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Volume 1 of this thesis is presented in three parts. Part 1 is a review of outcome studies on text-based guided self-help for depression and anxiety in primary care, specifically focusing on satisfaction, adherence and attrition. Part 2 is a qualitative interview study examining the views and experiences of 13 people (plus two more who gave details via email) who attended a guided self-help service and did not engage or did not benefit. Part 3 is a critical appraisal of the research process, which considers some of the conceptual and methodological issues encountered, before concluding with a discussion of personal reflections on the impact of the research on the participants and researcher.

Sub-Saharan Africa is thought to have the most genetic variation of any continent and to be the place of origin of anatomically modern human. Nevertheless it is the subject of relatively few studies of human genetic variation. This thesis contributes to redressing this imbalance. Sex-specific genetic systems (non-recombining portion of the Y chromosome (NRY) and mitochondrial DNA (mtDNA)) along with functional nuclear loci were characterised in multiple sub-Saharan African populations with large sample sizes to infer relationships of peoples and identify implications for healthcare. This thesis contains four projects which addressed questions in genetic anthropology, human evolution and pharmacogenetics utilising human genetic variation. In chapter 2, NRY analysis shows that a hypothesised paternal Yombe (Congo) ancestry of Palenque (Colombia), based on linguistic and historical evidence, is consistent with genetic data. Chapter 3, based on NRY data, demonstrates that a) multiple waves of migration occurred southwards during the expansion of Bantu-speaking peoples (EBSP), b) the eastern route displayed more recent migrations than the western route and c) the absence of substantial east to west NRY gene flow in sub-Saharan Africa over the past millennium. Chapter 4 suggests an eastern route out of Africa for the CASP12 truncated variant is more likely than a western route. (The stop-codon mutation was also dated to around 120,000 YBP). Chapter 5 demonstrates that a potentially functional CYP1A2 variant which has not been reported outside Africa is present at considerable frequencies in sub-Saharan African population groups and that exons associated with active sites in CYP1A genes are well conserved.

This thesis uses qualitative and quantitative methods to identify and explore resilience in informal carers using Windle and Bennett's (2011) ecological framework. First, we1 explore the ecological framework in older informal carers. We reveal that older spousal dementia carers and non-spousal informal carers can achieve resilience. Carers draw on assets and resources from across the resilience framework which interact with each other to facilitate resilience. Next we investigate the mechanisms through which emergent themes facilitate resilience over time. We find that older people display a positivity bias, with some evidence to suggest that this is more pronounced in older carers than older non-carers. We reveal that resilient and non-resilient carers share structurally and functionally similar support characteristics. Non-resilient carers are more likely to resist over-involved family support and resilient carers are more likely to receive support from friends with shared experience. Finally, we find that carers can remain or become resilient over time. Institutionalisation and widowhood provide opportunities to draw on more assets and resources. Together, the findings suggest that informal caregiving is not entirely burdensome; carers can achieve resilience and draw on several assets and resources from across the resilience framework. The findings emphasise the importance of social ecological approaches to resilience. However, resources are not always sufficient to facilitate resilience; practitioners and policy makers should deliver personalised carer services that match need.

Aims: Punjabi Sikh immigrants are more likely to develop and live with lifestyle related illnesses than the host population. Identifying factors that influence these health inequalities is challenging. Various socio-cultural factors have shown to pose barriers for this sub-group to access mainstream preventative health services. The current study aimed to explore how elderly Punjabi Sikhs made sense of taking part in a culturally adapted health promoting intervention (CAHPI), to facilitate physical activity and healthy eating behaviours. A newly developed behaviour change model: COM-B underpinned the intervention design and contents. Method: Semi-structured interviews were conducted with a purposeful sample of 7 Sikh immigrants who had taken part in a CAHPI. The resulting data was analysed using Interpretative Phenomenological Analysis, focusing on the participants lived experience of the CAHPI. Results: The following themes were revealed: 1) “for our good health, we are getting some help with our health”, 2) “It was in our Gurdwara”, 3) “We all got together, the time passed nicely”, 4) “We are in a different stage in our lives now, we are not the same people we were 10 years ago, and 5) “You can’t learn all the things in one day, we need some more”. Discussion: The in-depth analysis allowed this generally ‘unheard’ population, to voice their views of taking part in the CAHPI. The findings showed that by incorporating meaningful components relating to the design and delivery of such interventions, wider engagement of the target population can be achieved. The IPA approach helped capture the complexities that exist between individuals within these specific populations, and the meanings they attach to the phenomenon being explored. Conclusion and implications: The current findings show the importance of drawing on a range of disciplines and guidance from the newly developed COM-B model to help identify and understand the mechanisms that facilitate behaviour change in this context. Consequently, meaningful collaboration between health care professionals and local communities can help identify strategies for addressing some of the health inequalities that exist within this marginalised community. In particular, the utility of places of worship and fear appeal approaches for delivering such initiatives, have shown to be invaluable.

