A Health Promoting School (HPS) approach is now widely accepted internationally, with a focus on children’s health, the school curriculum, and whole school environment. In Thailand, the health and well-being of children is a fundamental value. HPS programmes have been implemented in schools as a strategy to focus on young people’s health. A number of barriers to successful HPS have been identified. While there is international evidence to show the steps and the key factors in creating successful HPS, little is known about successful HPS in the Thai context, in particular, in Northeastern Thailand which has been classified the poorest region. Ethnographic methods were used to examine what understanding of the meaning of HPS is necessary for a successful school, and how all those involved acted from the adoption of the HPS programmes by the local school until it achieved HPS status. A rural school which was successful in a HPS programme was selected, in Mahasarakham province, Northeastern Thailand. The data were obtained through participant observation, ethnographic interviews, and ethnographic records, and data analysis took place simultaneously with data collection. In this study, Lofland’s strategy for the analysis of the structure of human interaction was used. A variety of techniques for improving and documenting the credibility of the study such as prolonged engagement, persistent observation, and triangulation were used. This research revealed that the informants’ views reflected diverse understandings of the meaning of HPS. Those views were based on their experiences of HPS which differed according to the degree of participation, different levels of knowledge about HPS, and in the roles they played in the implementation of HPS in the school. Thai culture and school ethos influenced the success of HPS. Community participation was also crucial in supporting the school’s achievement. Key factors that underpinned success are identified. Implications of the findings for the HPS programme, health professionals, the school and community are discussed.

As the population ages it is increasingly important to understand the factors influencing dietary habits of older people. Social, biological and psychological factors influence food intake and affect nutrition risk among older people living in the community. The purpose of this study was to identify food-related behaviours that place older people at nutrition risk and to evaluate older peoples’ perceptions and experiences of various nutrition support options. Fifty-one community living people aged between 80 and 85 years were recruited in North Shore City. Food-related behaviours were explored with the use of three quantitative tools. Practitioner Assessment of Network Type (PANT) was used to evaluate social networks. Elderly Assessment System (EASY-Care) was used to evaluate physical and mental wellbeing. Seniors in the Community: Risk Evaluation for Eating and Nutrition Version II (SCREEN II) assessed nutrition risk. Five people participated in a qualitative interview about nutrition support they had received. A third of the participants (31 percent) were found to be at nutrition risk. Twothirds (67 percent) showed some evidence of disability and needed assistance with everyday tasks. Nearly half (47 percent) of these older people had supportive social networks including close relationships with local family, friends and neighbours. There was an inverse linear relationship between participants’ self-rated health and nutrition risk (p<.001). Those who perceived their health to be fair or poor were more likely to be at nutrition risk. The importance of social contact, a sense of gratitude, ‘getting a meal’, and ‘meeting the need’ were common themes that emerged from interviews with participants who received nutrition support. These findings indicate that nutrition risk may be prevalent among community living older people in New Zealand. Strategies and initiatives are needed to encourage independent living and to help older people with the procurement, preparation, cooking and sharing of enjoyable meals.

As the population ages it is increasingly important to understand the factors influencing dietary habits of older people. Social, biological and psychological factors influence food intake and affect nutrition risk among older people living in the community. The purpose of this study was to identify food-related behaviours that place older people at nutrition risk and to evaluate older peoples’ perceptions and experiences of various nutrition support options. Fifty-one community living people aged between 80 and 85 years were recruited in North Shore City. Food-related behaviours were explored with the use of three quantitative tools. Practitioner Assessment of Network Type (PANT) was used to evaluate social networks. Elderly Assessment System (EASY-Care) was used to evaluate physical and mental wellbeing. Seniors in the Community: Risk Evaluation for Eating and Nutrition Version II (SCREEN II) assessed nutrition risk. Five people participated in a qualitative interview about nutrition support they had received. A third of the participants (31 percent) were found to be at nutrition risk. Twothirds (67 percent) showed some evidence of disability and needed assistance with everyday tasks. Nearly half (47 percent) of these older people had supportive social networks including close relationships with local family, friends and neighbours. There was an inverse linear relationship between participants’ self-rated health and nutrition risk (p<.001). Those who perceived their health to be fair or poor were more likely to be at nutrition risk. The importance of social contact, a sense of gratitude, ‘getting a meal’, and ‘meeting the need’ were common themes that emerged from interviews with participants who received nutrition support. These findings indicate that nutrition risk may be prevalent among community living older people in New Zealand. Strategies and initiatives are needed to encourage independent living and to help older people with the procurement, preparation, cooking and sharing of enjoyable meals.

