Aim This thesis explores the seeking of help from a General Practitioner in the event of psychological distress. The study explores help-seeking, lay understanding around mental health, and the relationship between the two. Background Help-seeking has been shown to vary according to different demographic factors, and is not necessarily correlated with need. Frequently, those who need help most do not seek it, whilst those with low need are more likely to enter care; help-seeking is complex, and there is value in understanding more about current patterns. Lay knowledge is perceived as playing a crucial role in help-seeking, providing rationale for examining the two alongside each other. Method Qualitative interviews were used to explore the stories of people who have recently sought help, alongside interviews from a group of ‘lay’ participants who discuss distress, help-seeking and mental health more generally. 20 interviews were carried out, analysed using a combination of thematic analysis and the process of analytic induction. Findings The thesis sheds light on the limited role of lay knowledge; its role is most evident when considering hypothetical help-seeking. For recent help-seekers, journeys towards care were mediated by factors pertaining to their wider lives; help-seeking was intimately related to their context. Help-seeking is the outcome of a complex interplay of factors and the study sheds light on aspects of individuals’ stories that render distress more or less likely to enter Primary Care. The process of medicalisation is illuminated, for example, individuals receiving care for physical health problems are particularly prone to their distress being medicalised. Findings lend support to a contextually-rooted approach to understanding help-seeking. Expectations of – and preferences for – care are explored, evidencing a need for General Practitioners to consider referral to self-help and/or support groups within the community; individuals may not necessarily be seeking a medicalised response.

This thesis argues that health policy practices on access to medication in Cameroon have been shaped by global health partnerships (GHPs), with the result that the capacity of the state has been undermined and the national health system fragmented, with no resultant reduction in the incidence and burden of malaria and HIV I AIDS. GHPs have played an increasing part in relation to access to medication in a number of developing countries in Africa, defined in terms of potential and actual access to pharmaceuticals and healthcare services. GHPs are supposed to provide a better policy response to the practical problem of access to medication by combining the expertise of UN agencies, the pharmaceutical industry, international civil society organizations, national government and local groups to formulate and implement country-specific policies. Ostensibly, they are able to bridge the gap between medical technology and the public health needs of poor societies. Neither of these claims can be substantiated. Theoretical approaches to models, embodied knowledge and social constructionism are used to provide a conceptual framework to study the role of GHPs on access to medication. GHPs are conceptualised as 'models' that occupy the intermediate position between theory and policy practices, within which are found three major narratives, based on public health, economistic and human rights approaches to the issue of access to medication. These narratives became embodied within GHPs, and are analysed to show how they shape different elements of policy practices. The operation of GHPs within a 'transcalar network', this 'social space' in which global-national-local linkages are formed and interactions take place is also examined. Global and national (country-specific) perspectives on the emergence of the GHP as a facilitator of access to medication are identified, and the role of GHPs in determining national health policy and local delivery practices for achieving access to medication for the poor and most vulnerable population is investigated. Two programmes in Cameroon are used as case studies: 1) National Malaria Programme created on Roll Back Malaria partnership guidelines and 2) National HIV/AIDS Programme created on Accelerating Access Initiative and Equitable Access Initiative guidelines respectively. The empirical evidence from this thesis supports a critical evaluation. GHPs emphasise specific medical intervention programmes, and are effective only in this narrow technical sense. Even though their efforts have not reduced the incidence and burden of malaria and HIV I AIDS, they have legitimised the direct intervention of international agencies, private corporations and civil society organizations at the local level. The GHPs' pursuit of 'quick results' has fragmented the national health system and undermined the role of the state. This thesis suggests that the key to reducing disease burden and improving public health is a strengthened national health system, one that the current GHP model does not offer. Developed to address the supposed failure of African states to ensure access to medication, GHPs have further marginalised the role of the Cameroon state, thereby reducing its capacity to protect and advance the health of its citizens.

