Background: People with Intellectual disabilities within a residential context often do not have the information and support to make healthy lifestyle choices, which puts them at risk of weight management problems such as obesity and health conditions such as heart disease (Draheim et al. 2007; Emerson et al. 2011). An adapted version of the 'HealthMatters Program' developed by Marks et al. (2013) had the potential to provide people with intellectual disabilities with the knowledge and support to make healthy lifestyle choices. Aims: The overall aim was to test the efficacy of the adapted 'HealthMatters Program' on weight management and health related outcomes for people with ID, and assess staffs' knowledge and attitudes in supporting these individuals to adopt a healthy lifestyle. Methods: A four phase mixed method design was adopted .The first phase explored the feasibility of the adapted 'HealthMatters Program' within a UK residential context. The second experimental phase tested the efficacy of the intervention on outcomes for 38 staff and 62 people with ID. The third and fourth phases explored participants' experiences of engaging with the intervention and investigated organisational barrierslincentives to health promotion activities. Findings: Although knowledge outcomes improved for people with ID and staff after the adapted 'HealthMatters Program', this did not translate into Significant and sustainable weight loss outcomes for people with ID. It is proposed that staff did not get organisational support to help individuals with ID to sustain changes. This study has made a unique contribution to knowledge by highlighting how preparatory work needs to be undertaken on an organisational level before the Transtheoretical Model of Behaviour Change is applied to initiate and sustain behaviour change on an individual level for people with ID. Further directions for policy and research are suggested for implementing health promotion activities on an organisational and community level.

The purpose of this study was to understand the lived experiences of four overweight/obese Hispanic adolescents as individuals by utilizing Social Cognitive Theory’s (SCT) (Bandura, 1977, 1986, & 1989) reciprocal interaction of the environment, personal factors and behaviors of the participants in order to investigate the health risk behaviors of the participants as they related to overweight and obesity. Additionally, the commonalities and differences across participants were examined. Four female Hispanic adolescents whose BMI measured at the 99th percentiles for age and gender were randomly chosen from students enrolled in a junior high school physical education intervention class. Experiences of each participant were examined utilizing school cumulative records, a demographic questionnaire, participant observation in certain contexts, and a series of interviews, based on questions derived from SCT. Methodological triangulation and grounded theory were utilized in order to examine the research question. The accumulated data were presented in four separate case studies, which examined the life perspectives of each participant. A componential analysis was used to interpret the data. Results of the individual case studies showed that the school, home, and community environments were found to be influential to the health status of the four overweight participants, with the family appearing to be the primary source of influence. This study's conclusions indicate that the schools, homes and communities of the participants did not encourage physical activity or diet control and health risk behaviors in this regard were reinforced and perpetuated by family and friends.

This thesis endeavours to address the dual relationship of individual behaviours and characteristics of inhabited environments that affect individuals' choices for physical activity inducing the obesity epidemic. The thesis explores if environmental characteristics could impede engagement in energy expenditure activities such as leisure time spent on physical activity which may be responsible for the rising level of obesity. Generating a greater understanding on the determinants for engagement in physical activity could yield valuable understanding on the role the local environment implicates on rising obesity levels in NI. This research employs methodologies primarily used to value recreational demand and natural resources that are adapted in this study in order to improve the decision making process in the development of public health strategies improving the health of the NI population. The goal of this thesis is to explore how public health interventions can increase levels of physical activity among the population and value the health benefits of physical activity as 1well as the monetary benefits that society receive. This thesis employs three non-market valuation techniques, the Travel Cost Method (TCM), Contingent Behaviour (CB) and Contingent Valuation Method (CVM) in order to value the health benefits of increase levels of physical activity. The TCM questions explore the public health benefits stimulated by characteristics of local neighbourhoods. It is assumed that neighbourhood characteristics affect the level of engagement in physical activity and time allocated to other daily activities. The CB questions are used to assess physical activity levels under improved hypothetical neighbourhood characteristics, as well as value the health benefits of participation in physical activity. The CVM questions estimate the publics' willingness to pay for improvements to local neighbourhoods, motivating increased participation in physical activity.