As the population ages it is increasingly important to understand the factors influencing dietary habits of older people. Social, biological and psychological factors influence food intake and affect nutrition risk among older people living in the community. The purpose of this study was to identify food-related behaviours that place older people at nutrition risk and to evaluate older peoples’ perceptions and experiences of various nutrition support options. Fifty-one community living people aged between 80 and 85 years were recruited in North Shore City. Food-related behaviours were explored with the use of three quantitative tools. Practitioner Assessment of Network Type (PANT) was used to evaluate social networks. Elderly Assessment System (EASY-Care) was used to evaluate physical and mental wellbeing. Seniors in the Community: Risk Evaluation for Eating and Nutrition Version II (SCREEN II) assessed nutrition risk. Five people participated in a qualitative interview about nutrition support they had received. A third of the participants (31 percent) were found to be at nutrition risk. Twothirds (67 percent) showed some evidence of disability and needed assistance with everyday tasks. Nearly half (47 percent) of these older people had supportive social networks including close relationships with local family, friends and neighbours. There was an inverse linear relationship between participants’ self-rated health and nutrition risk (p<.001). Those who perceived their health to be fair or poor were more likely to be at nutrition risk. The importance of social contact, a sense of gratitude, ‘getting a meal’, and ‘meeting the need’ were common themes that emerged from interviews with participants who received nutrition support. These findings indicate that nutrition risk may be prevalent among community living older people in New Zealand. Strategies and initiatives are needed to encourage independent living and to help older people with the procurement, preparation, cooking and sharing of enjoyable meals.

There is a requirement for all services within the New Zealand health system to be accredited with an established quality organisation and to demonstrate an ability to provide a measurable quality service to consumers. For Māori these requirements must make sense in Māori terms. This thesis is based on the view that, for Māori, the concept of health is more effectively expressed as hauora - optimal health and wellbeing for Māori. This thesis makes five contributions to Māori health and Māori health research. First, it identifies a responsive approach to engaging kaumātua effectively in the process of qualitative research. Second, it identifies a fundamental underlying conceptual framework – kaupapa hauora Māori as a means of understanding hauora – expressed in terms derived from kaumātua in Taranaki and Kahungunu. Third, it adapts this conceptual framework into an analytical research framework and then applies it to allow kaupapa hauora Māori (described in terms of worldview, values and ethics) to be identified from a range of data. Fourth, it critically analyses popular models of Māori health – Te Whare Tapa Whā, Te Wheke and Ngā Pou Mana. Finally, it proposes and details post-doctoral research that will translate kaupapa hauora Māori into a quality services framework/tool. “Kaupapa Hauora Māori” is a conceptual framework articulated by kaumātua, and has its origins in te ao Māori, from which the aronga or worldview is developed. The aronga is composed of the kaupapa or values and tikanga or ethics that provide kaumātua with the values base of hauora. These components have been identified by kaumātua and not only inform the concept of KHM but also inform the analytical research framework that is applied to the data. The values have been identified as a core set of values comprising whakapapa, wairua, whenua, whānau, tikanga te reo Māori, tinana, and hinengaro, and the associated tikanga is expressed as behaviour or ethics. These, together, influence the perception and understanding individuals have of their world and of hauora.

