Organ transplantation is considered the optimal treatment for those in kidney failure, yet there is a growing gap between the global demand for transplantable organs and their supply. Transplant medicine has largely concentrated upon solving this problem by securing the willingness of the public to donate their organs after death. In the UK context, attention has been trained upon black and minority ethnic (‘BME’) groups, who make up 28% of the kidney transplant waiting list, yet just 4% of organ donors. Since transplant medicine has traditionally favoured sharing organs between similar ethnic groups, ‘BME’ patients have a greatly reduced chance of receiving a transplant, despite their higher levels of need. Searching for ways to solve this problem, policy and research responses have focused upon understanding the ‘cultural’ barriers which ‘BME’ ‘communities’ present for organ donation, with subsequent interventions aimed at promoting organ donation to these groups. In so doing, minority ethnic groups have been positioned as the cause of transplant inequalities, and handed responsibility for solving an issue originally created within the practices of transplant medicine itself. This study aims to resituate this ‘problem’ by focusing upon the institutional organ donation encounter: where potential donors are decided upon and families are requested to donate their relative’s organs. A multi-sited ethnographic approach was taken to examine the work involved in organ donation in two acute hospital Trusts in the North of England, and wider ‘community’ domains, such as religious temples. Narrative and observational methods were used to understand the experiences of Intensive Care staff and donation nurses involved in requesting donation from minority ethnic families, and those connected to the ‘problem’, such as religious leaders and minority ethnic transplant recipients. Findings reveal (‘BME’) organ donation to be an embedded, negotiated practice, which goes far beyond the willingness, or reluctance, of an individual to donate their organs after death. Instead, this study demonstrates that donation is dependent upon the practices of health professionals, who make decisions on the suitability of dead and dying patients for donation. Moreover, it shows how donation decisions are produced in the negotiations between families and health professionals over the medical diagnosis of death; in the discussions of the immediate and extended family of the potential donor; and by the ability of donation nurse to secure a family’s consent for donation. This study therefore illustrates how the ‘problem’ of ethnicity in organ donation is far from an isolated matter, created as a result of the ‘culture’ of ‘BME’ populations. Instead, it argues that the categories of the ‘BME organ donor’ and the ‘BME donor family’ – as problematic for donation – are maintained and reproduced within the very processes which make organ donation possible.

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Background: There is evidence that diets and active lifestyle that allows adequate body weight contribute to breast cancer prevention. It is important to keep the evidence base updated to inform lifestyle recommendations and provide useful guidance. Methods: As part of the work for the World Cancer Research Fund (WCRF) International Continuous Update Project, the accumulated evidence from cohort studies and randomised controlled trials on energy balance-related factors (total energy intake, physical activity and adiposity) and risk of female breast cancer development and mortality after breast cancer, was systematically reviewed and meta-analysed. The evidence was graded (convincing, probable, limited) and compared with the conclusions published in the 2007 WCRF Second Expert Report. Results: Overall, 230 publications were meta-analysed. Higher body fatness, as indicated by body mass index (BMI), and adult weight gain, convincingly increased (12% per 5 kg/m2 and 7% per 5 kg, respectively); and recreational and vigorous physical activity probably reduced (12% and 10% for high vs low levels) postmenopausal breast cancer risk. Evidence on abdominal and gluteofemoral fatness (waist and hip circumferences, waist-hip-ratio) supports these findings. As reported previously, BMI was inversely associated with premenopausal breast cancer risk. Physical activity remains graded limited suggestive, but new findings on vigorous physical activity suggested probable protection (21% for high vs low levels) against breast cancer in premenopausal women. Evidence from studies on breast cancer survivors was limited, but suggested that women with normal body weight and with higher levels of physical activity may have the most favourable survival after breast cancer. Conclusion: The new accumulated evidence is consistent with the previous WCRF conclusions, and supports the recommendations for women to aim to have normal body weight (BMI 18.5-24.9 kg/m2) and be physically active (≥ 30 minutes/day moderate-vigorous activity), and to prevent gain in weight and waist circumference. Breast cancer survivors may potentially benefit by following these recommendations after cancer treatment.

