Complex social problems (the continued rise in chronic disease; resource depletion, inequality etc.) call for new social marketing frameworks to accommodate midstream and upstream action which requires collaborations with multiple actors (government, public and private sector). Service-dominant logic (SDL) (Vargo and Lusch, 2004) theoretical developments (systems thinking, value creation, networks etc.) suggest a good compatibility with the collaborative approaches required by midstream and upstream social change (Russell-Bennett, Wood and Previte, 2013). This thesis interrogates the applicability of SDL concepts (value creation and actor engagement) to social marketing. This study focuses on examining the factors influencing engagement, actor motivation and perceived value in a health social marketing context. The study adopts a case study approach and draws upon interviews, observation and document analysis to examine a Smokefree homes and cars programme (‘Smokefree’) in a city in England. Key findings of this research indicate that adopting a service orientation facilitates contextualising social marketing programmes, building capacity at the community level and adopting a long-term approach which suits better the realities of individuals. However, it also reflects that understanding and addressing contextual factors means considering the fluidity of individuals’ goals and the subjective dimension of value which might challenge pre-set programme objectives. The study indicates that a collaborative approach to value creation poses challenges in addition to the benefits. This study is one of the few (Domegan et al., 2013; Lefebvre, 2012; Russell-Bennett, Wood and Previte, 2013) to contribute to the efforts to examine the implications of a service perspective for extending social marketing theory. One of the main contributions of this study is illustrated by the articulation of service dominant benchmarks for social change programmes. A key implication for policy is that building collaborations with community services is essential to understanding individuals in context, customising offerings and supporting skill development.

