The introduction of human papillomavirus (HPV) vaccination has caused some parents to report concern that their daughters may change their sexual behaviour following vaccination. This concern consistently relates to vaccination acceptance, but had not been investigated in detail. Accordingly, five studies addressed the thesis objective: to explore parents’ concern about adolescent sexual behaviour following HPV vaccination in the context of the UK immunisation programme and to examine whether such concerns were justifiable. The first study examined discussions of risky sexual behaviour and HPV vaccination in news articles published over five years in British newspapers. The second study investigated mothers’ concern about their daughters engaging in risky sexual behaviour after vaccination by questioning a sample of mothers. The third study explored whether adolescents would interpret vaccination consent from parents as carte blanche approval for sexual activity, by surveying 162 girls. The fourth study prospectively investigated the impact of HPV vaccination and a fifth study compared differences between vaccinated girls and girls who had not been offered the vaccine. Concern about the impact of HPV vaccination on sexual behaviour was raised and countered in the media. A minority of mothers were apprehensive about girls’ sexual behaviour following vaccination, however these concerns did not relate to vaccine acceptance. Before the vaccination programme was introduced, some adolescents would infer implicit consent to sexual activity if their parents were to consent to vaccination but most would also take positive messages. Once the HPV immunisation programme was underway, girls’ sexual behaviour did not become more negative following vaccination, despite perceptions of risk lowering. Parents’ concerns may have resulted in reluctance to discuss sex with their daughters in the context of HPV vaccination so that implicit messages of approval for sexual activity are not conveyed. Risk perceptions were pertinent in HPV vaccination acceptability and when exploring behaviour change. These findings may help reduce resistance to HPV vaccination. Implications for theory and practice are discussed.

As cancer outcomes improve there is growing interest in the role of health behaviours in enhancing health and wellbeing in cancer survivors. However, there have been few studies of health behaviours in cancer survivors in the UK. Study 1 used data from the English Longitudinal Study of Ageing to conduct the first investigation of health behaviours in an English sample of cancer survivors compared with the general population of older adults. Rates of current smoking and alcohol consumption were comparable, however cancer survivors were more likely to be ex-smokers and less likely to be physically active than adults without cancer. Study 2 examined health behaviours in a large sample of colorectal cancer (CRC) survivors. The results broadly confirmed suboptimal health behaviours in this population. Study 3 also demonstrated that better health behaviours were associated with better quality of life. In this same sample, believing that lifestyle factors may have contributed to cancer occurrence was associated with improvement in health behaviours following diagnosis (study 4). Receiving advice on secondary prevention from a clinician was also associated with an increased chance of health behaviour change (study 5). In addition the perceived barriers of age and mobility were associated with participating in less physical activity (study 6). Evidence that healthful behaviours improve quality of life, coupled with their preventive effect on second primary cancers and other diseases for which cancer survivors are at an increased risk, suggest cancer survivors are an important population for health promotion. However, evidence for effective lifestyle interventions among CRC survivors is scarce. Study 7 therefore examined the feasibility and acceptability of a lifestyle change intervention in a small pilot sample of CRC survivors (n = 11). The intervention was feasible and acceptable and associated with positive health behaviour change. This research has contributed to the understanding of health behaviours among cancer survivors in the UK, and provides insight into how to encourage health behaviour change in this vulnerable population.

