Background: A marked increase of type 2 diabetes and associated morbidity and mortality rate over the last 10 years has been recorded in Malaysia. Ineffective diabetes management and a lack of self-care practice among type 2 diabetic patients have been identified as the major reasons for this problem. Research in other countries has highlighted a range of factors influencing effective self-care of type 2 diabetes including patients' perspectives of diabetes, sociocultural issues, religious beliefs and support from healthcare. Nevertheless, there is paucity of research conducted in Malaysia. Therefore, the exploration of self-care practice and self-care support provision in patients with type 2 diabetes in Malaysia is needed to understand the problem. Aims: To understand the self-care practice of patients with type 2 diabetes in Malaysia and the factors that influence the patients' self-care practice. To understand the type 2 diabetes’ self-care support provision in Malaysia from the perspective of patients, healthcare professionals, and healthcare system. Methods: A qualitative, single embedded case study design was utilised. Eighteen patients with type 2 diabetes and 19 healthcare professionals (physicians, diabetes educators, nurse, pharmacist and dietician), involved in self-care support provision primary- and secondary-care settings in Kuala Lumpur and Putrajaya, Malaysia, participated in in-depth semi-structured interviews between November 2012 and June 2013. In addition, data were collected through participant-observation of clinic consultations, and analysis of relevant documents used in the provision of diabetes management in the respective clinics. The framework technique supported analysis of data. Data were stored and managed using Nvivo 9 software. Findings: The findings indicate that patients with type 2 diabetes had a good understanding of diabetes and self-care, but a lack of self-care support meant that effective self-care was difficult to sustain. Healthcare professionals’ (HCPs’) provision of self-care support was restricted due to several factors, including lack of opportunity to provide self-care support, unsuitable clinic environment and a fragmented management within primary and secondary care. Additionally, barriers in patient–HCP communication, a combination of the personal, interpersonal and inter-professional HCP factors, and a traditional medical model adopted by Malaysian healthcare system, seem to have influenced the practice and quality of the service delivered. Conclusion: It is clear that the increased incidence of uncontrolled type 2 diabetes is not merely due to poor self-care practice by patients, but also due to constraints in service delivery and underdevelopment of self-care support provision. The evidence generated can assist in the development of strategies to improve the quality of care and facilitate changes in the self-care support provision in Malaysia.

Evidence for the timing and frequency of monitoring chronic conditions in primary care is often of low quality or absent. Recently, a methodology based upon repeated measures of monitoring tests has been developed to evaluate monitoring strategies which differ by frequency and the length of interval. In studies using this approach, it has been shown that there is potential for substantial over-detection and over-treatment through routine monitoring. The aim of this thesis was to extend the existing methodology to outcomes with highly skewed distributions and tests that are interpreted as dichotomous or categorical states. These methods were applied to find evidence for the intervals of monitoring for microalbuminuria in people with type 1 diabetes and screening for diabetic retinopathy. Statistical models were used to describe the progression of albuminuria and retinopathy and estimate the rates of false positive and false negative tests over time. Simulation was then used to create hypothetical cohorts of people being monitored and screening at different frequencies and for different baseline risk. The impact of changing the timing of tests within the programme was measured and evaluated. The basic framework of the methodology can be usefully extended to tests that have categorical outcome or highly skewed distributions. More frequent monitoring of microalbuminuria in people with type 1 diabetes, and more frequent screening of diabetic retinopathy leads to disproportionate numbers of false positive results and potential over-treatment or referral to specialist services. As with any other clinical intervention, monitoring and screening intervals should be based upon solid evidence. Monitoring for microalbuminuria and screening for diabetic retinopathy less frequently would reduce the rates of false positives tests but the implications of less surveillance need further investigation.

