Malawi lost a significant proportion of its most experienced and qualified nurses to international migration between 2000 and 2005. The lure of overseas life and poor conditions of service at home caused an unprecedented wave of migration. This thesis is about the experiences and motivations of nurses who left Malawi, and of those who stayed behind. Using a qualitative biographical method to examine their experiences along a timeline of key life events, I develop a comprehensive picture of nurse migration. The findings show that nurses’ decisions and experiences have been shaped by demographic and political shifts and by a strong culture of family. Population growth has increased competition for higher education and caused a palpable shift in motives for becoming a nurse. Prospective students now see nurse training as a means to a guaranteed career, or to a marketable qualification which can lead to alternative employment. Working conditions have not improved despite numerous government initiatives, and nurses are still leaving for greener pastures. Many now move to Malawian Non-Governmental Organisations, but before 2005 nurses were able to take advantage of the United Kingdom’s (UK) active recruitment strategy. Most were motivated by the prospect of educational opportunities and the financial survival of their families, who often encouraged them because of the status accorded to migration. Whilst nurses in the UK were pleased with their lifestyle improvements, they found it challenging to integrate into society and the workplace. Many also found it difficult to achieve their educational and financial goals, and the stigma of returning to Malawi empty-handed led them to extend their stay. The enduring high status of migration and its unparalleled benefits mean that the desire to migrate is still strong amongst nurses, and many believe that the recent decline in migration is attributable only to tighter UK immigration restrictions.

This Ph.D. aims to investigate how women’s groups, aimed at reducing maternal and neonatal mortality in Malawi, affect quality of life. Quality of life was measured in 534 women, com- prising 179 women’s group members in 36 different communities, 174 non-members in the same communities and 181 women in 36 control communities. The WHOQoL-BREF, a 26-item ques- tionnaire developed by the WHO to measure quality of life from a broad perspective, was used. The WHOQoL-BREF has the following six domains: overall quality of life, overall health, phys- ical, psychological, social relationships and environment; and is compatible with the capability approach of economic evaluation. It was first translated into Chichewa, the main local lan- guage of Malawi, and validated for future use as part of this Ph.D. This Ph.D. also makes methodological contributions via adaptation of Discrete Choice Experiment best-worst scaling exercises for use in poor rural communities; and adapting Contingent Valuation techniques using time and maize flour as alternative payment methods to money. The choice experiments were employed to provide relative preference-weights to each WHOQoL-BREF attribute as an altern- ative to respondents indicating how important each attribute is on a scale not requiring them to trade-off attributes against each other. The results of the choice experiments were modelled using the newly-developed Sequential Best-Worst Multinomial Logit Model. The Contingent Valuation study contributes empirical data on whether, how much, and why the women in the three study arms value the women’s group intervention. This Ph.D. also explores philosoph- ical, political, psychological and economic literature surrounding measurement of quality of life, decision-making, economic evaluation and allocative efficiency. It hopes to contribute toward valuation of women’s groups in Malawi, and, more broadly, toward methods of cost-benefit ana- lysis of health interventions in low-income countries via the consideration of non-health costs and benefits.

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Physical activity (PA) is a determinant of health and a modifiable lifestyle factor; with an inverse relationship existing between PA and mortality. However, levels of PA remain low, particularly among those who are socio-economically disadvantaged (SED). Reasons for this are not clear. Therefore, this thesis aims to address this gap in knowledge and elucidate effective methods of PA intervention for the SED. The thesis includes four studies, The first was a systematic review of effectiveness of PA interventions implemented in SED communities. Results showed that multi-component adult group based interventions with theoretical frameworks are most effective. The second, using qualitative interviews, explored the development of PA interventions for the SED: evidence suggested better linkage and communication between all involved in interventions. The third analysed data from a household survey. Evidence highlighted that age, gender and employment status are associated with low levels of PA. The fourth study used accelerometers to assess the validity and reliability of two PA questionnaires and found that the Global Physical Activity Questionnaire (GPAQ) may be used to estimate and monitor levels of PA and assess the effectiveness of interventions on a community or population level. The Sport And Physical Activity Survey (SAPAS) maybe used to monitor trends in PA and to measure the extent of change at a community or population level. Thus in conclusion, PA interventions should be multi-factorial, underpinned by a theoretical framework of behaviour change, designed and implemented by a multi-disciplinary team and evaluated with care. Future research should aim to use standardised, valid and reliable measurement tools in its evaluation. To improve the effectiveness of interventions, practitioners should work in multi-sectoral teams and in partnership with researchers to obtain up to date research and evidence.