Interest has grown in the concept of using Nicotine Replacement Therapy (NRT) during attempts at smoking reduction (SR) and temporary abstinence (TA). This is partially due to data from clinical trials showing that the concurrent use of NRT and cigarettes can result in significant reductions in cigarette consumption, and increases the propensity of smokers to quit. However, it is not clear whether similar findings will emerge outside of that structured setting. Data are also limited on the acceptability among smokers of using NRT in these ways, and whether healthcare professionals will be opposed to offering such a strategy. This thesis aimed to address these issues using three methodologies: population-based surveys of English smokers; in-depth telephone interviews with smokers; and surveys of stop smoking practitioners and managers. More than 1/10th of smokers in England were found to be using NRT for SR and/or TA. Prevalence did not appear to have changed since 2007. The use of NRT for SR and/or TA was associated with greater probability of reporting a quit attempt and of subsequently stopping smoking, but any reduction in concurrent cigarette consumption was very small. Nicotine intake was similar whether smokers were or were not using NRT whilst smoking. This suggests that smokers may have instead been compensating for the additional nicotine attained from NRT by adapting the way they smoked their cigarettes. The interview study indicated a number of factors which may account for the lack of reductions in cigarette intake, including smokers’ failure to set specific goals. A significant proportion of those working in stop smoking services did not agree with offering NRT for SR. Overall, the research reported in this thesis supports the idea that the use of NRT for SR and/or TA may promote cessation in the general population, but in itself is currently conferring little health benefit. Future research should examine the range of methods smokers use to reduce smoke exposure, and whether interventions which promote clear goal setting and monitoring of intake, such as through the use of expired carbon monoxide readings, can lead to effective SR.

Evidence of a relationship between maternal psychological distress and child externalising behaviour is strong. However, less is known about the pathways and contexts involved, or how these may differ by gender or family structure. This thesis aims to contribute to the understanding of this relationship by investigating potential lifecourse hypotheses, moderators and mediators. Methods: This thesis consists of a longitudinal analysis of the UK Millennium Cohort Study. Linear regression analyses are used to examine potential lifecourse effects in the relationship between maternal psychological distress at nine months and three years and externalising behaviour at five years. The pathways from socio-economic position via maternal psychological distress to child externalising behaviour, and from maternal psychological distress via parenting to child externalising behaviour, are examined using mediation analyses. The potential moderating role of gender, family structure, socio-economic position, emotional support, father-child relationship quality and mother-father relationship quality are investigated. Results: Gender differences in the association between maternal psychological distress at nine months and three years and child externalising behaviour at age five were found, with a stronger association in boys. Lifecourse effects of a sensitive period at three years in girls and a cumulative effect of maternal psychological distress on externalising behaviour at five years in boys and girls were found. Self-rated financial status operated through maternal psychological distress to influence child externalising behaviour, whereas maternal education and housing tenure were independently associated with child externalising behaviour. The quality of the mother-child relationship was the strongest mediator in the relationship, and for boys the relationship was weaker in the context of a good quality father-child relationship and mother-father relationship. Conclusions: The thesis adds to evidence of the longitudinal association between maternal psychological distress and child externalising behaviour in the early years. Gender differences were found for the association, including differences in lifecourse and family relationship effects.

Cognitive decline is the first outward sign of dementia and has a major public health impact on individuals and governments around the world. There is a well-established relationship between specific lifestyle behaviours and cognitive decline, but extremely limited research on the role of combined behaviours. The aim of this thesis was to examine the role of lifestyle behaviours (alcohol, smoking, physical activity and dietary choice) separately and in combination on cognitive functioning in midlife (age 43) and on 20-year cognitive decline from mid to later life using data from the MRC National Survey of Health and Development. Key findings were that high quality dietary choices made in midlife were associated with slower memory decline as compared to low quality dietary choices, and active levels of physical activity were associated with slower visual search speed decline compared to those who were inactive. Smoking was marginally associated with faster decline in visual search speed compared to non-smokers, but not with memory decline. Associations for these behaviours were independent of each other, as well as of a range of covariates. Cluster patterns of two and three healthy lifestyle behaviours showed a stronger positive association with verbal memory decline compared to no healthy lifestyle behaviours adopted in early midlife. These results provide further evidence of the effectiveness of healthy lifestyle behaviours adopted in early midlife. Public health interventions based on modifiable lifestyle behaviours represent high level priorities and should be regarded as an important line of defence against cognitive decline and dementia.