During pregnancy and breastfeeding, women are concerned about the health and safety of themselves and their baby. They undertake many activities in order to maintain good health, manage minor ailments and improve their lifestyle, including seeking help and advice from pharmacies. Community pharmacists have an important role in selecting appropriate medicines and encouraging good health behaviours. The Thai population can purchase medicines from pharmacies without a prescription, and self-treatment or self-medication is commonly used and important to the health status of Thai people. In addition, culture, family and relatives have an influence on health behaviours in Thailand. There have been very few previous studies about self-care behaviours including self-medication in Thailand focused on healthy women during pregnancy and breastfeeding, and the views of community pharmacists in self-medication and self-care during pregnancy and breastfeeding. In addition, the modern lifestyle and accessible health information might be affected by the current attitudes and behaviours of women during pregnancy and breastfeeding. Therefore, an investigation of self-care behaviours in pregnant and breastfeeding women was needed to explore their recent behaviours in terms of maintaining health and well-being as well as managing minor ailments. Views and experiences of community pharmacists about self-care in pregnancy and breastfeeding were also explored. This study contributes to the understanding of self-care behaviours and indicates the actual situation in community pharmacies regarding self-care and self-medication in pregnancy and breastfeeding. Two in-depth interviews in the Thai language were held with 43 women in Chiangmai about their self-care experiences and behaviours during pregnancy (>34-weeks gestation) and 35 out of the 43 women in the breastfeeding period (>four weeks following birth). Audio-taped interviews were transcribed, translated and analysed by using interpretative analysis. In addition, a postal questionnaire survey was used to collect data from 198 full-time community pharmacists in Chiangmai province. The first mailing was sent in April 2006 and a reminder was posted in June 2006. The completed questionnaires were returned from 110 pharmacists and the response rate was 56%. The majority of pregnant women tended to change their habits and adopt activities that they thought could make them and their babies healthy. They tried to consult their doctor rather than self-medicating. The traditional beliefs still had a very strong influence on most women interviewed during both pregnancy and postnatal period. The majority of pharmacists strongly agreed that self-care is important for both pregnant and breastfeeding women and they believed they provided good support for these women. Some pharmacists, however, still lacked the confidence to provide appropriate advice for these women and appeared to need more support with up-to-date information. Regarding the implications of this study, some self-care activities are harmful to women and their babies, so their dangers should be widely advertised in appropriate places. Furthermore, health professionals should consider a balance between safe traditional beliefs and modern health systems to ensure the best self-care practices for both women and their babies. In addition, continuing education and up-to-date information will help to increase the pharmacists’ confidence in providing appropriate advice to pregnant and breastfeeding women.

This study is an empirical exploration of Foucault's theoretical ideas on resistance, through a case study of cervical cancer screening and women's responses to the official discourse surrounding it. In England, this form of screening is organised through a national programme and consistently achieves coverage of over 80%. Given this high attendance it may appear that any resistance is negligible. However, this thesis argues that such a focus on attendance, or behaviour, is misguided and that, by focusing attention on the level at which the official discourse on screening is interpreted, understood and made sense of by individual women, it is possible to identify instances of thought and talk based resistance. Using qualitative interviews with a sample structured to include a range of ethnic backgrounds and ages, the thesis identifies three key forms of resistance. Firstly, women may resist the general subject position suggested within the official discourse and make sense of screening in ways that are meaningful to them as individuals. Secondly, many women resist the general 'at risk' status suggested and negotiate their own position drawing on a range of risk factors that do not always fit well with those medically recognised. Thirdly, in making sense of the information they receive, women frequently attempt to create a rational framework of knowledge and understanding which can lead to them interpreting issues such as risk factors or disease development in different ways. Based upon these, the thesis argues for conceptualising power and resistance in terms of a complex network of possibilities with multiple points of potential difference or divergence that can lead to individuals adopting very different subject positions. Although the majority of resistance detailed is thought and talk based, this is nevertheless important as it provides the means for challenges to the official discourse and constitutes a necessary prerequisite for further behavioural resistance.

Statistical inference and model choice for partially observed epidemics provide a variety of challenges both practical and theoretical. This thesis studies some related aspects of models for epidemics and their inference. The use of the matrix exponential to facilitate exact calculations in the General Stochastic Epidemic (GSE) is demonstrated, most usefully in providing the exact marginal likelihood when infection times are unobserved. The bipartite graph epidemic is defined and shown to be a flexible framework which encompasses many existing models. It also provides a way in which a deeper understanding of the relation between existing models could be obtained. The Indian buffet epidemic is introduced as a non-parametric approach to modelling unknown heterogeneous contact structures in epidemics. Inference for the Indian buffet epidemic is a challenging problem, some progress has been made. However the algorithms which have been studied do not yet scale to the size of problem where significant differences from the GSE are apparent. Evidence confirming and demonstrating the importance of understanding the tail behaviour of proposals in importance sampling is presented. The adverse impact of heavy tailed proposals on the Grouped Independence Metropolis-Hastings (GIMH) and Monte Carlo within Metropolis (MCWM) algorithms is demonstrated. A new algorithm, the Kernel Metropolis Hastings (KMH), is proposed as an approximate algorithm for low dimensional marginal inference in situations where the GIMH algorithm fails because of sticking. The KMH is demonstrated on a challenging 2-d problem.