Aims: to investigate: 1) whether the magnitude of change in sedentary time and physical activity during adolescence varies in different time contexts, 2) whether the estimate of change in sedentary time differs according to the measurement instrument used and 3) whether self-reported sedentary activities are associated with sedentary time. Methods: In Study 1, changes in sedentary time and physical activity between the ages of 12 and 15 years were assessed using data from the PEACH project. Sedentary time and physical activity were measured using ActiGraph accelerometers (GT1M). To determine if the magnitude of change differed for during-school, after-school and at weekends random effects mixed models were used. For studies 2 and 3, 124 adolescents wore an activPAL and an ActiGraph (GT3X) accelerometer for 5 days. For Study 2, direct comparisons between the activP AL and the ActiGraph estimates of sedentary time were made using Bland-Altman plots. For Study 3, differences in activPAL-estimated sedentary time between younger and older adolescence during-school, after-school and at weekends were assessed and the association between objectively measured sedentary time and self-reported sedentary activities were assessed. Parallel analyses were carried out using ActiGraph-estimated sedentary time. Results: The results of Study 1 showed that the proportion of time spent sedentary increased between the ages o~ 12 and 15 years and that this increase occurred during-school, afterschool and at weekends (+8.2%, (95% CI = 7.4 to 9.1), +7.0%, (95% CI = 5.9 to 817), +6.9%, (95% CI = 5.1 to 8.6), respectively) and a concurrent decrease was shown in light intensity physical activity (-7.6% (-8.3 to -7.0), -7.0% (95% CI=-7.7 to -6.3) -6.7 (-7.8 to -5.7) respectively) and minimal changes in moderate to vigorous physical activity. There was no evidence that the magnitude of these changes differed between time windows. Study 2 showed that ActiGraph estimated sedentary time was 6.9 minutes an hour higher than the activPAL estimated sedentary time and there was a large degree of variability in the agreement (95% LoA=-2.3 to 16.2). Moreover, in Study 3 differential results were shown in the association between objectively measured sedentary time and self-reported sedentary activities and in the cross-sectional differences in sedentary time between younger and older adolescents depending on which monitor was used to measure sedentary time. For example, the activPAL found a difference of +11.4%,+11.6% and +3.0% in for during-school after-school and weekends whereas the differences in ActiGraph estimated sedentary time was +6.2%, +5.1 % and +4.7% respectively. Conclusions: Interventions to attenuate the increase in sedentary time between the ages of 12 and 15 years are required during-school, afterschool and possibly at weekends. Moreover, there are differences in the activPAL and ActiGraph estimates of sedentary time. If a more precise estimate of sedentary time is required, it may be that the activPAL compared to the ActiGraph may be the more appropriate measure to use.

A systematic review showed that the four most common health behaviours studied are smoking, drinking alcohol, diet and exercise. The Theory of Planned Behaviour (TPB) was adopted as a framework for investigating the use of HBA, and use of a methodology called Discriminant Content Validity enabled the validation of a direct estimation method of assessing TPB cognitions, which was then used in each of the following studies. A cross-sectional study with students at two British medical schools, of their intention to give HBA, demonstrated that TPB cognitions successfully predicted intention, as well as allowing comparison between the constructs.  Medical students in the early stages of their training had lower perceived behavioural control. An experimental study of the effect of manipulating two types of control on intention to give HBA found that higher actual control over a consultation situation increased intention and that higher personal control was also associated with higher intention. A longitudinal study of medical students during the first phase of their training showed that students displayed a pattern of polarisation, those who had initially negative beliefs became more negative over time, whilst those initially positive became more so. An observational study in a primary care setting (community pharmacy) provided more evidence for the success of the TPB in predicting HBA.  Both self-report and actual advice giving behaviour were predicted by TPB constructs. A range of different methodologies and settings have been utilised to demonstrate that the TPB has an important role in predicting whether HBA is given or  not, and further studies might utilise these findings to increase rates of HBA both directly and through medical education.