A review of the literature showed that Black and minority ethnic (BME) communities carry a disproportionately higher burden of illness than the general population and experience greater inequalities in health and health care provision. A growing body of research confirms that BME groups are under-represented in research. The main objective of the present study was to gain insights into the perspectives of BME community groups' experiences of accessing general and sexual health care services in Ayrshire. Semi-structured interviews were conducted with 11 participants, n = 5 men (age range: 32-65; mean age = 52.4 years), and n = 6 women (age range: 27-60; mean age = 47.67 years). Data were analysed employing Interpretative Phenomenological Analysis (IPA). The analysis is illustrated through the use of four super-ordinate themes: ‘It’s a Trust Thing’, ‘Minding the Gap(s)’, ‘Sexual Health: a Culture of Silence’, and ‘Personal Perception of Risk’. The findings both support and add to the existing trust literature by presenting a heuristic model of trust, and by showing that participants trust is dynamic in character, has a role, and serves various roles and functions that impact decisions about accessing health services. Significant gaps in knowledge about available health services and unique communication challenges that prevent full access to health care and health promotion information were found, resulting in unmet needs. Analysis charted culturally driven factors that prohibit discussions about sexual health concerns and found complex cognitions involved in the personal perception of risk that was meaningfully understood by participants that direct towards understanding risk in terms of a heuristic model. The implications for clinical practice, health promotion, health service development, and the direction of future research will be discussed.

Epidemic disease outbreaks of zoonotic origin such as Avian Influenza, SARSor BSEare increasingly common lately. The thesis aims at exploring the underlying reasons for risks occurrence in the public health sector due to the increase in animal production. It adopts an economic perspective and compares human health systems and animal health systems. A comparative literature review is undertaken of animal health andits humanhealth counterpart It explores the underlying economic reasonsfor the weakening of public health and animal health systems. The role of the structural adjustment programmes, followed by market-based economic principles (especially privatisation of public services) is analysed. The market failures existing in this field are examined along with associatedpolicy implications. Characteristic of the thesis is the underlying comparison of human and animal health systems from the funding mechanism to service delivery. In the latter case, community-based systemsin both the human and animal fields are chosen asa comparative case-study. Hence, the thesis presents first, the possible options to fund activities in the animal health field to prevent the spread of such types of diseases. The recent Avian Influenza outbreak in Vietnam (2004-2005) is taken as an example of implementation of funding mechanisms. In addition, data about financing animal health systems from Senegal was gathered through a questionnaire to the 3relevant authorities. Second, when focusing on community-based systems, a field research in Kenyan arid and semi-arid lands. was performed on animal health services. The gaps in the public health arena likely to influence the increase of zoonotic and emerging diseases occurrence are pointed out throughout the thesis.

Too often, patients in low and middle income countries receive inadequate quality healthcare. Technical capacity constraints - insufficient availability of competent health professionals, medicines and other essential inputs - are often seen as the cause. Whilst undoubtedly important, these constraints cannot fully explain poorly delivered health services. This thesis explores how supply-side incentives also influence the quality of healthcare doctors deliver to patients. It uses the analytics of the principal-agent model as the starting point for illustrating the impact of different incentives on medical effort, and through this effort, the quality of healthcare. Insights and testable hypotheses emerging from this conceptual approach are then evaluated through empirical studies of doctors working in 30 districts in the Philippines, using a variety of econometric methods. Data came from both primary and secondary sources. A first study explored the relationship between empirical measures of medical effort and the technical quality of healthcare. A second study analysed how various financial and non-financial incentives affect the amount of medical effort exerted by doctors on public hospital inpatients. A third study addressed the phenomenon of physician ownership of private pharmacies, and whether this has any adverse impacts on patients. Results showed that whilst the relationship between medical effort and quality is not straightforward, low effort typically results in lower quality care. Subsequent results illustrated how supply-side incentives can lead to public hospital patients with equal health need being treated unequally; and pharmacy-owning physicians unduly influencing a patient's use and expenditure in pharmacies. Suggested policy reforms are based on reshaping the incentive structure within which doctors operate, including reform of provider payment mechanisms and patient charges; improved monitoring and regulation; and policies to encourage greater use of generic drugs.

Development organisations have moved from reporting on 'what they do' to addressing 'what difference they make' in an environment that forces them to compete for resources. Thus, measuring their effectiveness has evolved from accountability reporting to results enquiries and to evaluation of the impact of interventions at the end user's level. To adapt to these changes, most development organizations and donors have adhered to results based management and use logical framework approaches for their operations. These approaches and systems have recognised usefulness in project planning, although their utility in project monitoring and organizational performance assessment is more contested. The analysis of recent experiences calls for alternative approaches to assessing performance to improve the effectiveness of development and technical organisations at the country level. This research explores the use of logframes to assess the programmatic performance in a multilateral organization at country level, in the context of an increased focus on results based management. It uses a qualitative methodology to a) assess the comparative advantages and challenges of various assessment tools and systems that WHO uses to measure its performance in EPR in Myanmar and in Nepal; b) address the WHO contribution in terms of results and impact in the area studied; and c) propose options for addressing WHO accountability performance and cooperation effectiveness in EPR at country level. The two case studies uncover the importance of contextual factors, and stakeholders' perceptions and intemctions. They further highlight the role that organisational setting and team profile play in using systems and tools to measure progmmmatic performance. Logframes proved useful for planning and financial accountability, although they confronted major difficulties when assessing the core contribution of the teams to the programme achievements and stakeholders' expectations. The research contributes to the understanding of how routine performance assessment systems work in practice. The comparison of the findings in the two countries raises institutional issues and offers the possibility for organizational learning. Finally, the research proposes alternative options that WHO may adopt to measure its programmatic performance in countries.