Chronic kidney disease (CKD) is insidious and most cases are diagnosed through opportunistic serum creatinine (SCr) testing before symptoms develop. However, efforts to accurately assess prevalence have been hampered by the lack of a universally agreed definition of SCr thresholds for the diagnosis of CKD. At the turn of the millennium, two crucial developments occurred. The first was the description of the Modification of Diet in Renal Disease estimated Glomerular Filtration Rate (eGFR) which closely correlated to cumbersome measured GFR and could be used instead in daily clinical practice. The second was the publication of the Kidney Disease Outcomes Quality Initiative (KDOQI) clinical practice guideline for the evaluation, classification and stratification of CKD detailing a new definition of CKD based on GFR thresholds. Together, these two developments formed the basis of CKD as we know it today. Prevalence of CKD varies, and accurate prevalence estimates are difficult to obtain especially with respect to fulfilling the chronicity criterion (reduced eGFR ≥ 90 days). Traditional risk factors for CKD are well described and non-traditional risk factors such as socio-economic status (SES), health literacy and rurality are gaining interest. SCr sampling patterns in the community mean that most individuals with CKD are tested routinely every year. This information may not be considered in its entirety by primary care providers (PCP) which may explain inaccuracies in PCP CKD registers. Accurate identification is important to direct evidence based clinical interventions to this patient group. In chapter 2, a novel algorithm for detecting CKD and confirming chronicity from a laboratory database was developed to identify a CKD cohort of the population served by NHS Ayrshire & Arran. Data linkage of additional laboratory data, Scottish Morbidity Records for co-morbidity, statin dispensing information from Prescribing Information Scotland, area SES, rurality and deaths from Information Services Division Scotland enriched the cohort. Patients on renal replacement therapy were identified and excluded through the Scottish Renal Registry. Multiple imputations were applied where appropriate to address missing values. There were 21,037 individuals from 2010 to 2012 fulfilling the definition of CKD stage 3 – 5. Prevalence of adults with CKD was 5.6% – 5.8%. Average age (± SD) of the cohort was 75 ± 11 years. 64.6% were female and average eGFR for the cohort was 47.32 ± 11.53 mL/min/1.73m2. In chapter 3, laboratory ascertainment of CKD identified 7% more cases than PCP CKD registers. Furthermore, around 25% of patients on PCP CKD registers may be wrongly coded as having CKD. There was a 3.9-fold variation in CKD prevalence amongst PCPs, ranging from 2.8% - 11.0%. Variation fell to 3-fold with laboratory ascertainment, ranging from 3.0% - 9.1%. This fell further with age and gender stratification. Stratified laboratory CKD prevalence was positively associated with SES and rurality, a novel finding, but in multivariate linear regression, only SES, in addition to age and gender, were significant predictors for CKD prevalence. Chapter 4 explored the association between SES, eGFR and all-cause mortality. One-way ANOVA demonstrates a linear relationship between eGFR and SES (F (4,15078) = 2.52, p = 0.039) with a mean difference in eGFR of 0.83 mL/min/1.73m2 between the lowest and the highest SES quintile. However, linear regression modelling found proteinuria, hypertension, peripheral arterial disease, age, gender and serum albumin to be significant predictors for eGFR, but not SES. After adjustment for age and gender imbalance, survival demonstrated substantial influence by SES, but weakened in effect with full adjustment with only Scottish Index of Multiple Deprivation (SIMD) quintile 3 demonstrating a 13% increased risk (HR 1.13, 95% CI 1.03 to 1.24) with no progressive increase in risk associated with lower levels of SES. As a quality of care marker, the dispensing of statin was examined in chapter 5. Having another diagnosis where statins are indicated, male gender, higher serum albumin, CKD stage 3B and age between 65 – 80 were associated with higher odds ratio for statin dispensing. 64% of the cohort was dispensed a statin in 2010, but the proportion fell by 5% to 58% in 2012. This fall in dispensing disproportionately affected younger and less co-morbid CKD patients who were all eligible for a statin. SES and gender did not appear to be a factor in falling dispensing rates. Average LDL levels were lower in the statin group by (mean difference) 0.78 mmol/L (95% CI 0.74 to 0.81) in 2010 and 0.93 mmol/L (0.90 to 0.97) in 2012. 37.2% of all statin prescriptions was for Simvastatin 40 mg. Statins reduce cardiovascular events and mortality in CKD. However, in older patients typical of CKD, evidence is lacking. Chapter 6 examines survival in those dispensed a statin. Those dispensed a statin were younger, more likely to be male, had higher serum albumin and more co-morbid. After full adjustment, statin dispensing was associated with a 24% lower risk of death (HR 0.76, 95% CI 0.71 to 0.83) overall, 18% benefit for primary prevention (no prior coronary heart disease or cerebrovascular disease) (0.82, 0.74 to 0.91), 32% benefit in secondary prevention (0.68, 0.60 to 0.77), 22% benefit in younger (< 76 years) CKD patients (0.78, 0.67 to 0.92) and 22% benefit in the older (≥ 76 years) CKD patients (0.78, 0.71 to 0.85) over 4.5 years follow-up. To illustrate absolute risk reduction, the number needed to treat to avoid one death for all patients is 15.8 (95% CI 12.3 to 22.2) and 12.4 (9.3 to 18.5) for older CKD patients. This thesis demonstrates that centralised ascertainment of CKD is better at case finding, than existing PCP CKD registers. The linkage of additional, routinely collated healthcare data can develop CKD registers into a powerful tool for monitoring quality of care, efficacy of therapy and hypothesis generation which can, and should be, integrated into clinical IT systems with the appropriate information governance oversight in place.

The focus of this thesis was to investigate, especially in the context of obesity, the interactions among sleep duration and quality, and adverse health outcomes. Three comprehensive studies are described in the thesis: 1. A cross-sectional epidemiological study examined factors that are associated with both short and long sleep duration among an older Chinese population, and also assessed whether there was a link between sleep duration and chronic conditions such as obesity, hypertension, and diabetes. This study showed that long sleep duration was associated with increased risk for obesity among women. Additionally, demographic, socio-economic, and medical conditions were associated with sleep duration. Identifying potential factors that affect sleep will inform future interventions for improving sleep with potential downstream effect on obesity and other chronic disorders. 2. A cross-sectional study of patients with extreme obesity indicated that the prevalence of sleep disturbance is high in this patient population. There was a positive association between sleep disturbance factors and depressive symptoms and quality of life among these individuals. The findings emphasise the importance of adequate assessment and treatment of sleep problems in this patient population. 3. A systematic review and meta-analysis assessed the effectiveness of lifestyle modification interventions on the treatment of obstructive sleep apnoea (OSA). Lifestyle interventions such as dietary and physical activity improved OSA parameters, but were insufficient to normalise them. The findings will inform the development of future interventions for OSA, and are likely to contribute to clinical guidelines for OSA management.

