Background: The Republic of Ireland has become a more ethnically diverse society with inward migration of men from geographically disparate regions such as Eastern Europe and Africa. These men now constitute ten percent of the Irish male population. Migrant men report poorer health than their indigenous counterparts for many reasons including socio-economic disadvantage, cultural and linguistic barriers. Migrants also report reduced engagement with health services in their host country Aim: To explore the health of Polish men resident in the Republic of Ireland. Methodology: This study used a survey design, with a convenience sample (n =900) of Polish migrant men drawn from across seven Irish urban centres. A self-administered questionnaire with three distinctive scales was used to measure respondents’: health status, health beliefs, health behaviours and demographic profile. Ethical approval was granted by the Ethical Governance Committee of the University. Data were analysed using the Statistical Package for the Social Sciences (SPSS version 18.0). Findings: A response rate of 47% (n=421) was achieved. Respondents reported significantly lower educational levels than those of indigenous men or Polish men resident in Poland. The health behaviours of this cohort were similar to those of their Irish counterparts. There were a number of notable exceptions: 63% (n=265) of respondents smoked, 23% (n=97%) reported feeling nervous or depressed but over 50% (n=213) reported they were unlikely to access mental health services. Conclusions: Socio-economic disadvantages are apparent and these disparities need to be addressed in order to meet the evolving health needs of Polish migrant men. Smoking cessation needs to be considered including, how these activities will be initiated, methods used to impart information and follow up care for those who cease. Greater information about mental health care facilities, accessibility and the support services available need to be made more explicit to populations such as these.

This thesis explores how innovative behavioural and virtual environment simulations could benefit healthcare and health policy. In the first half of the thesis I review the use of behavioural simulations in healthcare and contextualise an evidence-based approach for development and analysis. This approach is informs the successful design and completion of two simulations - The Crucible and Lateral Play. The Crucible was designed to improve leadership skills and understanding of the Health and Social Care Act amongst clinicians. Lateral Play was designed to aid organisational development of Imperial College Health Partners, the Academic Health Sciences Partnership in North-West London. Detailed analysis demonstrated, for the first time, the measurable positive effect of Behavioural Simulations on participant learning and behaviours. In the second half of the thesis I examine and demonstrate the potential for virtual world simulations to enhance major incident preparation, reviewing the evidence behind major incident training the potential benefits of using virtual world environments via a user-needs analysis and expert advisory group. I describe the successful design, development and assessment of three virtual world scenarios for multidisciplinary major incident training in the context of a bomb blast. Face and content validity is demonstrated and performance assessed in both technical and non-technical skills. Finally, I determine the feasibility of utilising a virtual trauma scenario for long-distance training between the UK, Canada and Southern Africa. The thesis concludes with an overall discussion of the pertinent findings, limitations and implications for future practice and research.

The characteristics of the Palestinian Healthcare sector has led to a poor quality of care being provided which in turn pushed the Ministry of Heath (MOH) to initiate the Quality Improvement Project ( QIP ). That project was held responsible for improving the quality of healthcare provided through implementing Total Quality Management. This study assesses the process of TQM implementation in the Palestinian Healthcare sector. The central thrust of this study involves the identification of: The main pitfalls and obstacles to TQM which impede its implementation. The process of TQM implementation in the Palestinian healthcare sector. The main driving and restraining forces while implementing Total Quality Management in the Palestinian healthcare sector. The main lessons and recommendations for the future development of quality improvement. Case study methodology will be used in this thesis as it is unique in its ability to deal with a full variety of evidence through the use of documents, interviews and observations. The data that will be produced cannot be generalised. To overcome this disadvantage in the case study approach, a multi- method approach will be used in this thesis. A postal questionnaire survey, as part of the evaluation study, will be also used. The use of multiple cases and questionnaire surveys will justify the validity and reliability of the data .The multimethod approach in collecting the data in this thesis shows that the Quality Improvement Project (QIP) was not methodology - bound when implementing TQM. In the first cycle of improvement, the PDCA cycle was used as a model for implementation. In the second cycle of improvement, the Tom Noland model was used as basis for implementation. In seeking to improve the quality ofhealthcare, the QIP utilised no single scientific methodology for the improvement of the quality of healthcare but combination of more than one methodology that could assist in achieving the best results possible. The thesis also shows that the Quality Improvement Project Team (QIPT) dealt with many driving forces during their attempts to implement quality improvement such as team work, planning, a well defined and a scientific methodology, the use of a simple quality improvement model, a new management system, enthusiasm of the team leaders for quality improvement, and strong coordination. Furthermore, the QIPT faced many obstacles during implementing quality improvement such as the turbulent external environment, internal problems and difficulties inside the subject organisations, lack of monitoring and follow - up systems, resistant to change, centralisation, poor communication, and the dissatisfaction of health personnel. The QIPT learnt many lessons and drew many conclusions from their efforts to implement quality management in the Palestinian healthcare sector; such as the importance of the commitment of macro level managers to quality improvement. Quality improvement in Palestine is possible and has the potential to be successfully introduced into the current professional and technical internal environment. Consumer (internal & external) views about the health services is very important to consider when seeking any improvement in the health sector, and of maintaining a cintinous pattern of consolidation for the gains made in quality provision. In particular, there is a need to note the importance of conducting improvement processes within the selected organisations in response to the annual improvement needs plan within those organisations, of meeting the demand of the MOH and the importance of providing the financial and staff support that quality improvementprocesses needed if they are to be brought to a successful conclusion are recognised and recommendations offered.