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Aim: To test the interactive effects of the constructs of Modified Social Learning Theory (MSLT) in relation to predicting health behaviour in Type 2 Diabetes. Methods: The study is mixed methods and employs an exploratory sequential design. Qualitative Phase: (N=12) Semi-structured interviews with adults with insulin-treated type 2 diabetes, explored how beliefs and values influence self-management behaviour. Interim Phase: Thematic analysis allowed development of an adapted Health Value Measure. Quantitative phase: (N=107) Valid questionnaires measured Health Value, Health Locus of Control (HLC) and Self-efficacy (SE). Health Value was measured pre and post diagnosis in order to compare any changes with time. Anxiety and depression was controlled for using the Hospital Anxiety and Depression(HAD) scale. Five subscales measured diabetes outcome behaviour: general diet, specific diet, exercise, blood sugar and foot care. Hierarchical Multiple Regression(HMR) analyses consisted of four blocks, including three two-way interaction terms and one three-way interaction term to test the interactive effects of the three-predictor variables on outcome behaviours. ANOVA’s were conducted in an effort to add support to HMR results. Results: The interviews suggest that people may hold terminal (beliefs about desired end states)/instrumental health values (beliefs about desired modes of action) pre-diagnosis but these are mainly instrumental post-diagnosis in order to meet their new needs and maintain quality of life. The qualitative data also drew attention to the way in which LOC and SE beliefs impact on behaviour. Additionally, differing dimensions of various emergent themes highlight the demands Type 2 diabetes places on a person and how this influences beliefs and values. Interim phase results resulted in the new items being removed from the adapted health value measure prior to the quantitative data analysis, as item 5 was deemed problematic. Sensitivity analysis was carried out to increase the robustness of the quantitative findings due to removing 29 cases with missing data from Dataset 1. Dataset 1 includes 78 complete cases and Dataset 2 contains 107 cases, 29 of which had missing values and were replaced using regression imputation. HMR analyses produced significant results that support MSLT when the three-way interaction variable was added to block 4. ANOVA results produced minimum support for MSLT. Conclusion: Support for MSLT has been found and can be used to inform interventions to change self-management behaviours of patients with poor diabetes control. Change in health value orientation post-diagnosis purports further investigation, as it is supported by qualitative results but not quantitative.

Mathematical models have been applied to biology and health to gain a better understanding of physiological systems and disease, as well as to improve levels of treatment and care for certain conditions. This thesis will focus on two different methodologies to investigate models of health, namely delay differential equations andBayesian based data mining. The first approach uses delay differential equations to model the glucose-insulin regulation system. Many models exist in this area, typically including four exponential functions, and take a number of different forms. The model used here is a system of two delay differential equations with two time delays. The one delay form of this model has previously been widely studied, but less is known about the two delay system from an analytical view point. This work improves upon the existing models by incorporating Hill functions instead of exponential functions. The new model presented is studied for its appropriateness and robustness to changing parameters such as glucose infusion rate and insulin degradation. A local and global stability of the two-delay system is presented both in general terms and explicitly using Lyapunov functionals and linear matrix inequalities. The second method employs data mining techniques including a robust and transparent naïve Bayes classifier for classification and prediction of aspects of health. A study into prediction of post-stroke mortality is made on a data set of stroke patients. Interesting results are obtained for the classification of naturally arising mortality periods and an investigation into the role of age as a risk factor for post-stroke mortality. A wide range of risk factors are then investigated for significance which are used to build new predictive models. These two approaches have the joint aim of improving the understanding of aspects of health through mathematical modelling techniques. A new model of the glucose-insulin regulatory system is developed and for the first time an analysis of the global stability of the two-delay model by use of a Lyapunov functional is provided. The second approach sees typical and robust data mining techniques used to analyse medical data. New models for stroke mortality and prediction of diabetes and obesity are created, which review risk factors and also illustrate the benefit of data mining techniques for analysing medical data.

