The overall objective of the study was to identify factors which play a key role in diet and exercise behaviour for migrant and Danish bus drivers in a workplace setting. The aim was to develop a framework to illustrate how the individual, contextual and cultural influences on health behaviour (diet and physical activity) interplay in an everyday perspective. Data was collected using a qualitative approach. Methods applied consisted of contextual based observations and semi structured interviews with sixteen (n=16) bus drivers. Four interviews were conducted with Danish, four with Somali, four with Turkish and four with participants with a Pakistani ethnic origin. The data was analysed using grounded theory. The core category which emerged from the data was „impact of individual, contextual and cultural influences on health behaviours‟. The core category was supported by five higher order categories. These were as follows: (1) Meanings of health (2) health behaviour and the potential to change, (3) Maintaining Balance (4) Workplace influences on health (5) Positioning in the social context. Each of the higher order categories was further supported with categories and sub-categories. The analysis illustrated findings on different levels. As a result of the impact of individual, contextual and cultural findings, strive for balance through a process of equilibrium was core to well-being and health in an everyday perspective. A collection of factors from the different levels of influence played a key role on diet and physical activity in an everyday work-day context. These have been illustrated through the use of quotes and frameworks. Based on the findings of the study, future research and practice recommendations are outlined.

The purpose of this research was to examine some of the factors which may affect body composition of postmenopausal women. The effect of estrogen, physical activity, diet and lifestyle were examined in 9 women receiving estrogen replacement therapy and 11 women not using this drug. For 3 consecutive days, the subjects collected 24-hour urine samples and recorded their dietary intake. Body fat was estimated by obesity indices based on height and weight and a regression equation based on abdominal skinfold, abdominal circumference and bideltoid diameter (Young, 1964). Lean body mass (LBM) was estimated from urinary excretion of creatinine (Forbes & Bruining, 1976). Physical activity and lifestyle were assessed by a self-administered questionnaire. Age, height, physical activity, diet and lifestyle were similar for the two groups. Estrogen users were heavier than non-users (p < 0.05) and as a group had a higher prevalence of obesity. Percent body fat and LBM also tended to be higher in the estrogen users than in the non-estrogen users. The weight difference between the two groups was already present at age 25 years and persisted through the subsequent 30-year period. All 20 subjects maintained their weight between ages 25 and 35 years, thereafter, increasing in weight significantly (p < 0.05) by decade through age 55 years. For all 20 subjects no correlation was found between energy intake and any measure of obesity or body fatness. Obesity was unrelated to energy consumption. Physical activity did not correlate significantly with any estimate of body composition. Energy intake showed an inverse correlation with hours spent watching television (r = -0.82, p < 0.002). Nutrient intake for most women was adequate; however, calcium intake in women not receiving estrogen replacement therapy may be insufficient. / Graduation date: 1987

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The Scottish Executive (SE) commissioned the first phase of a National Coronary Heart Disease (CHD) Demonstration Project, Have a Heart Paisley (HaHP), in 2000. HaHP was a complex community-based partnership intervention. An independent evaluation of HaHP (phase one) was commissioned by the SE in 2001. This thesis presents the learning from the evaluation. The first aim is to identify the key implementation, evaluation and policy lessons to result from the evaluation. The second is to contribute to learning about how best to evaluate complex community-based interventions. The evaluation consisted of four approaches: a theory-based approach (the Theories of Change); the mapping of the context; a quasi-experimental survey; and, a range of integrated case studies. This thesis uses the programme logic (the intervention’s Theories of Change) articulated by the HaHP stakeholders to integrate the results from each of the evaluation approaches. HaHP (phase one) did not achieve significant changes in population level CHD risk factors, behaviours, morbidity or mortality. Like many previous community-based CHD interventions HaHP did not fully implement its intended Theories of Change. HaHP’s activities were not consistently based on best practice. It did not articulate or implement clear strategies for addressing health inequalities. The project delivered mainly individually focussed, ‘downstream’ interventions and struggled to achieve wide-scale local service, policy and agenda changes. It did, however, make progress with regard to improving partnerships and jointly delivering interventions. The findings from HaHP add to existing evidence that large-scale behaviour and cultural change will only be achieved through national action and the increasing use of ‘upstream’, legislative, or policy solutions, or changes in mainstream services and organisations. Activity in localised demonstration projects can add to such change rather than create it. The Theories of Change approach claims to improve planning and implementation, enhance evaluation, and address attribution. The approach (as applied within this evaluation) provided substantial amounts of formative feedback that was of use for improving programme implementation. This learning, however, was not always acted upon.