This thesis investigated drinking patterns in the Russian city of Novosibirsk, with a specific focus on hazardous drinking. It explored the relationship between hazardous drinking and social-economic characteristics, depressive symptoms and self-reported health. The study also provided an in-depth description of drinking patterns, consumption of ‘surrogate’ alcohol, and perceptions of the Russian drinking culture and the state’s alcohol policies. The research used a combination of quantitative and qualitative methods. First, it assessed alcohol consumption and drinking patterns using data from the HAPIEE (Health, Alcohol and Psychosocial factors In Eastern Europe) cohort. Second, a series of 44 semi-structured interviews were conducted with men and women sampled from the HAPIEE cohort. Third, 40 semi-structured interviews were conducted among clients of an alcohol treatment facility. These interviews were focused on hazardous drinking. The main findings were as follows. First, hazardous drinking was common among men, but rare among women (30% of men and 1% of women reported binge drinking, 19% of men and 1% of women reported problem drinking, and 9% of men and less than 1% of women reported more than two negative consequences of drinking). Second, hazardous drinking was associated with lower education (e.g. men with secondary education were 1.9 times more likely to binge drink than men with university education), unemployment, poor health (men and women rating their health as good were more likely to binge than people with poor health), and with certain occupations (e.g. drivers or construction workers were likely to report binge drinking). Third, high accessibility of alcohol and a need to relieve withdrawal symptoms were common reasons for surrogate consumption given in interviews by participants from alcohol treatment facility. Finally, the Russian drinking culture was perceived as characterised by heavy drinking and strongly influenced by the interplay of individual and structural factors.

Background: Dental caries is a significant public health problem in many countries. There is equivocal evidence of an association between caries and children's anthropometric outcomes. On the other hand, some studies from developed countries showed that dental treatment of severe caries accelerated weight gain in low weight children. Objectives: 1) To assess the relationship between caries and children’s anthropometric and health related outcomes in a high caries population. 2) To evaluate the effect of treatment of severe caries on children’s anthropometric and health related outcomes. Methods: Two studies were conducted. Study I was a cross sectional survey of 417 school children between the ages of 5-8-year (42.0% males and 58.0% females). Dental and anthropometric examinations were performed using WHO standardised procedures. Study II was a randomised controlled trial of 86 children from Study I who satisfied certain selection criteria. CONSORT guidelines were followed. Dental treatment was provided to the test group and all selected outcomes were measured 6-month post-intervention for test and control groups. ANCOVA and regression modelling were used to analyse data. Results: Study I: Children with higher levels of caries had significantly lower anthropometric outcomes and higher dental impacts than those with lower caries levels. Study II: There were insignificant improvements in anthropometric outcomes between test and control groups after treatment of caries. Children in test group reported to have significantly better health related outcomes than controls. Conclusions: The negative linear trend which was detected in Study I between caries and all anthropometric outcomes implies that caries level may be a risk factor for poor growth in children. In Study II, although dental treatment did not significantly improve the mean weight and height Z-scores, treated children had lower levels of dental pain, sepsis and dissatisfaction with teeth and smiling. Interestingly, a significant increase in appetite was identified in test group compared to controls.

The aim of this thesis is to test one of the assumptions of the behavioural susceptibility model of weight that inherited differences in appetite are already present in infancy, and that shared genetic effects are contributing to associations with weight from very early on in life. Data from a British birth cohort of 2402 families with infant twins (Gemini) were used to explore associations between appetite and weight, assess genetic influences on appetite, and examine shared genetic pathways underlying appetite and weight. Study 1 describes the development of a parent-report psychometric measure of infant appetite during the period of exclusive milk-feeding. Four underlying dimensions were identified – ‘enjoyment of food’ (EF), ‘food responsiveness’ (FR), ‘slowness in eating’ (SE), ‘satiety responsiveness’ (SR), along with a single general item that correlated with all traits (‘appetite size’, AS). Study 2 established that all traits were significantly associated with higher weight at 3 months and greater increase in weight from birth to 3 months. Study 3 used the twin design to demonstrate moderate to high heritability for all traits (EF: 83%; FR: 59%; SE: 84%; SR: 72%; AS: 77%). Study 4 showed common genetic influence on EF, SE and SR, which explained 78% of the covariation between them, and Study 5 demonstrated common genetic influence between the two satiety-related traits (SE and SR) and weight. Finally, Study 6 was an in-depth exploration of a single case of an infant with extreme appetitive avidity whose parents were forced to exert drastic control measures to avoid severe overeating. This thesis provides evidence for a behavioural susceptibility model of weight because inherited individual differences in appetite are present from early infancy, are phenotypically associated with weight, and share common genetic pathways with weight. Inherited differential susceptibility to the obesogenic environment may be contributing to variability in childhood adiposity.