Content removed due to copyright restrictions: Appendix 6: Paper presented at the 15th New Zealand Ergonomics Society Conference: Ergonomics for the Ageing Population, Martinborough. Scuffham, A., Stevenson, M., Legg, S. & Firth, E. Prevalence of musculoskeletal discomfort in New Zealand small animal veterinarians. In: 15th New Zealand Ergonomics Society Conference: Ergonomics for the Ageing Population. Eds R. G. Adank & L. Gardner Wood. Martinborough, New Zealand Ergonomics Society. 27-28 May, 2009, [CD-ROM]. Appendix 7: Paper presented at the Society of Diary Cattle Veterinarians of the New Zealand Veterinary Association 26th annual conference, Rotorua. Scuffham, A., Firth, E., Stevenson, M., & Legg, S. Musculoskeletal discomfort in New Zealand large animal veterinarians. In: Proceedings of the Society of Dairy Cattle Veterinarians of the New Zealand Veterinary Association 26th annual conference. Ed. T. Parkinson. VetLearn, Palmerston North. 24-27 June 2009, pg 201-204. Appendix 8: Paper presented at the New Zealand Equine Veterinary Association Annual Conference, Taupo. Scuffham, A., Firth, E., Stevenson, M. & Legg, S. Musculoskeletal discomfort in New Zealand equine veterinarians. In: Proceedings of the New Zealand Equine Veterinary Association of the NZVA Annual Conference. Ed. M Leyland. VetLearn, Palmerston North. 24-27 June 2009, pg 163. Appendix 9: Paper presented at the 17th International Ergonomics Association World Congress on Ergonomics, Beijing. Musculoskeletal discomfort in New Zealand (non-clinical) veterinarians. Scuffham, A., Legg, S., Stevenson, M. & Firth, E. (9-14 August, 2009). [CD-ROM] / This thesis comprises three chapters about musculoskeletal discomfort (MSD) in veterinarians. Two of these chapters have been submitted to peer reviewed journals and one is in preparation for submission. The first chapter describes the prevalence and risk factors associated with MSD in New Zealand veterinarians. The second chapter is a paper on the tasks considered by veterinarians to cause MSD. The third chapter is a review of published literature on musculoskeletal problems (MSP) in veterinarians. The first chapter in this thesis describes a cross-sectional study of 867 New Zealand veterinarians. We used a modified Nordic musculoskeletal questionnaire to enquire about the presence or absence of MSD, whether this affected normal activities and if MSD necessitated absenteeism from work. Additional questions enquired about work activities, psychosocial factors and workload. The overall period prevalence of MSD was 96%. Normal activities were affected in 67% and 18% of participants reported that they had been absent from work due to MSD. Factors associated with the presence of MSD requiring time off work for clinical veterinarians included 10 year increases in age (odds ratio (OR) 1.26, 95% CI 1.05 - 1.52), work involving awkward grip and hand movements 100% of time (OR 12.91, 95% CI 3.46 – 84.21) and those who were dissatisfied with the level and difficulty of their work (OR 2.72, 95% CI 1.11 - 6.56). In the second chapter in this thesis, veterinarians were asked to indicate tasks that they considered ‘most likely to lead to musculoskeletal aches and pains’ and ‘why these tasks were likely to be the most risky’. They were also asked to suggest ‘any solutions that they applied or knew of’ to reduce musculoskeletal aches and pains. They identified the following tasks: lifting, surgery, rectal palpations and animal handling. Their reasons were primarily related to physical risk factors. Few identified psychosocial risk factors. The most common suggested solutions involved training and selection strategies rather than redesign of tasks, activities or facilities. These findings are consistent with a participatory ergonomics approach for reducing the risk of MSD, which aims to enhance personal well-being and improved system performance. The third chapter in this thesis - a review of the literature - focuses on the prevalence and nature (discomfort, pain, injury and disorders) of MSP amongst veterinarians. Veterinarians are exposed to a range of physical and psychosocial occupational hazards that have been well documented and associated with MSP. The range of reported prevalence estimates in this review was 50% to 96%. This range may reflect real differences among the veterinary populations studied, or more likely be due to differences in MSP definitions, study methodologies, and response rates. The magnitude of the reported prevalence justifies further research to triangulate data and determine other factors associated with MSD. Most of the studies in the review focused on physical risk factors. The lack of studies into psychosocial risk factors for MSP needs to be addressed.

Nutrigenomics studies the genome-wide influence of nutrients to understand the association between nutrition and human health. Studies in animal models and humans have demonstrated that dietary n-3 polyunsaturated fatty acids (PUFA) from fish oil may be beneficial in inflammatory bowel diseases (IBD). This thesis aimed to test the hypothesis that dietary n-3 PUFA eicosapentaenoic acid (EPA) reduced and n-6 PUFA arachidonic acid (AA) increased colitis in the interleukin- 10 gene-deficient (Il10–/–) mouse model of IBD, and that these PUFA altered the intestinal bacteria community during colitis development using genome-wide expression and bacterial profiling. Using a combined transcriptomic and proteomic approach, the time-course study defined the onset and progression of colitis in Il10–/– mice. Histopathology, transcript and protein changes before and after colitis onset involved in innate and adaptive immune responses suggested delayed remodelling processes in colitic Il10–/– mice and 11 weeks of age as suitable time point to study the effects of dietary PUFA on colitis development. Comparing the transcriptome and proteome profiles associated with colon inflammation of mice fed with the AIN-76A or oleic acid (OA) diet showed that OA was an appropriate control for unsaturated fatty acids in multi-omic studies. The PUFA intervention study indicated that dietary EPA-induced lipid oxidation might have a potential anti-inflammatory effect on inflamed colon tissue partially mediated through activation of peroxisome proliferator-activated receptor alpha (PPARα). Unexpectedly, dietary AA decreased the expression of inflammatory and stress colonic genes in Il10–/– mice. Altered intestinal bacteria community observed in Il10–/– mice before and after colitis onset was associated with the lack of IL10 protein led to changes in intestinal metabolic and signalling processes. Interestingly, dietary EPA and AA seemed to change intestinal bacteria profiles during colitis development. The role of PPARα in the colon was further examined in a concluding study which identified vanin1 as a likely new PPARα-target gene which may also be involved in lipid metabolism. These findings using a state-of-the-art approach combining transcriptomics, proteomics and physiology provide a basis for future research on molecular mechanisms underlying the effects of dietary PUFA, and might contribute to the development of fortified foods that improve intestinal health and wellness.