The judicial system calls upon expert witnesses to testify in court when complex or specialized knowledge, beyond that of the lay person, is needed to interpret the evidence. Expert witnesses explain the meaning of the evidence and can express their opinion of its significance within the context of the circumstances of a given case. In a jury trial, it is the responsibility of the jury to listen to, assimilate, comprehend and to place the appropriate weight on the expert testimony in their final decision making. Knowledge of how juries comprehend forensic science evidence and how this type of testimony influences decision-making is sparse. The United States National Academy of Science report, “Strengthening Forensic Science in the United States: A Path Forward” (National Research Council, 2009) called upon the greater forensic science community to address weaknesses in the forensic science disciplines. One of the weaknesses highlighted was a lack of research into how juries use and comprehend forensic evidence. This study aimed to investigate the perceptions jurors have of expert witness testimony, delivered as oral evidence, by prosecution forensic scientists in homicide cases in the United States. Data was gathered from juries after they had completed jury duty in one of nine homicide cases through both questionnaire (n=29) and direct one to one interviews (n=22). How jurors determined the credibility of an expert witness and their views of the reliability of evidence presented to them by the witnesses they were exposed to were explored. The importance of forensic evidence in the jury decision making process and the tensions between the expertise and experience of the witness were also explored together with jurors’ view of technology and their understanding of the science presented. The role of the use of narrative in evidence was explored in particular through the use of demonstrative aids to explain the scientific evidence. Jurors described a deeper understanding as a result of such testimony. Jurors also suggested that the expert witness’s education and years of experience were move favored over certification and laboratory accreditation and the credibility of the witness was reported to be a key factor in the juror’s acceptance that the evidence presented was reliable. The results of this study underpin the importance of the role of the judge as a gate keeper to ensure only valid and reliable scientific evidence is admitted and presented to the jury in court. This work has also exposed the degree to which jurors evaluate the reliability of forensic science evidence based on the credibility of the expert witness.

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The aim of this thesis is to document and analyse the practices and experiences of poor and uninsured patients and their families living with Chronic Kidney Disease (CKD) and using Continuous Ambulatory Peritoneal Dialysis (CAPD) in Mexico, tracing them throughout multiple contexts in the process. This study draws on a critical and interpretive social science methodology, one that takes into account the social, political, cultural, and experiential dimensions of a condition and treatment that are often regarded as exclusive to the biomedical domain. I carried out ethnographic fieldwork in Jalisco, Mexico, from September 2012 to May 2013, during which I conducted in-depth interviews with patients, family members, healthcare professionals, and charitable organisations’ staff, and undertook ethnographic observations in domestic, hospital, and community settings. The ethnographic perspective adopted in this study allowed me to provide a richer account of the unequal, hierarchical, and historically rooted social relationships that underpin interactions between patients and the health professionals who represent and control access to the health system. Focusing on the socio-material conditions within which the problem is situated, the study starts off by following the trajectories of uninsured patients from their diagnosis to treatment, and the work that they are required to undertake throughout. At a public hospital for the uninsured, patients have a catheter inserted in their abdomens and they are put on peritoneal dialysis, the mainstay therapy for CKD patients in Mexico. They have to go through an admission process, which takes the form of a rite of passage, in which they are drilled in new body techniques, a part of their homes is turned into a para-clinical space, and they are transformed into productive CAPD patients to whom peritoneal dialysis can be outsourced in the home. Ultimately, this process aims to create a nexus between the body, the therapy, and the clinic. Patients and families do, however, modify, accommodate and thus domesticate CAPD by the constant practice of the therapy, although complications of the disease and therapy occur all throughout their trajectories, sometimes with fatal consequences. In the absence of proper public healthcare coverage for CKD and CAPD, a biosocial community has emerged around CKD and its therapies, characterised by exchange practices among its members, operating according to various quid pro quo logics, which I call the informal economy of renal replacement therapies. However, renal biosociality and the informal economy that arises from it cannot provide all the support uninsured patients need. I conclude that, while considered a global health concern, to fully understand the social and political implications of CKD and its therapies we need to adopt an ethnographic perspective that traces the practices of patients and families through different sites of care – the hospital, the home and the community. I argue that CAPD is a therapy situated at the margins of social welfare, which makes patients and their families directly responsible for its success and failures, a process which imposes substantial long-term financial and social costs on those already in desperate need. Although collective responses have emerged through the local biosocial community and its informal economy, those responses, I argue, are just another consequence of the problematic social context within which CKD and CAPD are embedded.

