Cholera is a diarrhoeal disease caused by the infection of the intestine with bacterium vibrio cholera. The diarrhoeal disease is a recurrent feature of Zimbabwe's post 1990s history. From 1993 to 2018, the country has experienced several cholera outbreaks in both rural and urban areas. The country's worst cholera outbreak occurred in 2008/2009 and resulted in over 4000 deaths. The dissertation analyses three global health actors' responses to persistent cholera outbreaks in Harare, the capital city of Zimbabwe. Building on previous scholarship of water, cholera and politics, the dissertation compares global health actors' responses to the 2008/2009 and September to November 2018 cholera outbreaks. The dissertation used the qualitative research method including analysis of existing academic literature, Zimbabwean national legislation, non-governmental organisation (NGO) publications and conference reports, news articles and Zimbabwean government policy documents. In-depth interviews with personnel from the World Health Organisation, United Nations Children's Fund, Médecins Sans Frontierès (Doctors without Borders) and the Harare City Council Health Department were conducted in Harare, Zimbabwe from June to July 2019. The dissertation demonstrates that the scope and speed of global health actors' emergency cholera interventions in Harare are shaped by Zimbabwe's political climate and the state of Harare's health, water and sanitation infrastructure.

Despite a growing body of studies on the relationship between housing and health, it is unclear whether and how (a) the housing cost burden deteriorates health and whose health it deteriorates, (b) housing assets interact with income in influencing one’s health, and (c) protective policy measures alleviate mortality risks predicted by housing cost burden. This thesis aims to reduce these knowledge gaps. First, in Chapter two, I synthesize prior literature that focused on the association between housing cost burden and health and discussed methodological issues. Also, the chapter proposes future research directions. Chapter three, co-authored with Dr. Michel Grignon, Dr. Marisa Young, and Dr. James R. Dunn, assesses the potential moderating effect of housing asset level on the link between income and mortality. Although housing assets and income are independently related to mortality risks, the value of housing assets did not significantly moderate the link between income and mortality. Income-related inequalities in mortality are observed among each group of housing asset level. Our findings offer insight into the importance of redistribution of resources that can reduce risks of premature mortality and achieve healthy aging. Chapter four documents that housing cost burden was significantly associated with preventable mortality, treatable mortality, and suicide during post-Global Financial crisis (2009-2017). Also, in countries with an increased level of social spending, higher levels of social housing stock, and rent control, the observed association was substantially attenuated. Taken together, the findings of the three chapters contribute to understandings about the link between housing and health by (a) synthesizing the prior literature and mechanisms, (b) estimating housing inequalities in health, and (c) highlighting the protective roles of social and housing policies that reduce health inequalities. / Thesis / Doctor of Philosophy (PhD) / This thesis aims to investigate housing inequalities in health and the roles of protective social and housing policies in reducing health inequalities. The second chapter, as a scoping review, synthesizes prior literature that estimates the association between housing cost burden and health, and explores potential mechanisms linking housing cost burden to health. Chapter three relies on one of the nationally representative linkage datasets in Canada in order to estimate the association between housing asset, income, and mortality in Canadian older adults. It reveals that the value of housing assets and income predicts mortality risks, but housing assets do not significantly change the link between income and mortality. The fourth chapter examines whether and how housing cost burden is associated with avoidable mortality in OECD countries. Also, the roles of preventive measures including social spending and housing policies are revisited. The thesis strengthens the rationale for identifying housing as one of the important social determinants of health.