A longitudinal, prospective and controlled trial was undertaken to identify the most cost-effective treatment for children with severe malnutrition. Children <60% weight-for-height or with oedema aged 12-60 months, were sequentially allocated to i) in-patient treatment ii) day-care treatment iii) domiciliary management after one week of day-care. Institutional and parental costs incurred to reach 80% weight-for-height are compared. The groups were comparable as regards age, sex, nutritional status, presence of infection and socioeconomic status at recruitment. A total of 437 children completed the study. Mortality during treatment was low in all groups <5%). Although the domiciliary group took the longest to achieve 80% weight-for-height they did so at the lowest overall cost. Day-care treatment approached in-patient care as regards speed of recovery at less than half the total cost, but it was an unpopular option and only 4% gave this as their preference. Although parental costs were highest for the domiciliary group as no food supplements were provided, this was the majority's preference (67%) especially among the group who experienced it. Children continued to be followed for one year after they reached 80% weight-for-height to determine longer-term progress. Data were collected fortnightly for morbidity and monthly for anthropometry, mortality and relapse rates. All three groups increased in weight-for-height during the year from 80% to 91 % on average but no increase was observed in height-for age. There was a high prevalence of infection with an average incidence of 7 diarrhoeal episodes, and 30% presented with acute respiratory infection on more than 3 occasions. Without access to medical care it is likely that many would have relapsed. Only 0.6% however required readmission for severe malnutrition and 1.6% died. It is concluded that domiciliary management after 1 week of medical care is a cost effective option for treating severe malnutrition.

INTRODUCTION: Mexico is one of the top 10 countries with the highest prevalence of obesity worldwide. In 2012, 22 million Mexican adults were classified as obese. As a consequence, the country has seen an increase in morbidity and mortality from obesity-associated diseases that have impacted the country’s health and economy. OBJECTIVE: To develop a computer simulation model that estimates future obesity prevalence and its impact on four cardiometabolic risk factors in the Mexican adult population aged 20-79y from 2015 to 2030. METHODS: Using the best and most recent available Mexican data, I developed the Mexican Obesity Forecast Model (MexOb-Model), a population-based computer simulation model that is composed of two sub-models: 1) a linear trend model that projects future prevalence of obesity; and a 2) discrete-state Markov model that estimates the impacts of rising levels of obesity on morbidity and mortality from hypertension, type 2 diabetes, hypertriglyceridaemia and hypercholesterolaemia in the adult population. Additionally, I estimated the potential health benefits of three hypothetical obesity prevalence reduction scenarios. RESULTS: If current trends continue, by 2030 there would be 48million obese adults (20─79y) in Mexico. The prevalence of hypertension, hypertriglyceridaemia and hypercholesterolaemia in the obese population would reach >50%, and 30% for diabetes. Decreasing the projected 2030 obesity prevalence by 3% would reduce the number of disease cases in the obese population by 150,000-500,000 and would reduce the number of deaths by 16,000-30,000. If Mexico achieved a bigger reduction in obesity levels, a 10% reduction in 2015 obesity prevalence by 2030, the number of disease cases avoided could be between 2 million and 7 million and total deaths reduce by nearly 500,000. CONCLUSION: The country’s prevalence of obesity, and obesity-related cardiometabolic risk factors, are expected to increase. A reduction of as little as 3% in the projected prevalence of obesity could result in a significant reduction in the health burden of obesity in Mexico.