People of Black African heritage in the UK have increased susceptibility of being diagnosed with Type 2 Diabetes Mellitus (T2DM) compared to the general White population. Nutrition is central in halting T2DM and the progression of complications such as cardiovascular diseases. However, little is known about the factors influencing the diet of women of Black African heritage with T2DM. In addition, clinical and public health conceptions of the problem tend to be individualistic in orientation. This study is an exploratory and in-depth inquiry into food choice and the implications of dietary change for women of Black African heritage who self-manage T2DM by diet alone. Eight participants were recruited using purposive sampling. Recruitment sites included Black and Minority Ethnic charities in Norfolk and Suffolk. Data was derived from direct observation using the ‘Accompanied Shopping Task’, combined with a ‘Think Aloud Technique’ called a ‘Product Choice Reasoning Task’. In-depth interviews were undertaken and transcribed verbatim. Framework Analysis was used to provide a procedure to manage data analysis, which was informed by the PEN-3 public health cultural model which moves beyond overly individualistic conceptions of the issues. The study showed that six participants prioritised the disease and used what I have called a ‘Disease Focused Approach’ to self-manage T2DM. Two used a ‘Family Focused Approach’, as family played a crucial role in T2DM self-management. All participants undertook T2DM self-care by following a culturally appropriate diet. Their least preferred options for managing T2DM were medical therapy and physical activity. The study showed that although food choice is influenced by many factors, culture was particularly important. Moreover, participants showed greater knowledge than had been anticipated about the role of nutrition to prevent progression of T2DM. Results are explored and presented for three main domains of experience for the participants: first, food shopping and decision-making; second, diet choice and lifestyle; and third, the interface with health services. For each of these the culture was found to be of paramount importance. The implications of the findings are presented in relation to the importance of culturally appropriate advice; culturally sensitive service provision; and the significance of household composition in managing the illness, especially for people with T2DM who have young children living at home.

The purpose of this thesis was to aid in the development of a web-based physical activity intervention for people with type 2 diabetes living in remote and rural areas. Chapter 1 introduces the research area, the design of the thesis and the key research questions. The thesis is then made up of 5 key studies. Study one, a systematic review of the literature was conducted and reported in chapter 2. This review identified the technologies that have previously been used to promote physical activity in type 2 diabetes, it identified the methodological quality of each included technology and the key components for effective change. Web based technology was the most commonly used and the most effective in increasing physical activity using components such as goal setting and physical activity trackers. These results informed study 2 (chapter 3) which explored patient and health professional's views on diabetes, physical activity and use of the internet. The need for clear information was identified with regard to diabetes as well as the call for accurate physical activity advice in relation to diabetes for both patients and health professionals. Study 3 (chapter 4) explored key information and components for an effective website. Included features were the need for a personalised approach; detailed advice on how the body responds to physical activity; a physical activity tracker and goal setting. The need for a 'virtual trainer' for support, advice and help with goal setting and interactive maps showing physical activity opportunities were all deemed important. The fourth study, chapter 5 described the design of the website and its features as well as the protocol for a six month pilot randomised controlled trial to examine the effectiveness of the development website, with and without interactive design elements. The final study in this thesis (chapter 6), describes the physical activity, physiological and biochemical results from a randomised controlled trial to test the effectiveness of the website and its features. The final chapter summarises the findings in response to the research questions and the future recommendations based on the outcomes.

This study is about young people (age 11-16) with diabetes. Based on fieldwork in a paediatric diabetes centre in Scotland, it describes the ways diabetes is lived and done by young people, their health carers and insulin pumps. This enactment is contrasted with other ways of doing diabetes, as observed on short fieldwork trips to paediatric centres in Brussels, Gothenburg and Boston. I explore the dynamics of diabetes care on two levels. I consider the interaction between health carers and patients. Comparative data from various paediatric centres make apparent how culturally and socially informed approaches towards adolescence, health and illness shape both care practices and patients' experiences, resulting in different medical outcomes. Concretely in the Scottish centre, a non-hierarchical holistic care approach by health carers emphasizing quality of life over health, informs the young people's perspective on diabetes. Being a free adolescent takes priority over managing diabetes, with the results of ill health and possible future complications. The existing dynamics in this care framework change as a third actor enters the scene: the insulin pump, a pager-sized technological device continuously attached to the body. I explore the balancing act between young people and their pumps. As the adolescents actively engage with their pumps not to search for better health but rather to pursue a better quality of life, the guiding question becomes: how can a technological device for insulin injection double as a tool towards a desired identity and a different illness? This work then, can be read as a concrete case study of how a uniform technological device is embedded and used in a specific cultural and social context. It can also be read as an argument for a re-orientation of paediatric diabetes care in the Scottish centre: care centred on collaboration and inclusion rather than focused on merely containing underlying conflict (between adults and adolescents, diabetes and life, health and quality of life). Centres in Brussels, Gothenburg and Boston, and the insulin pump concretely, show how collaboration can lead to good health and quality of life. To leave us to wonder: is 'doing diabetes differently' synonymous with 'doing a different diabetes'?