Conditional cash transfer schemes (CCTS) are increasingly popular interventions aiming to improve the welfare of the worst off: Families receive regular cash as long as they comply with behavioral conditions concerning uptake of preventive healthcare and schooling. Literature Review, however, finds that associated health impacts are often small or inconsistent and are occasionally adverse. The aim of this thesis is to advance understanding of the impact of CCTS on health and on health equity. It does this by examining the effect of Familias, the Colombian scheme, on outcomes little discussed in the literature, namely rates of obesity in women and in children (an unintended outcome), and women’s healthcare knowledge. It sets findings within a conceptual framework that sees health as being co-produced between individuals and society. Co-production requires investment in individuals’ human capital, material resources and creation of fairer socioeconomic environments, somewhat resembling the underpinning philosophy and structure of CCTS. Multiple regression on a range of individual, household and community level covariates using an intention-to-treat protocol on prospectively collected data with matched controls finds that Familias is associated with increased odds of obesity in women (O.R.=1.41, 95% C.I. 1.09, 1.82; p=0.01) and odds of overweight or obesity in girls aged 2-7 at baseline (O.R.=2.13, 95% C.I. 1.23, 3.69; p<0.01). Furthermore, Familias fails to improve healthcare knowledge, a marker of human capital, in women despite being a core objective of the programme (logit coefficient= -0.20, 95% C.I. -0.41, 0.01; p=0.06). Given these negative findings, a number of policy recommendations are made emphasising the importance of social determinants of health: balancing imposition of behavioural requirements with the realisation of rights to high-quality public services, considering the potential for universalising aspects of the schemes and exploring a greater role for the health sector in CCTS design, operation and evaluation.

Tooth enamel is formed incrementally during specific age periods. Enamel formation is sensitive to changes in its environment and embodies significant changes into the structure of developing enamel that manifest as clinically detectable permanent “defects”. These features make enamel a unique tissue which can aid researchers to obtain or validate existing relevant data on health-related events during gestation and early childhood. Using enamel as a marker for epidemiological studies requires robust methods for recording the time when adverse life event occur by linking the location of defects with the age of enamel formation. The main objectives of thesis were to: 1.determine the best method of assessing enamel defects, 2.develop an accurate method to collect data retrospectively on life events in early childhood, and 3.test whether developmental defects of enamel of permanent incisors accurately indicate adverse events in early childhood. Methods: Age range of stages of enamel formation was calculated from published data. A life-grid method was developed for collecting past childhood life events by questioning parents. Field work was in Shiraz, Iran. Pilot study revealed suitability of methods. A prevalence study (Study I) was conducted on a representative sample of 335 8-11-year-old schoolchildren. Main objectives were addressed in Study II when detailed investigations were carried out on selected subjects from prevalence study. Three methods for detecting defects were compared and then findings were related to life events recorded on the life-grid. Results: Digital photographic method was better than clinical examination and replication methods for detecting DDEs (N=90). The events recorded in early childhood life-grid method were almost identical to recorded health documents (N=30). Final results showed that presence, type, and location of enamel DDEs in permanent incisors can serve as reliable markers of occurrence, nature, timing, and in some degrees severity of adverse events in early childhood (N=87).