It is estimated that more than 50% of persons with hepatitis C in the UK remain undiagnosed, which should be considered a failure of current screening processes. Further, treatment uptake is poor and linkage and retention to care is a significant barrier to virus elimination. In this thesis we demonstrate the impact of long term linkage to care using the example of hepatocellular carcinoma surveillance. We demonstrate that in scenarios where patients are required to followed up long term, there are currently significant shortfalls in maintaining linkage to specialist services. In at least 40% of cases, lack of linkage was not due to patient related factors and were institutional failures. We also evaluated the impact of hepatitis C cirrhosis on hospital admissions. Patients who did not achieve SVR were associated with more frequent admission events and more days of admission. Whilst it is unclear if this was primarily associated with greater likelihood of advanced liver disease solely it does provide a compelling argument for treatment at earlier stages of disease. After demonstrating the burden of disease, health economic evaluation was performed comparing real-life screening and treatment outcomes in a drug-treatment unit, antenatal screening service and a homeless shelter. In all scenarios the screening was followed by direct linkage into specialist services aiming to increase retention. Finally a exploratory analysis was performed on a UK birth cohort screening programme using real-world age distributions of hepatitis C patients. All health economic analysis was performed using a validated hepatitis C natural history Markov modelling model. Hepatitis C screening at varying viraemic prevalences as seen in the drug treatment unit (41%) and antenatal screening (0.16%) are demonstrably cost-effective as long as patients are appropriately linked up to care with specialist services to reap the benefits of SVR at earlier stages of disease and minimise onward virus related liver complications.

In this research, the barriers and enablers to new and different ways of working and role extension in dysphagia care were explored using the grounded theory approach described by Corbin and Strauss (2008). Despite calls for new and innovative ways of providing clinical care, including role extension, researchers have pointed to slow progress amongst Allied Health Professionals (AHPs). Barriers to change that have been identified include professional resistance. Role extension in the field of dysphagia care has made very little progress. The purpose of the research was to construct a substantive theory to help explain the process of role extension in the field of dysphagia care and associated nutrition and detail the enabling conditions and the barriers to these new and different ways of working. In order to explore the process of role extension, data were collected in two phases using semi-structured interviews. The first phase identified the initial theoretical categories and theoretical model; the second phase further developed these categories and refined the theoretical model. Data were collected from two main research settings, with additional data collected from the respective professional bodies and other areas that had initiated role extension. The two main research settings were: an acute and a community care site with limited role expansion in dysphagia, and a combined community and acute Trust with a nationally celebrated programme of role expansion for nurses. Participants included dietitians (n=10), SLTs (n=15), assistant staff (n=2), nurses and other health care professionals (n=8), service users and their carers (6 interviews, n=12), commissioners (n=3) and service managers (n=6). The model and theory developed from the analysis was a shift in the perception and definition of explicit and tacit skills and knowledge. The model that was constructed describes how the professional groups in the domain manipulated this line in order to retain or relinquish professional control over the area. The substantive theory and model developed from this research provides an insight into both how and why professionals at the frontline of dysphagia care in the research settings studied use the tacitness or explicitness of clinical knowledge and skills to retain, or relinquish, control over the clinical area, thus allowing or preventing role extension. Future research may identify that the concepts identified in this research also have applicability in other clinical settings and between other clinical groups.