In this thesis, I describe a series of studies of the prevalence, causes, and management of asthma in the Pacific. The core study of the thesis is Phase III of the International Study of Asthma and Allergies in Childhood (ISAAC). The ISAAC study is the largest worldwide epidemiological study on asthma prevalence and was established partly in response to the increases in asthma prevalence in most parts of the world over the last two to three decades. The ISAAC Phase I study found large variations in asthma prevalence globally, but no Pacific countries were involved. Thus, the situation in the Pacific was relatively unknown due to lack of standardised studies on prevalence and time trends. The burden and impact of other non-communicable diseases such as cardiovascular and other metabolic disorder on the other hand have been the target of various studies in the Pacific for the past few decades The ISAAC Phase III study was therefore conducted in eight Pacific countries to address the above issues, as well as to enhance Pacific participation and contribution to international research on the causes and control of asthma. The collaboration also served the purpose of encouraging and strengthening health research capacity in the Pacific. The ISAAC Phase III study was followed by an asthma self-management intervention trial conducted in Tonga by the ISAAC Tonga study team. Methods The work presented in this thesis involved: (i) the conduct of the ISAAC Phase III study in the six Pacific islands of Tokelau, Samoa, Fiji Islands, Tonga, Niue and the Cook Islands, as well as the incorporation into the analysis of data that had already been collected in French Polynesia and New Caledonia; (ii) analysis of the data from an environmental asthma risk factor questionnaire which was included in the ISAAC survey in three countries (Samoa, Fiji and Tokelau); (iii) the conduct of the Tonga Asthma Self-management Study which was intended to assess whether the introduction of asthma education, including asthma self-management plans, would reduce morbidity from asthma. Results A total of 20,876 13-14 year olds, in the eight countries involved, participated in the ISAAC Phase III survey, with an overall response rate of 92%. The survey showed that there was considerable variation in the prevalence of asthma symptoms between the eight countries, ranging from 5.8% for current wheeze in Samoa to 16.2% in Tonga. Tokelau reported the highest prevalence (19.7%) for current wheeze, but the number of participants was relatively small. The prevalences of asthma symptoms among Pacific children in the Pacific were lower than those reported for Pacific, Māori and European children living in New Zealand from a previous study (ISAAC Phase I) conducted ten years earlier using the same methodology. The prevalence of 'asthma ever' in Pacific children living in the Pacific was also lower than that found among Pacific, Māaori and European children in New Zealand. The ISAAC Phase III environmental questionnaire data was collected in Samoa, Fiji and Tokelau. The analyses indicated that the major factors associated with current wheeze (across the three countries) were paracetamol use in the previous year (odds ratio (OR) = 1.36, 95% CI 1 15-1.61), the use of open fires for cooking (OR = 1.34,95% CI 1.13-1.58), lack of physical activity as indicated by television viewing more than 3 hours per day (OR = 1.24,95% CI 1.04-1.47), regular meat consumption (OR = 1.30,95% CI 1.09-1.54) and regular cereal consumption (OR = 1.29,95% CI 1.07-1.54). However, these risk factors were not particular strong, and did not account for a large proportion of asthma cases (i.e. they had relatively low population attributable risks). The asthma self-management plan intervention study resulted in significant improvements in asthma morbidity and the management of asthma among individuals and the service provision. The success of the introduction of the self-management plan, in the context of an asthma clinic, was reflected by improvement in measures of asthma morbidity, such as peak expiratory flow rates and nights woken with asthma or coughing. There was also a reduction in the requirement for acute medical treatment, indicated by a decrease in emergency department hospital visits for asthma and hospital admissions. The programme was so successful that the intervention study evolved into a full regular asthma clinic for the main island of Tonga. It is now intended that the asthma self-management programme will be extended throughout the rest of Tonga, through the primary health care system. Conclusions The ISAAC Phase IIII survey has shown that, although there is a significant level of morbidity, asthma prevalence in Pacific countries is lower than those among Pacific people in New Zealand. Together with the large variations in prevalence between the six Pacific countries that participated, this further lends support for the role of environmental risk factors in asthma. The availability of data on eight countries using a standardised methodology also provides useful information on the burden of asthma in the Pacific that is comparable to other countries regionally and internationally as well as forming a basis for ascertaining trends in the future. The crucial role of asthma self-management plans in asthma management is supported by the findings of the Tonga study, and its implementation is essential in the resource-scarce Pacific health setting. The collaborative nature of ISAAC in the Pacific has further raised awareness of the need for capacity building and creating networks and environments that enhance health research in areas other than asthma. The study has also nurtured an environment and network that encourages and strengthens the establishment of health research as one of the vital tools for achieving better health.