In the United Kingdom (UK), an estimated 107,800 people were living with HIV in 2013, of whom 55% were heterosexual men and women. Black African men and women accounted for the majority of heterosexuals living with HIV in the UK in 2013. In this PhD by prospective publication my research question is “How is the epidemiology of heterosexually-acquired HIV infection evolving, particularly among black Africans, in England, Wales and Northern Ireland?”. I conducted a quantitative analysis of national surveillance datasets and undertook literature searches. Most of my analysis was based on data from the three national HIV surveillance systems which constitute the HIV and AIDS Reporting System (New HIV Diagnoses database; Survey of Prevalent HIV Infections Diagnosed; CD4 Surveillance Scheme). I published the results of my analyses in six peer-reviewed papers between 2007 and 2014. My key findings were as follows: over the last decade an increasing proportion of black African heterosexuals born abroad but diagnosed with HIV in the UK acquired HIV whilst living in the UK; outward migration from the UK may explain why some black African heterosexuals were lost to follow-up from HIV care; the proportion of black African heterosexuals diagnosed late with HIV has not changed substantially; the uptake of HIV testing among black African heterosexuals has increased over time but remains low compared with that among MSM. To minimize the risk of HIV transmission and to maximise the benefits of earlier detection my key recommendation is to promote regular HIV testing among black African women and men in a range of healthcare and community settings in E,W&NI, particularly in primary care.

Food welfare for low-income women and children in the UK is an unexplored area of food policy. The current food welfare scheme for low-income women and children in the UK is called Healthy Start, and this replaced the previous Welfare Food Scheme in 2006. The main changes were that Healthy Start was intended to be more health focussed and aimed to influence behaviour change by providing a voucher that could be spent on fresh (and later frozen) fruits and vegetables, milk or infant formula. The previous scheme only provided milk and infant formula. In addition it was intended that there would be more interaction with health professionals as part of the scheme. Little is known about why the Welfare Food Scheme changed to Healthy Start and what influenced the initiation, formation and implementation of Healthy Start. Nor is there substantial information on how Healthy Start operates in practice. The objectives of this thesis were to consider what influenced the development of Healthy Start and to consider how Healthy Start as a policy relates to Healthy Start in practice. After mapping how Healthy Start was developed, what is known about the scheme, undertaking a literature review on subject specific literature, research questions were developed to direct the line of inquiry. A theoretical literature review explored methods of policy analysis that could inform the overarching methodology. Models of policy analysis and literature on the policy process were developed to better understand the policy process that informed Healthy Start. To address the research questions, three phases of research were undertaken. The first was a policy analysis of publically available policy documents using Kingdon’s concept of policy streams to make sense of the process; the second was a series of semi-structured interviews with policy participants to add detail to the first phase. A recurring issue was the role of the Health Professional in delivering Healthy Start, and a case study with health professionals who deliver Healthy Start in one Borough of London was developed to further explore this issue. The findings indicate that the shift from the Welfare Food Scheme to Healthy Start was largely influenced by political factors, with inadequate consideration of public health objectives and practical components of behaviour change. A lack of training and support for health professionals who are gatekeepers of the scheme was apparent at all points of the policy process. By tracking the development of the Healthy Start scheme and its place within food welfare this research highlights the need for more thorough consultation and thoughtful development if complex schemes crossing welfare and food policy are to be successful.

Implementation of protocols and guidelines is an important strategy used by hospitals in their fight against healthcare-associated infections (Pratt et al., 2007), yet their use remains a challenge (Boaz et al., 2011; Grimshaw et al., 2001). This thesis addresses the topic of behavioural change through exploring how protocols and guidelines are used on hospital wards to manage the risk from Clostridium difficile infection, the difficulties ward staff faced with their use and what happened in practice as difficulties were experienced. A qualitative study was conducted using a single case study methodology (Yin, 2009) with one acute NHS hospital in the UK. Methods used included nonparticipant observation (184 hours), informal conversation, interviews (49) and document review. An adapted version of the topic guide developed by Michie et al. (2005) based on their theoretical framework of behavioural change was used in the interviews. Data collected was analysed inductively using NVivo 8 and compared against Michie et al’s (2005) framework. The findings illustrate that nurses and doctors were detached from protocols and guidelines. Instead they relied heavily on informal sources of knowledge to guide their practice. Examples include experiential knowledge, common sense, intuition, ‘‘rules of thumb’’ and “mind lines’’ (Gabbay and le May, 2004, 2011). They also took account of preferences, their perceptions of risk, social norms and other contextual issues. Four emergent themes illustrate the complexity of factors hindering and assisting the use of protocols and guidelines into practice. These are ambiguity, organisational issues, professional frustrations and perceptions of contamination. Variations in practice were widespread as protocols and guidelines were ‘worked around’ and improvisations were made as ward staff struggled against a tide of organisational constraints, unrealistic conflicting priorities and difficulties with protocol ambiguity. The way that difficulties were being solved on the ward means that the underlying causes were not being addressed as concerns were not brought to the surface. Professional frustrations such as feeling overwhelmed and powerless acted as barriers to nurses’ reflection. The study has empirically expanded Michie et al’s (2005) behavioural framework whilst exploring the dynamics and complexity of categories influencing the use of protocols and guidelines through a ‘thick’ description of the study findings. This study has made a conceptual contribution to the literature by identifying that Michie et al’s (2005) framework does not seem to take into account tacit and experiential knowledge, professional knowledge, how sense is made of information from the local context or the process of reflection as part of learning. Recommendations are made to address the findings from this study.