This thesis explores rejuvenation of eastern Great Basin Archaic period atlatl dart points within the contexts of artifact curation, variability, use-life, and type. By analysis of past rejuvenation experiments, a contemporary rejuvenation experiment, and dart point assemblages from Archaic period strata of four major eastern Great Basin caves, a system that quantifies rejuvenation signatures on atlatl dart points was developed. This system is proposed as Rejuvenation Signature Analysis (RSA). It is advanced that RSA can quantify the extent and kinds of rejuvenation that occur in a population of atlatl projectile points. If levels of rejuvenation can be quantified in atlatl dart point populations, then conclusions can be advanced concerning curation and the integrity of morphologically derived types from within these populations. Using morphology alone to determine projectile point types as temporal markers should be reconsidered. Using RSA analysis in practical applications to quantify rejuvenation in other dart point assemblages from both inside and outside the eastern Great Basin is also discussed.

Rationale: It is widely reported that young people engaged in promoting the health of their peers benefit from the experience and this has been used as a justification for recruiting young people into the role of peer health promoter (PHP). Empirical data, however, is lacking and little systematic research has been carried out to determine the extent to which young people benefit or otherwise from becoming PHPs. Aim: This thesis explores and tests the contention that peer health promoters (PHPs) benefit from the experience. Methods: A mixed method research design was adopted and the research was carried out in two phases. A multiple holistic case study was used to explore the nature of the peer work experience. The principal data collection method was unstructured interviews. PHPs (110) were interviewed in groups and individually and 16 coordinators were interviewed individually. This was followed by a longitudinal postal survey of PHPs and young people from the same school or youth centre, who had not elected to become PHPs. Uniquely coded questionnaires in individual envelopes were distributed via coordinators at the beginning, midway through and at the end of a project year. Baseline data was collected from 430 PHPs and 271 non-PHPs, interim data from 160 PHPs and 133 non-PHPs and from the 103 PHPs and 76 non-PHPs who returned the final questionnaire. Findings: For young people, becoming a PHP is empowering, health-promoting, educational, developmental, rewarding and enjoyable. Young people who have experienced disadvantage and who lack confidence and self-belief benefit most from the experience. For some young people the experience is life-changing. These benefits are predicated on PHPs‟ commitment to the role and the support they receive from each other and the coordinator. Conclusion: This thesis provides new insights into peer health promotion and its contribution to health promotion strategies and has implications for the future development of strategies aiming to promote the health and wellbeing of young people.

Background Better health is strongly associated with higher social position. The poorest in society suffer the shortest life expectancy and are disproportionately affected by chronic illness and disability. This group participates less in the physical activity that could benefit their health and are less likely to engage with physical activity interventions. Social marketing has shown promise as a means of improving engagement with health programmes, however its effectiveness at increasing physical activity levels has not been fully tested. This study aimed to test whether social marketing could be an effective approach to increasing recruitment and adherence to organised physical activity in a disadvantaged neighbourhood. Method This study took a mixed methods approach. The formative research used a combination of quantitative and qualitative research methods to assess provision and attendance at physical activity sessions and to research motivations, barriers and enablers for participation in physical activity. Mixed methods were also used to assess the effectiveness ofthe social marketing intervention and to evaluate the intervention process. Results The formative research found that many participants in activity sessions in the study area were not from that area; word of mouth was the most influential form of promotion; and adherence rates were higher amongst older adults. Practical barriers to physical activity were cost, access to childcare, lack of time and low awareness. In addition, a perception of a lack of social support, and low perceived confidence and competence was widespread, particularly amongst women. Key enablers to being active were high levels of social interaction, interest and enjoyment. Using a grounded approach, Self Determination Theory was found to be the most appropriate theory to provide structure to the social marketing intervention. The intervention showed that social marketing is an effective approach to recruiting low income participants into exercise sessions, maintaining excellent levels of attendance and reasonable levels of adherence. Conclusions This thesis indicates that social marketing is an effective approach to increasing the recruitment and adherence of a low income group into organised physical activity. However clearer definitions of recruitment and adherence are required to enable a clearer comparison with other approaches. It is important that social marketing campaigns are well designed and implemented and that promotional or communications campaigns are not wrongly labelled as social marketing. Overall this study suggests that providing a variety of activities, incorporating some dance based sessions, and providing high levels offun, enjoyment and socialising appear to be key elements to successful recruitment and adherence. Low session cost and a high profile promotional campaign substantially impact campaign success and have implications for how organised physical activity in low income neighbourhoods is funded.