Anthocyanins (ACNs), which are responsible for the red and blue colours displayed by many vegetables and fruits (particularly berries), belong to secondary plant metabolites, and are a component of our daily diet. There is an increasing interest on their biological activities as they are claimed to enhance health by protecting against some chronic diseases. However, before ACNs can perform health-promoting effects in vivo, they must first be sufficiently absorbed, distributed within the human body, and reach target tissues in adequate concentrations. To date, all studies investigating ACN absorption and metabolism came to the conclusion that their bioavailability is extremely low. To benefit from the proposed health effects of ACNs, their bioavailability, including absorption, metabolism, and excretion must first be understood. The main objective of this thesis was to provide further knowledge on ACN absorption, including the absorption site and mechanism, and the influence of food and other flavonoids on ACN absorption, as well as the investigation of their antioxidant effects in vivo. In vitro experiments using Ussing chambers showed that a strong absorption of ACNs occurred from the jejunum in mice. This was supported with a further in vivo study, where the major absorption site for ACNs may be the jejunum in rats. The limitation of ACN absorption to mainly one part of the intestine suggested the participation of a particular transport mechanism. In a further Ussing chamber study it was shown that flavonols, another common flavonoid group present in many fruits and vegetables, strongly inhibit ACN absorption, indicating a specific transport mechanism, with preference for other flavonoid compounds. Further in vivo studies have shown that the simultaneous ingestion of food components, such as breakfast cereals, resulted in a delayed absorption profile in two animal species. However, the additional food did not influence the antioxidant effect of ACNs. During a human intervention study, several measures of oxidative stress improved, but this improvement occurred equally in the treatments and placebo control, and may have resulted from changes in lifestyle. The results of these studies aid to understand details of ACN absorption and help to formulate future recommendations for ACN intake with increased bioavailability in humans.

A Health Promoting School (HPS) approach is now widely accepted internationally, with a focus on children’s health, the school curriculum, and whole school environment. In Thailand, the health and well-being of children is a fundamental value. HPS programmes have been implemented in schools as a strategy to focus on young people’s health. A number of barriers to successful HPS have been identified. While there is international evidence to show the steps and the key factors in creating successful HPS, little is known about successful HPS in the Thai context, in particular, in Northeastern Thailand which has been classified the poorest region. Ethnographic methods were used to examine what understanding of the meaning of HPS is necessary for a successful school, and how all those involved acted from the adoption of the HPS programmes by the local school until it achieved HPS status. A rural school which was successful in a HPS programme was selected, in Mahasarakham province, Northeastern Thailand. The data were obtained through participant observation, ethnographic interviews, and ethnographic records, and data analysis took place simultaneously with data collection. In this study, Lofland’s strategy for the analysis of the structure of human interaction was used. A variety of techniques for improving and documenting the credibility of the study such as prolonged engagement, persistent observation, and triangulation were used. This research revealed that the informants’ views reflected diverse understandings of the meaning of HPS. Those views were based on their experiences of HPS which differed according to the degree of participation, different levels of knowledge about HPS, and in the roles they played in the implementation of HPS in the school. Thai culture and school ethos influenced the success of HPS. Community participation was also crucial in supporting the school’s achievement. Key factors that underpinned success are identified. Implications of the findings for the HPS programme, health professionals, the school and community are discussed.