite left-wing and local publications being more positive and sympathetic in their construction of deservingness for asylum seekers and refugees to seek healthcare, the volume of articles from right-wing publications which portrayed asylum seekers and refugees as undeserving outweighed these. This created a hostile tone, constructing migrants as a threat to resources, to the health of others and to British culture. The hostile environment created by both newspaper constructions of deservingness and the asylum system was internalised by asylum seekers and refugee women. This affected their presentation at services. Being female and an asylum seeker creates an intersection of vulnerability and acts as a barrier to accessing preventive healthcare. This is worsened by the intersection of other identities such as language, culture, educational level, religious beliefs and socioeconomic status. Healthcare workers shared frustrations that they had little influence over the asylum system as they realised the effect this was having on their patients. They also acknowledged the impact of the hostile environment but took little personal responsibility about how to combat this within their own service. However, a key finding in this thesis was that if the offer for cervical screening was encouraging, informed, supportive, and empowering, it would be more likely accepted. Conclusion This thesis found that asylum seeking, and refugee women operate within a hostile environment and have many intersecting factors which make them particularly vulnerable when accessing healthcare. However, if they are given the correct support both within healthcare and in the community, they are keen to seek preventive sexual healthcare, such as cervical screening. Recommendations from this thesis include widening the availability of clinics, to include drop in, evening and weekend periods; encourage community organisations to signpost for cervical screening; further training for primary healthcare workers in working with this population, recording data, and increase awareness of their role in reducing health inequalities for this population. This thesis critiqued how candidacy, intersectionality, and deservingness work together as theories. Through using these theories together, a more nuanced understanding was achieved, particularly around the impact of structural and system inequalities affecting health access for this group. This thesis offers an advancement of the Mackenzie (2012) figure of candidacy to show the direct relationship of intersecting structural and system factors on individual interactions in healthcare, in addition to the impact of deservingness discourses.

This thesis investigates Russian civil society organising around disability. It seeks to demonstrate the construction of legitimacy through depoliticization, and its opportunities and threats for disability organising. It proposes an analytical framework of resistance which foregrounds actors' intent and meaning-making to identify resistance which strategically aims to evade perception. Civil society research has characterised the Russian state as relating to civil society in two broad ways: (1) encouraging its action as a partner of state which responds to legitimised social welfare needs and (2) restricting action which it perceives as politically threatening. Within this research, disability organising has largely been naturalised as belonging to the first category. However, just as the categories of legitimised and delegitimised civil society are more fluid than the above binary might suggest, understandings of disability organising as legitimate are also contingent. This raises questions about how disability civil society organisations (CSOs) enact, negotiate, and instrumentalise legitimacy, and how the category of legitimacy interacts with constructions of disability. I explore these questions through four empirical chapters, based on interviews with actors involved in disability organising. The first chapter asks how people organising around disability perceive their environment and how this influences action. Their perceptions of risk result in strategic management of action to appear compliant. They link compliance to depoliticised social action. In the second chapter, I ask why this works in relationship to disability organising. I demonstrate how disability, and thus disability organizing, have been naturalized as apolitical via association with the private sphere, medical expertise, charity, vulnerability, and dependence. I show that assumptions of vulnerability are instrumentalized by some actors to resist; organizing from within the disability sphere manages the risk of sanction by benefitting from the sphere's assumed depoliticization. In the third chapter, I explore the everyday, ambiguous forms that resistance takes so as not to trouble apparent compliance. While some actors strategically avoid identification by the state of their action as contentious, research does not need to reach the same conclusions. Rather, I argue for the need to extend the forms of action which we recognise as resistance under these conditions. In the final empirical chapter, I look to how normatively politicized LGBTQ+ identities interact with normatively depoliticized disability identities. I demonstrate that legitimization as a civil society actor is contingent on perpetuating the misrecognition of disabled people as non-agentic, passive, and desexualized. I thus demonstrate how apparent compliance structures unequal recognition and exclusions. Analyzing how LGBTQ+ disabled actors negotiate this through strategies of fluid identity management and community building extends our understandings of resistance. Through the thesis, I unite civil society and disability literatures to make three main contributions. First, I challenge the notion that enacted compliance is forced or passive; it is rather highly strategic. Second, I demonstrate that apparently social action cannot be understood as non-resistant and apolitical. In doing so, I highlight actors' instrumentalization of assumed vulnerability as a resistant strategy and uncover a range of forms of resistance which aim to evade dominant perceptions. Finally, I show how enacted compliance both functions as strategy and struggles to address existing power relationships. These findings call for research which recognises and values a wider range of resistance, and for organizing which is reflexive about and responsive to how its strategies may replicate exclusions.