Adolescent obesity is a public health problem associated with significant immediate and long-term health complications (Kelly et al. 2013). Amongst obese adolescents, a third are severely obese (BMI >99.6th centile UK90 reference charts) (Ogden et al. 2012) with severe obesity the fastest growing classification in this age group (Wang et al. 2011). The evidence for managing and treating child and adolescent obesity generally is poor, with multidisciplinary lifestyle programmes failing to derive significant and sustained weight loss and often reporting high attrition (Luttikhuis et al. 2009). Furthermore, this evidence has predominantly focused on young people as a whole with little differentiation of treatment and outcomes by age and severity of obesity. As a result, successful treatments for severely obese adolescents are lacking with permanent bariatric surgery increasingly considered. This thesis aimed to enhance the understanding of the needs of obese adolescents, contribute to what is known about current treatment options for severely obese adolescents specifically and pilot a novel treatment approach within this population. A qualitative enquiry (Study 1) of the lived experiences of obese adolescents (n = 12) reinforced the complexity of the impact of obesity on the lives of obese adolescents across social, emotional, behavioural and cultural contexts. All participants experienced low self-esteem and feelings of shame and there were frequent accounts of debilitating bullying. Adolescents required intensive support to develop skills for coping and managing emotional choices, and the importance of family-support within treatment was highlighted. Data confirmed weight loss programmes need to consider the complex experience of obese adolescents in their design, focusing on how to implement long-term lifestyle changes into their ‘real’ lives. Informed by the findings from Study 1 and a comprehensive review of existing treatment options for severely obese adolescents, the use of an intra-gastric balloon alongside a lifestyle support programme (BOB; Study 2) to promote weight loss was piloted in 12 severely obese adolescents (5 males, 7 females; mean age 15 yrs; BMI >3.5 SD; puberty stage 4 or above). Mean weight loss at 12 months (n=9) was 3.05 kg ± 14.69; d=0.002 with improvements in psychosocial health, physical activity and cardiorespiratory fitness also maintained at 12 months. Although, the use of an intra-gastric balloon as an adjunct to a lifestyle programme was well tolerated by participants, large variations in outcome data suggest alternative treatment solutions in this population are warranted. That said, the comprehensive reporting of the intervention and the focus on validated behaviour change techniques to support change is a strength of this study. The qualitative experiences of treatment for participants and their family members were captured throughout treatment (Study 3). All participants acknowledged the experience was harder than anticipated, but recognised the importance of creating shared ownership over making lifestyle changes. Single case data pointed to successful and sustained weight loss where the whole family were actively engaged in treatment, modelling positive lifestyle changes alongside the adolescent. Future studies are encouraged to explore the most effective methods for engaging family members in treatment.

Background: Increased body fatness along with other conditions typical of the metabolic syndrome (MetS) such as insulin resistance have become more prevalent in Qatar due to rapid transitions in the Qatari's population lifestyle in the last few decades. The government of Qatar is seeking to improve the public's health; however, epidemiological studies on Qataris are limited. Aims: This research aims to 1) describe the features of the MetS and its determinants among a sample of Qataris, 2) explore the difference between four obesity subgroups regarding selected factors of metabolic health and 3) investigate the association of total and central body fatness indices with C-peptide and glycated haemoglobin A1c (HbA1c) as insulin sensitivity biomarkers and with fibrinogen as a biomarker of inflammation. Methods: This is a cross-sectional study of 879 Qatari men and women from the Qatar Biobank pilot phase. The MetS prevalence was estimated using the National Cholesterol Education Programme Adult Panel III (NCEP ATPIII), International Diabetes Federation (IDF) and the harmonised criteria. Metabolic health status for the four obesity subgroups (metabolically-healthy normal weight, metabolically-abnormal normal weight, metabolically-healthy obese and metabolically-abnormal obese) was identified using the harmonised guidelines. Multiple linear regression analyses were conducted to test the relation of the obesity indices (including body mass index, body fat percentage, waist circumference (WC) and waist-hip ratio) to C-peptide, HbA1c and fibrinogen. Results: The prevalence of the MetS was 18.4% (NCEP ATPIII), 27.0% (IDF), and 28.9% (harmonised definition). Central obesity was the most prevalent determinant of the MetS. There were significant differences in multiple factors of metabolic health for each of the four obesity subgroups. There were strong positive associations between the examined obesity indices and C-peptide, HbA1c and fibrinogen. WC had the strongest positive association with C-peptide, HbA1c and fibrinogen compared to the other examined body fatness indices. Conclusions: The current findings suggest that future interventions should target reducing WC in Qataris. The four obesity subgroups differed significantly regarding multiple factors of metabolic health; this implies that they might need to be treated differently. More epidemiological studies are needed to aid the Qatari government in their decision making to improve the public's health.

No description available.