Tackling health inequalities is a policy priority. Research on cancer and particularly oral cancer aetiology has somewhat overlooked this area, in favour of pursuing genetic and 'lifestyle' risk factors. The over-arching aim of this thesis was to investigate the epidemiology of oral cancer in relation to individual socioeconomic status (SES), area-based socioeconomic circumstances, and socioeconomic inequalities. Descriptive epidemiology studies undertaken demonstrated that the burden of oral cancer was increasing across the UK, especially in Scotland, and a socioeconomic gap was widening with those from more deprived communities having significantly greater and increasing incidence of the disease. A systematic review and meta-analysis of the world literature showed that low compared to high SES was associated with significantly elevated risk of oral cancer independent of behavioural factors. A local case-control study provided unclear findings when individual- and area-based socioeconomic factors were explored together; however, a framework for future analyses was developed. In totality, this thesis suggests that public health policy to address the overall rising incidence and widening inequalities of oral cancer needs to acknowledge the complexity of the risk factors; in addition, the findings provide evidence to steer policy, which focus on lifestyles factors towards an integrated approach incorporating measures designed to tackle the root causes of disadvantage.

Background: The increase in the number of people living with HIV (PLHIV), especially in sub-Saharan Africa, is a major public health concern. To date, most attention has been paid to prevention strategies and clinical trials of therapy. In comparison, there have been very few studies of care and support programmes. The ‘HOPE’ programme is a major community-based care and support programme in Ghana. ‘HOPE’ provides nutritional support, skills training for employment, health education and psychological support for PLHIV and for those orphaned through AIDS. Therefore, it was seen by policy makers in the country as desirable that it should be evaluated. A PhD scholarship was funded and the researcher presenting this thesis was appointed. Broad Aims The overall aim was to carry out an evaluation of the ‘HOPE’ programme in Ghana in order to make wider recommendations for evaluation of community-based interventions (CBIs) in Ghana and Africa generally. The timing was less than ideal as many of the major decisions about the intervention had already been made and baseline data had been collected. Therefore, the preliminary aim was to explore a range of possible evaluation methods so that the most suitable approach could be selected. Thereafter, a range of more specific aims, objectives and research questions was identified. Methods: A ‘mixed methods’ approach was adopted. The first component was a desk-based analysis of the literature on the various evaluation approaches that might, at least in theory, be applied to an HIV/AIDS intervention like ‘HOPE’. From this, a decision was made to evaluate ‘HOPE’ in terms of structure, process and outcome. The second component operationalised this decision by reviewing HOPE’s working documents and conducting two pieces of field work: a quantitative and a qualitative study. The quantitative study was a structured questionnaire administered to 200 PLHIV on the ‘HOPE’ programme. The qualitative study consisted of 14 interviews with stakeholders directly involved in the programme implementation and 8 focus group discussions with the programme beneficiaries. Results: The desk-based analysis achieved three main outcomes. First, it set out in a systematic manner the different approaches to evaluation that could in theory have been applied to ‘HOPE’. It identified strengths and weaknesses and the perspectives behind each approach. Second, it set out and then summarised a detailed description of the ‘HOPE’ programme and the national context in which it operated. Third, it set the above within the context of global literature on HIV, community-based interventions and nutritional support programmes. The analysis of the quantitative data showed that beneficiaries were being provided with soy-fortified wheat and vegetable fortified oil at the time of the evaluation. On average, beneficiaries gained weight (Mean difference in weight was 2kg with 95% CI (1.1, 2.9), p-value < 0.001) and increased Body Mass Index (BMI) (Mean difference in BMI was 0.8units with 95% CI (0.4, 1.2), P-value < 0.001). Over a third of the beneficiaries (37.5%) was currently unemployed and only one in five of the beneficiaries had been trained in a skill that might have been useful to find employment: this, despite skills training for all being a programme goal. Multivariate analysis showed that the support group to which the beneficiary belonged was the most important determinant of a positive outcome. Qualitative components demonstrated perceived successes and challenges. Beneficiaries indicated that the anti-retroviral drugs were making them hungry and the food helped to alleviate that effect. They further indicated that the food was nutritious and contributed to their weight gain. Support groups have been sustained and membership increased. Some indicated that food should be more varied and some mentioned selling food to earn money to pay for their medications. Most of the beneficiaries indicated they were unemployed having lost their jobs as a result of stigmatisation. Only a few benefited from skills training leading to employment because of inadequate budgeting. Some who had been trained could not use their newly acquired skills because of lack of capital to start a business. To compound these weaknesses, most reported that they preferred petty trading to the skills offered. The monthly education and the training workshops generated hope, and improved knowledge of HIV/AIDS, promoted drug adherence and helped to reduce stigmatisation. The training of the PLHIV as peer educators is an effective method for HIV education and counselling since PLHIV listen to their peers more than health workers. Respondees predicted dissolution of the support groups when the programme ends. This is because they were not adequately involved in the decision making. Beneficiaries identified participation and cooperation as key prerequisites for sustainability but they also identified important weaknesses in ‘HOPE’ with respect to these criteria. Discussion: Despite the challenges presented by the timing and context of this study, it has been possible to carry out an evaluation that provides important learning. A mixed methods approach was appropriate and is likely to be useful in many similar evaluations. Beneficial outcomes were identified but these cannot be attributed, without qualification, to the intervention. Nonetheless, the findings indicated that participants were highly satisfied with the food support and monthly education. They were dissatisfied with the numbers trained in new skills and in other aspects of the skills training components. Also, the sustainability of the food component when the funding stops was a concern. However, the educational component could be sustained because peer educators could continue at very low cost. Most importantly, community involvement, using locally available resources, inter-sectoral collaboration and harnessing the motivation of local people were seen as key but underutilised ingredients. So, the results of the evaluation are encouraging but not conclusive. Nonetheless, care for people living with HIV is such an important problem that the desirability of conducting a cluster randomised controlled trial among a large number of support groups to assess the programme effectiveness on health, nutrition and economic status should be seriously considered despite the practical and ethical challenges implicit in such a recommendation.