NDM-producing bacteria are associated with extensive antimicrobial resistance (AMR). This thesis reports on detailed molecular analysis, including whole genome sequencing, of Acinetobacter spp. and Vibrio cholerae isolates. A study of clinical Acinetobacter baumannii isolates from India, demonstrated spread of a single strain containing blaNDM-1 but with evidence of significant genetic plasticity between isolates. A novel plasmid, pNDM-32, was fully characterised in isolate CHI-32. This contained multiple AMR genes including blaNDM-1 and the aminoglycoside methyltransferase gene armA. A repAci10 replicase gene was identified but no conjugation machinery and the plasmid could not be transferred in conjugation experiments. A single isolate of Acinetobacter bereziniae from India contained plasmid, pNDM-40-1, harbouring blaNDM-1, which was closely related to plasmids from NDM-producing Acinetobacter spp. isolated in China, and was readily transferred into Escherichia coli and Acinetobacter pittii by conjugation. Five blaNDM-1 positive Acinetobacter spp. isolated from a faecal screening study in Pakistan also included three, clonal, Acinetobacter haemolyticus isolates harbouring a similar plasmid. Three environmental V. cholerae strains from India and a blood isolate from a traveller returning to the UK from India were found to include three distantly related strains. 2 isolates of a single strain contained an IncA/C plasmid, pNDM-116-17, harbouring AMR genes including blaNDM-1. In one isolate pNDM-116-17 had become integrated into a chromosomal region containing a SXT-like element. In the other isolates blaNDM-1 and other AMR determinants were localised to a large plasmid, pNDM-116-14, with a novel replicase and a full complement of conjugative transfer genes, and a novel genomic island, SGI-NDM-1. Most previous studies have focused on Enterobacteriaceae. Thecurrent work contributes to an understanding of the full extent of the genetic diversity of blaNDM-1 contexts, and their dissemination. Such knowledge should help to infer factors which contribute to the spread of AMR in bacterial pathogens.

This thesis seeks to determine the macro-economic impacts of changes in health care provision, whilst recognising the simultaneous effects of consequent changes in health on effective labour supplies and the resource claims made by the health care sector. The resource allocation issues have been explored in theory, by developing an extension of the standard Rybczynski theorem from a low-dimension Heckscher-Ohlin framework, and empirically, by developing a Computable General Equilibrium model, calibrated to a purpose-built dataset for the UK. The theory predicts that, if the government is solely concerned with improving per capita income, a morally questionable policy of targeting health care provision towards skilled workers performs best. Furthermore, the impact of an expanding health sector on the outputs of non-health sectors is shown to depend on the sign and magnitude of a scale effect of increased effective labour supplies and a factor-bias effect of changes in the ratio of skilled to unskilled labour, although the latter effect dominates if effective labour supplies are relatively inelastic with respect to health care provision. The theoretical predictions are not generally validated by the applied model due to added real-life complexities. The main findings are that a rise in NHS expenditures, the employment of foreign health care-specific skilled workers, and costless factor-neutral and skill-biased technical change in the UK health sector have a positive impact upon overall welfare via direct improvements in population well-being and indirect benefits from increased worker incomes. The study indicates that if an expansion of the health sector is financed from a reduction in state benefits, the non-working households and pensioners may require some compensation since they rely relatively heavily on these as a source of income. The presence of health care-specific factors and rising pharmaceutical prices impact negatively upon the health sector and overall welfare, suggesting the importance of tackling rising input costs and structural rigidities. This may be achieved by the immigration policy, although since effects on domestic workers if their wages are not sustained, and on countries of origin faced by a 'brain-drain', are negative, in the long-term increasing the number of medical school places may be more desirable. Another suitable policy response is to purchase a more effective pharmaceutical product. Fairly small productivity gains in health care were shown to generate overall welfare gains. Finally, factor-neutral and skill-biased technical improvements yield significant welfare gains and cost-savings in the health sector. Such technical improvements may come in the form of improved medical procedures, which have been developed abroad yet are freely available or have been funded by charitable institutions, but also may reflect domestic policy which aims at reducing administrative overheads so that more resources can be devoted to front-line staff. The sensitivity of the results to the elasticity of the waiting lists with respect to health care indicates the importance of ensuring that additional resources are effectively employed, attainable by the technical and administrative improvements in health care.