The severity of the outbreak of an infectious disease is highly dependent upon the structure of the population through which it spreads. This thesis considers the stochastic SIR (susceptible → infective → removed) household epidemic model, in which individuals mix with other individuals in their household at a far higher rate than with any other member of the population. This model gives a more realistic view of dynamics for the transmission of many diseases than the traditional model, in which all individuals in a population mix homogeneously, but retains mathematical tractability, allowing us to draw inferences from disease data. This thesis considers inference from epidemics using data which has been acquired after an outbreak has finished and whilst it is still in its early, `emerging' phase. An asymptotically unbiased method for estimating within household infectious contact rate(s) from emerging epidemic data is developed as well as hypothesis testing based on final size epidemic data. Finally, we investigate the use of both emerging and final size epidemic data to estimate the vaccination coverage required to prevent a large scale epidemic from occurring. Throughout the thesis we also consider the exact form of the households epidemic model which should be used. Specifically, we consider models in which the level of infectious contact between two individuals in the same household varies according to the size of their household.

Background and aims: Recent decades have seen material shifts in global migration flows. Migrants now come to the UK for an increasing number of reasons and from an increasing number of countries. This presents a challenge for health services that must provide care to individuals with a broad range of needs. In particular, there is concern that asylum seekers and refugees (ASRs) are at heightened risk of poor wellbeing and of receiving suboptimal healthcare. Concurrent with these shifts in migration, increasing attention is being paid to noncommunicable diseases (NCDs), which are now the most significant drivers of morbidity and mortality in most regions of the world. In the UK, the burden of NCDs is not evenly distributed, with inequalities related to ethnicity and socioeconomic status shaping an individual’s risk of ill health. Little is known, however, about how diverse migrant groups, including ASRs, conceptualise health and respond to health prevention messaging. Against this backdrop, this thesis aims to understand the health-related experiences of one such group – asylum seekers and refugees (ASRs) from Sub Saharan Africa living in Glasgow Scotland. Specifically, it explores: a) perceptions of health, wellbeing, and illness causation, b) experiences of accessing primary and preventive healthcare, and c) the factors influencing these perceptions and experiences. It also seeks to elucidate professional perspectives on ASR health. Methods: To gain an in depth understanding of ASR health perceptions and experiences, as well as professional perspectives, a focused ethnography was undertaken. This approach utilised four qualitative methods: community engagement, participatory focus groups, semistructured interviews, and go- along interviews. In total 12 primary care and public health professionals were interviewed, and 27 ASRs took part in either a focus group, an interview, or both. The thesis took a theoretically informed approach, seeking to determine whether and how two theories – ‘candidacy’ (Dixon-Woods et al 2005) and ‘structural vulnerability’ (Quesada et al 2011) – might deepen our understanding of ASR health. Results: Candidacy enhanced understanding of how ASRs identified and responded to messages about ‘healthy lifestyles’. ASR participants considered keeping healthy to be an individual responsibility, with diet and exercise highlighted as especially important. At the same time, however, perceptions and experiences of health and wellbeing were shaped by a number of structural influences, which limited the capacity of ASRs to engage in health practices. Therefore, while ASRs considered health to be an individual choice in theory, they did not necessarily feel they had the ability to be healthy in practice. The theory of structural vulnerability proved useful in identifying the wider structural determinants that impacted on an individual’s capacity to respond. There were several important structural influences, including poverty, racism, discrimination, and language barriers. The greatest negative influence, however, and one that compounded all the others, was the asylum process. This diminished individuals’ capacity to identify as candidates for prevention messages, engage in preventive health practices, and/ or access care in an optimal fashion. Conclusions: Efforts to engage ASRs in preventive health programmes and practices must take into account the ways in which the immigration and asylum system acts as a determinant of health, affecting both what it means to be healthy and what capacity individuals have to engage. The NHS, together with non statutory bodies, has a role to play in mitigating some of the vulnerabilities to which ASRs are subject.