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Yes / Restrictions implemented by the UK Government during the COVID-19 pandemic have served to worsen mental health outcomes, particularly amongst younger adults, women, those living with chronic health conditions, and parents of young children. Studies looking at the impact for ethnic minorities have reported inconsistent findings. This paper describes the mental health experiences of mothers from a large and highly ethnically diverse population during the pandemic, using secondary analysis of existing data from three COVID-19 research studies completed in Bradford and London (Tower Hamlets and Newham). A total of 2807 mothers participated in this study with 44% White British, 23% Asian/Asian British Pakistani, 8% Other White and 7% Asian/Asian British Bangladeshi s. We found that 28% of mothers experienced clinically important depressive symptoms and 21% anxiety symptoms during the pandemic. In unadjusted analyses, mothers from White Other, and Asian/Asian British Bangladeshi s had higher odds of experiencing symptoms, whilst mothers from Asian/Asian British Indian s were the least likely to experience symptoms. Once loneliness, social support and financial insecurity were controlled for, there were no statistically significant differences in depression and anxiety by ethnicity. Mental health problems experienced during the pandemic may have longer term consequences for public health. Policy and decision makers must have an understanding of the high risk of financial insecurity, loneliness and a lack of social support on mother’s mental health, and also recognise that some ethnic groups are far more likely to experience these issues and are, therefore, more vulnerable to poor mental health as a consequence. / This study was funded by The Health Foundation COVID-19 Award (2301201), with further contributions from a Wellcome Trust infrastructure grant (WT101597MA); a joint grant from the UK Medical Research Council (MRC) and UK Economic and Social Science Research Council (ESRC) (MR/N024391/1); the National Institute for Health Research under its Applied Research Collaboration Yorkshire and Humber (NIHR200166); ActEarly UK Prevention Research Partnership Consortium (MR/S037527/1); Better Start Bradford through The National Lottery Community Fund; and the British Heart Foundation (CS/16/4/32482). The research conducted in London was funded by UKRI-ESRC ES/V004891/1 (Tower Hamlets), and by London Borough of Newham Public Health. Heys was supported by the NIHR Great Ormond Street Hospital Biomedical Research Centre.

Yes / Pregnant British Pakistani women have disproportionately poorer health than the wider population. Bradford has a strong Pakistani presence and a wide range of public health problems including high levels of gestational diabetes, high obesity rates and a high infant mortality rate, which is highest for babies of Pakistani origin. For women to be healthy, we need to know what concerns they have about their health so they can be addressed appropriately. The aim of this study, therefore, was to explore the health concerns of pregnant British Pakistani women living in deprived areas. Methods Semi-structured qualitative interviews were conducted with 21 pregnant Pakistani women in a hospital setting. Data were analysed using thematic analysis. Results Pakistani women identified safety issues, barriers to undertaking physical activity in the areas where they live, concerns surrounding exercising during pregnancy and cultural and religious constraints that prevented them from engaging in physical activity. They reported issues around food, concerns around a lack of culturally appropriate diet information, the cost of unhealthy food locally, and the lack of healthy food options in their residences. Women were unsure on where to obtain health promotion information and reported a lack of access in obtaining that information. Language barriers in accessing health promotion information were further reported as a concern. Discussion Researchers, midwives, health providers, local authority and policy makers interested in improving the health of pregnant Pakistani women may use these findings to develop further research and interventions to improve the poor health of this population. / National Institute for Health Research (NIHR) under its Applied Research Collaboration (ARC) Yorkshire and Humber [NIHR200166]; UK Prevention Research Partnership (UKPRP) [MR/S037527/1], the NIHR Clinical Research Network; and NIHR ARC Yorkshire and Humber

Yes / Objectives: Longitudinal evidence documenting health conditions in spousal caregivers of people with dementia and whether these influence caregivers’ outcomes is scarce. This study explores type and number of health conditions over two years in caregivers of people with dementia and subgroups based on age, sex, education, hours of care, informant-rated functional ability, neuropsychiatric symptoms, cognition of the person with dementia, and length of diagnosis in the person with dementia. It also explores whether over time the number of health conditions is associated with caregivers’ stress, positive experiences of caregiving, and social networks Methods: Longitudinal data from the IDEAL (Improving the experience of Dementia and Enhancing Active Life) cohort were used. Participants comprised spousal caregivers (n = 977) of people with dementia. Self-reported health conditions using the Charlson Comorbidity Index, stress, positive experiences of caregiving, and social network were assessed over two years. Mixed effect models were used Results: On average participants had 1.5 health conditions at baseline; increasing to 2.1 conditions over two years. More health conditions were reported by caregivers who were older, had no formal education, provided 10 + hours of care per day, and/or cared for a person with more neuropsychiatric symptoms at baseline. More baseline health conditions were associated with greater stress at baseline but not with stress over time. Over two years, when caregivers’ health conditions increased, their stress increased whereas their social network diminished Discussion: Findings highlight that most caregivers have their own health problems which require management to avoid increased stress and shrinking of social networks / Economic and Social Research Council (ESRC) and the National Institute for Health and Care Research (NIHR) - grant ES/L001853/2. Alzheimer’s Society, grant number 348, AS-PR2-16-001. Sabatini was supported by an ESRC Postdoctoral fellowship (ES/X007766/1).