In the last 10 years there has been a growth in working collaboratively with sex offenders by focusing on goals, tailoring treatment to the needs of the client, and an emphasis on therapist features (Andrews & Bonta, 2003 ; Ward, 2002). This thesis explored how sex offender treatment workers are responding to working with sex offenders in light of the changes. The introduction covers the key concepts and theory relevant to the thesis, and highlights the aims. The second chapter is a systematic literature review investigating the impact of working therapeutically with sex offenders. The review highlighted the extent sex offender treatment workers are impacted by their work was inconclusive. The third chapter focused on critiquing the Trauma Symptom Inventory (TSI; Briere, 1995) as a potential tool that could be used to assess distress in sex offender treatment workers. The critique revealed that the TSI had good reliability and validity. The fourth chapter explored the experiences of sex offender treatment workers using semi-structured interviews. All participants reported enjoying their work despite experiencing some negatives (i. e., intrusive images, suspiciousness, and concerns about clients re-offending). This chapter also highlighted that sex offender treatment workers reported using a range of coping strategies to manage the work. In addition, it was found that sex offender treatment workers believed a genuine interest in the work, hope, optimism, self-efficacy, and circumstances outside of work were related to enhanced resilience. The last chapter of the thesis involved discussing the implications of the findings from each of the chapters.

Childhood obesity is a global public health concern. In England, the prevalence of overweight/obesity increases from one fifth at the start of the primary school years to one third by the age of 10-11 years. This thesis examines the role of primary schools in preventing obesity. Stakeholder views are considered through a systematic review, and two qualitative studies investigating the perceptions of headteachers, parents and children. Data from a childhood obesity prevention trial (the WAVES study) are also used to examine the relationships between school policy/practice and pupil weight status/physical activity levels. Findings show that stakeholders support the school role in preventing obesity, and in helping families to lead healthier lifestyles, though limited expertise and resources are barriers. Although most schools actively promote health, there is much variation. For example, time allocated for physical education and breaks varies by school and has a significant impact on children’s physical activity levels, particularly for boys. In conclusion, school policies and practices can impact on children’s health, and schools are ideally placed to support families to prevent obesity. However, schools require support to perceive this role as a feasible and integral part of their function, rather than as an increasing burden of responsibility.

This thesis examines the effects of psychosocial factors and physical activity on antibody response to vaccination in healthy young, older, and HIV+ populations. Chapter Two found that a brisk walk prior to vaccination did not improve antibody response to pneumococcal or influenza vaccinations in young (18-30yrs) or older (50-64yrs) adults. Chapter Three examined whether a lifestyle physical activity intervention affected antibody response to pneumococcal vaccination in sedentary middle-aged women. There was no effect on antibody response, body composition or fitness measures, although there was an improvement in quality of life for the intervention group. Finally, Chapter Four investigated the relationship between psychosocial and physical activity status and antibody response to vaccination in HIV+ patients. Antibody response to some strains of the pneumococcal vaccine were predicted by higher physical activity levels (pn1, pn6b, pn18c), greater social support (pn3) and lower life events stress (pn1). However, the majority of analyses found that antibody response to vaccination was not affected by these measures. In conclusion, neither acute nor chronic walking interventions improve antibody response to vaccination, and only limited relationships are seen between psychosocial factors, physical activity status and antibody response to a variety of vaccinations.

Analytical methods based on gas chromatography in combination with electron capture negative ion/electron ionisation mass spectrometry were developed and validated for the separation and determination of legacy and emerging flame retardants (EFRs) in a wide range of samples including indoor air, dust, diet and human milk. A broad suite of EFRs and legacy flame retardants (FRs) including polybrominated diphenyl ethers (PBDEs) and hexabromocyclododecane (HBCDDs) were determined in indoor air and dust taken from offices and homes in Birmingham, UK. Comparison with previous data, suggests that temporal trends in contamination with EFRs and legacy FRs reflect changes in production and use of such compounds as a result of bans and restrictions on the use of legacy FRs. Using inter alia a simple, single compartment, steady state pharmacokinetic model, human exposure to FRs via air inhalation, dust ingestion and diet was estimated for different age groups and the relative importance of each exposure route to overall exposure assessed under different exposure scenarios. Concentrations of target EFRs were detected for the first time in UK human milk samples (n=35). Human exposure to EFRs and HBCDDs via diet was estimated for a population impacted by a rudimentary e-waste processing area in Vietnam.