The process of extracting modal parameters using vibration response data from aerospace, civil and mechanical structures is well-established and many techniques exist to cater for the availability of spatial and temporal data. These techniques need extensive interaction with an expert user to guide them towards an acceptable set of solutions and are not adequate for structural health monitoring which fundamentally requires an automated process. Research into automated algorithms for the extraction and tracking of modal parameters started to gather momentum recently due to advances in technology and computing. Currently there is a lack of automated procedures due to the difficulty of replacing the interactions of an expert user with software algorithms and those that have been proposed have not yet been widely adopted. In this thesis, we propose a new automated method to track resonant frequencies for the purpose of detecting change. The method uses wavelet decomposition, principal component analysis, spectrum estimation and adaptive filtering. The aim is to identify resonant frequencies and then to monitor their magnitudes and frequencies in an automated fashion without user interaction for the detection of change in performance. The proposed method is validated on several benchmark problems widely studied in the literature, one simulated and four experimental. It is shown that using the new method it is possible to detect all the data cases for these benchmark structures because they produce changes in the resonant frequencies or in their magnitudes. The new method is also compared with an existing automated method called frequency domain decomposition (FDD) and it is shown that for the benchmark problems considered in this thesis the frequency tracking performance of the new method is superior.

This thesis contributes further understanding on how to pursue improvements in healthcare and informs the academic growth of improvement science. Derived from manufacturing industries, QI methods are common approaches to structure the process of making improvements in healthcare, however, questions over their scientific legitimacy and application have arisen due to their varied effectiveness. A review of how QI methods are associated with science identifies the prominent theoretical role of QI methods in facilitating change and improvement by supporting the local application of the scientific method. The Plan-Do-Study-Act (PDSA) cycle method is identified as playing a central role in this and a theoretical framework is developed to assess the use of the method in published and local team's accounts. This demonstrates that the method is commonly not used with high fidelity; a key novel addition to the research literature. Studies are presented to further understand the reality of PDSA cycle use. These provide a novel identification and empirically grounded description of the social dimensions of applying the PDSA cycle method including negotiating through a single PDSA cycle and navigating the iteration and scale up of change and complexity of learning. A novel association between understanding, intentions and process of applying the PDSA cycle method and the fidelity of the methods use is also presented as well as the views of teams using the method which demonstrate different conceptual views of the PDSA cycle method and the wider social benefits of using the method. Overall, this thesis provides clarity in regards to the technical and social elements of PDSA cycle use. It demonstrates research approaches to open the 'black box' of PDSA cycle use and investigate the use of QI methods more widely. It calls for continued exploration of applying science to improve the quality of healthcare for patients.