Introduction: Gastrointestinal (GI) infections are a significant burden both to the NHS and to society; affecting around a quarter of the UK population each year at an estimated cost of £1.5 billion. Socioeconomic inequalities in health are a serious problem and reducing such inequalities is high on the public health agenda in this country. Many infections are socially patterned but the role of socioeconomic inequalities in the risk of and exposure to GI infections is unclear, with published studies providing conflicting results. This thesis aims to investigate whether risk of or exposure to GI infections in the UK is socially patterned and if so, which sectors of society experience a greater burden of infection and through what mechanisms. Methods: I undertook novel analyses of existing UK-based high-quality and comprehensive secondary data on GI infections to explore the relationship between GI infections and socioeconomic status (SES) using a variety of analytical techniques. Study 1 explores the role of SES in risk of GI infections in high income countries through a systematic review and meta-analysis of 102 published studies using random- and fixed-effects meta-analysis and random-effects meta-regression. Study 2 assesses the association between SES and GI infections in a community cohort of 6,836 participants, using a Cox proportional hazards survival analysis approach. Study 3 presents results from an observational study utilising two NHS telephone-based services to explore the role of SES amongst individuals accessing remote health advice. Finally, Study 4 presents results of a case-study of a severe GI infection, Shiga toxin-producing Escherichia coli (STEC), to investigate socioeconomic patterning of risk factors for infection and to explore the role of demographic and socioeconomic factors in progression from STEC to a severe outcome, Haemolytic Uraemic Syndrome (HUS) in a separate cohort of paediatric HUS cases. Results: In high income countries, disadvantaged children but not adults had a significantly higher risk of GI infection compared to less disadvantaged children. In England, odds of calls to NHS helplines about GI infection symptoms in disadvantaged children and adults were significantly higher compared to their less disadvantaged counterparts. Disadvantaged adults were found to have lower risk of GI infections in the community cohort and both children and adults were less likely to be reported as having STEC infection or developing HUS. Overall, the results provide strong evidence to suggest that risk of GI infection differs by SES across the life course, with disadvantaged children at highest risk of GI infections. Conclusions: Disadvantaged children are at greater risk of GI infections compared to their more advantaged counterparts in the UK. The relationship between deprivation and risk of GI infection in adults is less clear. This thesis found that increased risk may relate to differential exposure, vulnerability or healthcare-seeking behaviours, including symptom recognition, across socioeconomic groups. This work has provided further insight into relationship between SES and GI infections and sets the direction for policies to reduce inequalities in GI illness in children and for more focussed research to deepen the understanding of the relationship particularly between SES and GI infection in adults.

Background: Gastrointestinal (GI) infections are very common and are associated with numerous adverse consequences for the individual, healthcare sector and economy as a whole. Relatively little is known about whether the consequences of having a GI infection are experienced by all members of society equally or whether certain groups are disproportionately affected. Some evidence suggests those of lower socioeconomic status (SES) are more likely to present to healthcare services with GI infections. This may reflect greater need amongst more disadvantaged groups, either due to increased risk of infection or disease severity. This thesis endeavours to expand current understanding, by comparing inequalities in the incidence of infection amongst cases occurring in the community and those presenting to healthcare services. In addition, it explores the extent of inequalities in disease severity, sickness absence and hospitalisation outcomes due to GI infections. Methods: The framework of this thesis is based on theoretical knowledge of the mechanisms by which social stratification influences health outcomes. Three studies are presented. I begin by conducting a systematic literature review to examine inequalities in the risk of symptomatic GI infections in high income countries, using studies that have identified cases via healthcare records, laboratory notifications and population-based surveys. Narrative and meta-analytic methods are used to synthesise evidence and explore sources of statistical heterogeneity. I also analyse data collected in the UK-based Second Study of Infectious Intestinal Disease in the Community (IID2 study) to examine inequalities in self-reported symptom severity and sickness absence, amongst individuals with infectious intestinal disease (IID) aged > 5 years. Regression modeling is used to investigate inequalities in these outcomes, whilst exploring the impact of several covariates such as age, sex, ethnicity, urban/rural residency and recent foreign travel. Finally, I perform an ecological analysis using routinely collected Hospital Episode Statistics data, to evaluate inequalities in emergency hospital admissions for IID and the duration of these admissions, across England. Stratified analyses for children and adults are performed, and the effects of several neighbourhood-level characteristics on inequalities in admissions are assessed. Results: Firstly, the systematic literature review identified age as a statistically significant modifier of the association between SES and the risk of symptomatic GI infections. Children (aged < 18 years) of lower SES, but not adults, had a greater risk of infection compared to their more affluent counterparts. Lower SES was also associated with higher risk of infection amongst studies that identified cases via hospitals, most of which analysed children only. Secondly, analysis of the IID2 study revealed that IID cases aged >5 years, of lower SES, were more likely to experience severe symptoms and be absent from work or school. The association between SES and sickness absence was largely explained statistically by greater symptom severity amongst the more disadvantaged cases. Thirdly, in English neighbourhoods, increasing deprivation was associated with increasing emergency hospital admission rates and admission duration for IID, for both adults and children. The social gradient in admission rates was partly explained statistically by geographical factors and the higher prevalence of long-term health problems in the more deprived neighbourhoods. Conclusions: Important consequences of GI infections such as sickness absence, disease severity and emergency hospitalisation incur heavy burdens for individuals and societies. Evidence from this thesis suggests these adverse outcomes disproportionately affect socioeconomically disadvantaged groups. With this in mind, due consideration should be afforded to policies that address inequalities in the consequences of being ill with a GI infection, as well as current UK policies designed to reduce the risk of acquiring an infection.