Rationale: Hypoxaemia plays a role in the aetiology of abnormal skeletal muscle function in chronic obstructive pulmonary disease (COPD) via abnormal protein synthesis and mitochondrial function. Patients exhibiting exercise-induced desaturation (EID) have exercise intolerance, perhaps a consequence of muscle hypoxia. Ambulatory oxygen therapy (AOT) is indicated in these patients; however the evidence is derived from single assessment studies. This thesis explores the role of longer term AOT and whether it favourably alters skeletal muscle gene expression in patients with COPD and EID. Methods: A 12 week randomised controlled trial of AOT against air in 25 patients with COPD and EID was undertaken. Participants underwent skeletal muscle biopsies and exercise assessments. In parallel a systematic review of published literature from 1980-2014 for trials in which AOT was compared to placebo in COPD was completed. Results: The systematic review showed that AOT had no statistical effect on improving exercise capacity (6 minute walk or endurance shuttle walk tests); p=0.44 and p=0.29 respectively. Gene set enrichment analysis show the KEGG pathways of oxidative phosphorylation, PPAR signalling and fatty acid metabolism to be up-regulated following AOT (q < 2%) in the clinical trial of AOT versus Air. Conclusion: AOT has limited long term benefit in improving functional exercise capacity. It may however favourably alter gene expression in patients with COPD and EID.

The aim of this research was to evaluate the utility of innovative in vitro techniques as an alternatives for human/animal tissues to study the transdermal uptake of organic flame retardants from indoor dust and consumer products. Firstly, we successfully designed and applied an in vitro physiologically based extraction test to provide new insights into the dermal bioaccessibility of various FRs from indoor dust. These investigations revealed the bioaccessible fraction for the brominated flame retardants (BFRs) α-, β-and γ- HBCD and TBBPA to 1:1 (sweat/sebum) mixture to be 41%, 47%, 50% and 40%, respectively, while for the phosphate flame retardants (PFRs) TCEP, TCIPP and TDCIPP, the values were 10%, 17% and 19%. With the exception of TBBP A, the presence of cosmetics had a significant effect (p < 0.05) on the bioaccessibility of our target FRs from indoor dust. The presence of cosmetics decreased the bioaccessibility of HBCDs from indoor dust, whereas shower gel and sunscreen lotion enhanced the bioaccessibility of target PFRs. Secondly, we developed a protocol for studying dennal uptake of legacy and novel brominated flame retardants using two 3D-HSE (three dimensional human skin equivalent tissue) models, EpiDerm™ and EPISKIN™ in compliance with the OECD guidelines 428. Overall, results showed a significant negative correlation between the permeability constant of FRs and their Log K_ow values. We also mimicked real life exposure scenarios by exposing the skin surface in turn to FR-containing dust, reference material plastics and upholstered fabrics. Our findings showed that under such scenarios dermal exposure to FRs was appreciable for UK adults and toddlers. For example, for dust exposure, our estimates of daily intake indicated toddlers to be 10 times more highly exposed than adults in the presence of sweat and sebum. This differential exposure is likely attributable to more dust adhering to toddler's skin and their higher exposed skin surface area to body weight ratio compared to adults.

This thesis investigated the effects of acute eccentric exercise on the immune response to vaccination in young humans. Study one investigated whether the efficacy of the eccentric exercise intervention was affected by manipulating the timings of exercise prior to influenza vaccination. Three exercise groups were vaccinated immediately, 6 hr or 48 hr after exercise and antibody responses at 28 days post-vaccination were compared to those from a resting control group. All participants exhibited robust antibody responses to the vaccine and no effect of exercise was observed; therefore, it was not possible to determine the effects of exercise timing on vaccine responses. Study two investigated whether the antibody response to influenza vaccination was influenced by the intensity of eccentric exercise. Three groups exercised at an intensity eliciting 60%, 85% or 110% of one repetition maximum, and the antibody responses at 28 days post-vaccination were compared to those from a resting control group. In the exercise groups, both men and women showed enhanced antibody responses against the B/Florida strain, and men had enhanced responses against A/Uruguay, in comparison to resting controls. In both cases, the control group exhibited poorer responses against these strains, but no effect of exercise intensity was observed. Study three investigated whether the site of vaccine administration affected the efficacy of the immune response to hepatitis B vaccination following eccentric exercise. The antibody seroconversion rate to the vaccine was low (approx. 5 %), and thus, further analysis between exercise and control participants was not feasible. In sum, supporting previous research, it appears that acute eccentric exercise can enhance the immune response to poorly immunogenic strains of influenza, but research is needed to establish if exercise can enhance other poorly immunogenic vaccines, or vaccine responses in the immuno-compromised.