This thesis explores the economics of health inequalities in the English National Health Service (NHS). It consists of five applied economic studies that explore different questions regarding socioeconomic inequalities and the NHS. It is bound together by an integrative chapter that provides the historical background to, and draws conclusions across, the body of work. The first of the five applied studies examined the financial costs that socioeconomic inequalities exact on the NHS, the second looked at socioeconomic inequalities in access to primary care, the third looked at socioeconomic inequalities in health outcomes attributable to the NHS, and the final two studies extended the established methods for the economic evaluation of health care programmes to explicitly value minimising socioeconomic health inequalities as well as maximising population health. These extended methods were termed distributional cost-effectiveness analysis. The studies found that dealing with the excess morbidity associated with socioeconomic inequalities cost the NHS approximately a fifth of its annual budget. Socioeconomic inequalities in access to and quality of primary care significantly improved from 2004 to 2011 in response to government policy to tackle these. However, socioeconomic inequalities in health outcomes stubbornly persisted over this period, by 2011 socioeconomic inequality was still associated with over 158 000 patients experiencing one or more preventable hospital admissions and almost 40 000 patients dying from causes amenable to health care. Distributional cost-effectiveness analysis methods were shown to be practically applicable in an NHS setting. This was demonstrated using a case study comparing population health programmes in which trading off between health maximisation and health inequality minimisation was necessary. The thesis provides an evidence base and practical new methods that should serve as a foundation to better understand the role of the NHS in tackling socioeconomic inequalities in health. In so doing, it also outlines an exciting programme of further research.

Health care expenditures have been increasing rapidly. Economic evaluation can be used to aid decision making on resource allocations to secure a more efficient use of scarce resources. In cost-utility analysis, one method used to measure health outcomes is the Quality adjusted life year (QALY). Given the wide differences in clinical settings, health systems and religious beliefs, "utility" scores should be derived from the local population. This thesis aims to estimate population-based preference scores for health from the Thai general population. The generic health description EQ-SO is used as a proxy to describe health. This measure was selected because it has been translated officially into Thai and the measure seems to be straightforward to use. A representative sample was randomly recruited using a stratified four-stage sampling method. A series of pilot studies were conducted to develop the interview protocol based on the Measurement and Valuation in Health (MVH) protocol. A group of interviewers were employed and extensively trained to interview the respondents. A sample of 1,409 Thai respondents was interviewed during May - August 2007 in 17 provinces in face-to-face interviews. Eighty-six health states, classified into twelve sets, were used in the interview. logical inconsistency was identified when a higher score was given to a poorer state. The greatest number of inconsistent responses was identified in the scores derived using the Time trade-off (nO) interview. A Negative binomial regression model was used to analyse the determinants of the numbers of inconsistencies. Elderly respondents and those with a lower education level tend to make more inconsistent responses. A Random effects model was used to estimate the model to predict the preference scores. The best model was chosen on the basis of logical inconsistency in the predicted scores, model robustness, parsimony and the responsiveness of the predicted scores. The best model is the model using the variables from Dolan 1997 model estimated from the scores given by the respondents with fewer than 11 inconsistencies. The model still suffers from heteroskedasticity, and floor and ceiling effects were identified. The Thai scores and the scores derived from respondents in the other five countries were extensively compared to examine the extent of the differences. It seems that the Thai scores are more similar to those of the UK. A costutility analysis of the prevention and control measures for cervical cancer in Thailand was used to demonstrate the difference of cost per QALYs if the scores from other countries were used to approximate the Thai preferences. The thesis makes a number of contributions. The modelled scores are the first original population-based preference scores on health derived from the Thai general population. The determinants of logical inconsistency were examined, as well as an exploratory qualitative interview to learn the strategies that respondents employed to cope with the preference interview. Three reasons are identified to explain the high level of inconsistent responses. Respondents may: (1) have difficulties imagining themselves living in the hypothetical states; (2) use only part of the given information in the health cards or add other information to assist their decisions; and (3) have difficulties in trying to understand the elicitation methods, especially the no. Including the inconsistent responses had, to some extent, significant impacts on the model specifications and the modelled scores. Exclusion of the scores from the highly inconsistent respondents was justified because the scores may not represent their preferences towards health. The results from this thesis should be taken into account for future surveys to be successfully administered. Close collaborations with the field coordinators and arrangement of appropriate interview settings contribute greatly to the success of the survey.