The study was conducted in two phases. Phase I consisted of generating models of risk reduction behaviors in order to implement and test risk reduction interventions for Phase II. The purposes of Phase I were: (a) to identify among a group of African-Americans individual and group risk factors for hypertension, and to identify demographic and psychosocial variables most predictive of risk reduction behaviors for hypertension, (b) to design and test a model that combines important demographic and psychosocial determinants of risk reduction behaviors, and (c) to generate data based models of the predictors of each risk reduction behavior for hypertension in the group of African-Americans. The conceptual model for the study was developed by combining variables from the Health Belief Model--susceptibility, severity, and barriers with variables from social learning theory-health locus of control and self-efficacy. The focus of Phase I was to test the model to determine the interactions among the variables, because the assumptions of the underlying theories suggest multiplicative rather than linear relationships. One hundred forty-three subjects completed Phase I. The demographic variables age, gender, and education entered the model as direct effects and strong moderators. Education was a direct effect for stress reduction and moderated the effect of risk severity in diet fat. Age as a direct effect explained 19 percent of the variance in diet sodium intake and 21 percent of the variance in diet fat as a direct effect and moderating effect of risk severity. Twenty-seven percent of the variance in alcohol use was explained by age (B = -.24) difficulty (B =.26), and risk health value moderated by age (B = -.27). Sixty-three percent of the variance in smoking behaviors was explained by the direct effects of age (B = -.20), gender (B = -12) and difficulty (B =.25), and by the interaction of age and difficulty (B =.52). In Phase II, interventions were developed that used either motivational or educational skills strategies such as monetary incentives, screening, risk assessment, health education, dietary analysis, and self-monitoring. Twenty-eight subjects participated in the pilot test of Phase II. Participants were most interested in modifying their diet fat intake and increasing stress reduction. The findings that each risk reduction behavior was predicted by different variables and/or different interaction patterns of the same variables supports further study of each risk reduction behavior rather than looking at risk reduction behavior as a conglomerate or as a summed health-promotive behavior. The study also supported the underlying theoretical assumptions of the Health Belief Model, and Social Learning Theory that the relationships between the variables is multiplicative, as moderating effects were found, but no mediating effects were supported.

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