Urban renewal interventions aim to improve physical infrastrucutres, promote social integration and increase economic gains. However, they also have the potential to improve the wellbeing of residents. The objective of this dissertation was to better understand how an urban renewal policy, the Neighbourhoods Law, could affect health and health inequality in Barcelona, Spain. Using a mixed-methods approach, three studies were produced to better understand this connection. The first study used Concept Mapping techniques to study the perception of neighbours towards changes that had occurred in their intervened neighbourhoods in recent years and their importance for their wellbeing. The second study used the Barcelona Health Survey to analyse poor self-rated health and mental health status in women and men, before and after the intervention in participating neighbourhoods while comparing them to a group of non-intervened neighbourhood but with similar socio-demographic characteristics. The analysis was repeated to introduce the dimension of health inequality using social (occupational) class as a stratifying indicator. The third study used the results attained from previous studies and the existing literature to propose possible mechanisms linking urban renewal to health. The results from these studies indicate that the Neighbourhoods Law had a positive effect on residents’ health and health inequality. / Les intervencions de renovació urbana tenen com a objectiu millorar les infraestructures físiques, promoure la integració social i augmentar els guanys econòmics. A més, també tenen el potencial de millorar el benestar dels residents. L'objectiu d'aquesta tesi és poder comprendre com una política de renovació urbana, la Llei de Barris, pot afectar a la salut i a les desigualtats en salut a la ciutat de Barcelona. Per respondre a aquest objectiu s’han realitzat tres articles usant un enfocament de mètodes mixtos. El primer estudi utilitza la metodologia de “Concept Mapping” per analitzar la percepció dels veïns en relació als canvis que s’han produït en el barri en els últims anys i la seva importància per al seu benestar. El segon estudi utilitza l'Enquesta de Salut de Barcelona per analitzar la mala salut autopercebuda i l'estat de salut mental, abans i després de la Llei de Barris en els barris participants utilitzant com a grup de comparació un grup de barris no participants de característiques socio-demogràfiques similars. Les anàlisis es van repetir per introduir la dimensió de la desigualtat en salut utilitzant la classe social (ocupacional) com a indicador. El tercer estudi utilitza els resultats obtinguts dels dos estudis anteriors i de la bibliografia existent per proposar possibles mecanismes que vinculin la renovació urbana en la salut. Els resultats d'aquests estudis indiquen que la Llei de Barris té un efecte positiu en la salut i en la desigualtat en salut dels veïns.

The primary objective of the work presented in this thesis was to identify trends in maternal body mass index (BMI) over time, the demographic predictors of those women most at risk of being obese in pregnancy, health inequalities, and the impact of maternal obesity on maternity services. A mixed methodology utilised quantitative and qualitative research to address these objectives. Data were collated from 34 maternity units across England, including 619,323 deliveries between 1989 and 2007 inclusive. Analysis identified an increasing incidence of maternal obesity over time, regional differences in incidence, and significant inequalities with women residing in the highest levels of deprivation, and Black ethnic group. A systematic review was carried out including 49 studies investigating obesity and pregnancy outcomes with acute maternity resource implications. The meta-analysis found significantly increased odds of a number of outcomes, and concluded that maternal obesity had a considerable impact on maternity resources, and contributed towards a poorer prognosis for the mother and the baby during delivery and in the immediate post-partum period. Qualitative interviews and focus groups with 30 HCPs across eight NHS Trusts in the North East of England were carried out to identify barriers in implementing maternal obesity services, and to gain HCPs perspectives on what they felt was required in order to address maternal obesity effectively. The study identified the themes of ‘Service Development’, ‘Psychosocial Issues and Maternal Obesity Services’, ‘Information, Evidence, and Training’, and ‘Where to go From Here?’. Overall this programme of research has identified that maternal obesity is increasing over time and is significantly associated with health inequalities. The increase in maternal obesity has an impact on acute services, and HCPs feel that a holistic approach is required through partnership work in order to address maternal obesity effectively. This programme of research has primarily contributed to the knowledge of maternal obesity with the provision of the first national level statistics for trends in maternal obesity. The research has also provided a holistic view of the impact of obesity in pregnancy on maternity services, including the impact on resources and the issues relating to addressing the maternal obesity in clinical practice. The research has also identified aspects of service that need to be improved, and knowledge gaps in how to move services forward to effective address maternal obesity. The contribution of this research to the knowledge base is emphasised in the journal pre-publications, dissemination through UK and European, and international conference presentations, being an invited speaker at a number of conferences in the UK, and I received the 2007 Association for the Study of Obesity (ASO) Student Researcher Award for producing exemplary work in the study of obesity.