This thesis covers the organisational factors affecting the integration and implementation of primary health care programmes of a provincial public sector health department in South Africa. It responds to the problems of district-level management structures and front-line health care providers being inundated and undermined by the implementation of uncoordinated and fragmented PHC programme activities and strategies. The organisational factors assessed included structural factors such as the interaction between line authority and staff authority, the relationship between divisions located at the centre and periphery of the department and the complementarity between positions and their ranks; management style and leadership; the variables inherent within different PHC programme areas that should influence organisational design; and relevant contextual factors. The thesis is a single case study. Data is mostly qualitative in nature, based mainly on participant observation, interview and document review. The thesis discusses the methodological and epistemological challenges to conducting in-depth research into the functioning of health departments, and illustrates the potential of such research for the strengthening of public health systems in developing countries. One of the main conclusions of the research was that the structural design of a health department can be very significant to its functioning. Some of the structural design faults identified by this research were the inadequate definition of the roles, functions and inter-relationships of several positions with the department; and the lack of congruence between the distribution of rank and the structural configuration of the department. The thesis suggests certain generalisable lessons that could be applied to the design of a developing country public health sector organogram. The study also confirmed that the contribution of management leadership to effective organisational cohesion and inter-divisional coordination is very important in the context of PHC programme coordination. Of particular note was the importance of providing a clear and appropriate strategic framework for planning, which would include the use of planning as a strategy to enhance organisational cohesion and coordination. Finally, the thesis describes the fundamental importance of adequately skilled human personnel within health departments to the effective integration and implementation of PHC programmes.

The practice of engaging the ‘community’ has established presence in public health efforts to target inequalities. However, there remains a lack of critical consideration of how ‘community’ is conceptualised in delivering and evaluating participatory health interventions. This may contribute to the lack of conclusive evidence of the impact of 'community' engagement on health inequalities in the UK and elsewhere. This thesis explored how ‘community’ was enacted through an area-based, ‘community’ empowerment initiative in the UK, to contribute to approaches for evaluating the impacts of such interventions. Drawing on post-humanist, ontological perspectives and actor-network theory, I examined how ‘community’ was enacted through the delivery of the ‘community’ initiative in two areas. I conducted an ethnographic case study over 13 months between 2014 and 2015, and employed multiple qualitative methods to identify practices and conceptualisations constituting enactments of ‘community’. The research was conducted in parallel with a study evaluating the initiative’s impacts on determinants of health inequalities. ‘Community’ was enacted through ongoing ‘boundary work’; or, the assertion and negotiation of spatial, material and social boundaries around eligibility to contribute to and/or benefit from the initiative. Practices and values of the initiative contributed to positioning the individual as separate from the ‘collective’, and to constructions of the ‘community’ as a holistic but segmented entity. Finally, relations of disconnection – of ‘missing out’ – were identified as inherent to enactments of ‘community’ and to the process of aligning my ethnographic practice with evaluation research. These findings hold implications for theorising the pathways to improved health via collective empowerment, and processes of inclusion and exclusion in participatory initiatives. They indicate that evaluation practice must explore how the multiple ways of doing ‘community’ cut across the intervention-context divide, and consider the relevance of this for producing transferable evidence on engaging the ‘community’ to address health inequalities.

Since the 1970s, public health research has shown a renewed focus on the social determinants of health. A focus on the social or ‘upstream’ determinants of health suggests the value of developing sociological analyses. My research applies a sociological imagination to public health science to develop an understanding of the interrelationship between, on the one hand, individual experiences and, on the other, societal arrangements and social position. This research is critical because a public health science oriented towards equitable improvement of people’s lives will require attending to the connections between health and their social contexts. In this critical overview I re-assess the publications I have submitted for the degree of PhD by publication, which includes six peer-reviewed journal articles published between 2013-2015 in top ranking journals in sociology and public health. I highlight the original empirical, theoretical and methodological contributions the publications have made to two domains of public health research and practice: a) school health and b) systematic review methods. The common thread underpinning my research across these domains is situating an understanding of health within a framework of larger social processes. A key aim of this overview is therefore to elaborate and extend my thinking from individual publications to bring this to fruition. I do so by using Anthony Giddens’ notion of structuration as an over-arching theoretical lens to interpret my qualitative research (including interviews, focus groups, documentary analysis and qualitative systematic reviews including meta-ethnography and meta-narrative synthesis) and to illustrate that attending to the duality of structure and agency is useful for providing a framework through which to assess research and practice, and for developing theories which could inform the design and evaluation of complex health interventions.