This thesis investigates the implications of area-based regeneration for residents' health and well-being. The last three decades have seen significant investment in area-based initiatives in the UK to regenerate declining areas. However, there is a dearth of robust evidence on the impact that area regeneration practices have on health and health inequalities. This is particularly so in the case of the Scottish Area Regeneration Partnership (SARP) Programmes initiated in the mid-1990s, the evaluation of which was beset by a lack of baseline data and poor data collection generally. This study therefore seeks to address the lack of evidence by employing a rigorous mixed methods approach to evaluate the SARP programmes. Firstly, a quasi-experimental analysis of data from the Scottish Longitudinal Study (SLS) is undertaken. Comparator areas were identified using propensity score matching and a series of models was fitted to examine whether health outcomes of residents and migrants differed between regeneration areas and comparator areas. This is followed by a qualitative study exploring experiences of regeneration, carried out to provide insight into the results of the quasi-experiment. The findings provide no evidence that the programme had a positive impact on the health and well-being of SARP area residents relative to comparator area residents, and moreover, suggest that the programme may even have had a negative impact. Nor do they support the often stated hypothesis that those who move out of regeneration areas have done so because they have benefited from the programme and been replaced with residents who are likely to be more deprived. In addition, interviews with regeneration professionals and residents found that smaller initiatives overlapped with the SARPs, making it difficult to isolate the impacts of the programme under study. The conclusion reflects on the implications of these findings for the evaluation of public policy programmes.

Les effets à court ou moyen terme de certaines expositions professionnelles biomécaniques sur lerisque de lombalgie sont reconnus. Les effets à long terme sont moins connus. Ces expositionscontribuent aux inégalités sociales de lombalgies,mais ceci est peu documenté une fois la carrièreterminée.Dans un contexte de débat sur l’âge de la retraite et la prise en compte de la pénibilité au travail,l'objectif de cette thèse était d'apporter des éléments de connaissances sur les liens entreexposition aux risques professionnels physiques et lombalgies autour de l’âge de la retraite, ainsique sur la présence d'inégalités sociale de lombalgies parmi des actifs vieillissants et des retraitéset la contribution de ces expositions à ces inégalités.Les lombalgies ayant duré plus de 30 jours au cours des 12 mois précédents ont été étudiéesdans la cohorte Gazel et l'Enquête Décennale Santé 2002 (EDS).Des arguments en faveur de la persistance des effets d'expositions physiques professionnelles audelà de la période d'activité ont été trouvés. Les données de l’EDS suggèrent que ces effetss’estomperaient au-delà d’un certain âge.Les expositions professionnelles, en particulier biomécaniques, jouent un rôle majeur dans lesinégalités sociales de lombalgies chez les hommes de la cohorte Gazel, actifs vieillissants etjeunes retraités. Par contre, de telles inégalités ne sont pas observées chez les retraités de 60 à74 ans de l'EDS.Ce travail montre l'importance en matière de lombalgies persistantes/récidivantes d'expositionsprofessionnelles a priori accessibles à une démarche de prévention, et l'intérêt de considérer leparcours professionnel dans les politiques de retraite / Some biomechanical exposures at work are recognized short term risk factors for low back pain(LBP). However, long term effects, are not well known. In addition, occupational exposures seemto contribute to social inequalities in low back pain, but this contribution is less documented forolder subjects.In many developed countries, governments are now reconsidering retirement policies. In thiscontext, the objective of this work was firstly to provide additional knowledge about the linksbetween physical exposure and LBP among aging workers and retirees, and secondly to assesssocial inequalities in LBP in this age group and the contribution of occupational factors to suchinequalities.Two populations were studied : volunteers from the Gazel cohort and participants to a Frenchnational survey on health (EDS 2002). The same definition for LBP could be used in bothpopulations : LBP which lasted more than 30 days in the previous 12 months.LBP was associated with physical occupational exposures among aging workers and youngretirees in both populations. Results were consistent with the hypothesis of a persistence of effectsonce occupational exposure has ceased, except among the oldest retirees in the EDS 2002.Biomechanical exposures played a major role in social inequalities for LBP among aging workersand young retirees in the GAZEL cohort. Such inequalities were not observed among the retireesaged 60 to 74 years (men and women) from the EDS 2002.The results highlight the importance of past occupational exposures at retirement age.