Background: Early detection strategies for oral cancer aim to decrease the mortality rates and improve outcomes of the disease through early diagnosis and treatment. Guidance and regulatory bodies have an expectation that general dental practitioners will be able to promptly detect and refer patients with suspected oral cancerous lesions. However, the opportunities for early detection of oral cancer in primary dental care settings (particularly considering the low overall volume of the disease, the potentially increasing incidence rates, and the possibility of certain communities exhibiting particularly high rates) have not yet been investigated. This thesis examines the feasibility of early detection of oral cancer in primary dental care services, and undertakes risk-stratification to identify “high-risk” communities that can be utilised to target future early detection efforts. It further explores potential or missed opportunities for early detection in dental and other healthcare settings (both primary and secondary care), and assesses the feasibility of exploring routes to diagnosis. Aim: The aim of this thesis was to investigate opportunities for the early detection of oral cancer in Scotland by measuring the current burden of the disease, examining the feasibility of early detection in a dental setting, and exploring the potential role of alternative health care settings in early detection efforts. Methods: Descriptive epidemiological and data linkage cohort studies utilising national routine administrative health datasets were undertaken. The descriptive epidemiological analysis included all cases of head and neck cancer diagnosed between 1975 and 2012 and registered on the Scottish cancer Registry and annual midterm population estimates. These data were used to examine the incidence trends between 1975 and 2012 and the projected burden up to 2025 by individual subsites (oral cavity cancer, oropharyngeal cancer, and laryngeal cancer), age, sex, health board region, and socioeconomic status. The cohort study included all patients diagnosed with oral cancer between 2010 and 2012 and registered on the Scottish Cancer Registry. The individual patient data were linked to NHS dental service activity in the two years prior to diagnosis, and this linked cohort dataset and published NHS Scotland dental workforce and registration and participation statistics were used to examine dental attendance rates and the feasibility of early detection of oral cancer in the primary dental care setting. The individual patient data from the cohort were also linked to the hospital outpatient, hospital inpatient/day case, primary dental care, and general practitioner prescription databases. These four healthcare services were selected based on data availability. The linked data were used to examine all healthcare service contacts made by the cohort in the two years prior to referral. Additionally, a preliminary exploration of the referral period (defined as the one-month period prior to diagnosis) was also undertaken. Results and conclusions: The findings of this thesis showed that the incidence rates of head and neck cancer had increased in Scotland between 1975 and 2012, and this appeared to be largely driven by a dramatic rise in the rates of oropharyngeal cancer in recent decades. This burden was predicted to continue to rise up to 2025, with the rates of oropharyngeal cancer bypassing the rates of oral cavity cancer, which were expected to exhibit only a modest increase. Males, individuals above 60 years of age, and those from the most deprived areas of Scotland consistently exhibited the highest rates of cancer, irrespective of subsite. Moreover, an almost dose-like effect was seen to exist, with the rates of cancer increasing with the level of deprivation. Therefore, contrary to previous reports that oropharyngeal cancer exhibited an inverse socioeconomic profile, Scotland country-level data showed that those from the most deprived areas consistently bore the greatest incidence burden of head and neck cancer. Despite these increasing trends, the overall burden of oral cancer in Scotland was relatively low, and just over half of the cohort examined in this thesis had not contacted a general dental practitioner in the two years prior to diagnosis, thus automatically limiting opportunities for early detection. Dentists were estimated to potentially encounter one patient with oral cancer every 10 years, one patient with oral cavity cancer every 17 years, and one patient with oropharyngeal cancer every 25 years. Therefore, strategies for early detection must consider the rarity of oral cancer incidence and the poor dental attendance patterns of patients, and the expectations of dentists in these efforts must be tempered. These results also highlight the importance of improving access and uptake of dental services among those at the highest risk of developing oral cancer (i.e. those from the most deprived communities). When examining the linked cohort data and undertaking a look-back analysis of their healthcare service contact history, just under half (45%) of the patients diagnosed with oral cancer were seen to have actually visited a primary care dental service clinic in the two years prior to the start of the referral period. However, the majority of the patients with oral cancer had contacted one of the four healthcare services examined (hospital outpatient, hospital inpatient/day-case, primary dental care, and general practitioner prescription) at least once over the same period, suggesting that there were potential or missed opportunities for the early detection of oral cancer in primary dental care and alternative healthcare settings. The proportions of patients contacting the four services increased closer to the start of the referral period, as did the mean number of contacts made with each service. Although not all of these instances would have necessarily been associated with missed opportunities for early detection, it was highly likely that there were potential or missed opportunities amongst at least some of the patients with oral cancer. The two most common services contacted most recently before the start of the referral period were general practitioner prescription and hospital outpatient, and there was a possibility that these services were the sources of referral. The hospital specialties contacted most frequently during the one-month referral period were ENT, oral surgery, oral and maxillofacial surgery, and general surgery, suggesting that these contacts were likely to have been associated with the signs and symptoms of oral cancer. While no significant opportunities for the early detection of oral cancer in hospital or secondary care settings were identified, these findings demonstrated considerable potential in other primary care settings, particularly general medical practices and community pharmacies.

The global population is rapidly urbanising, with East Africa experiencing some of the fastest rates of urban growth. Urbanisation drives changes in diet, including increased consumption of animal source products (ASPs), and livestock value chains are becoming increasingly long and complex to meet these demands. This may place urban consumers at increased risk of food-borne infectious diseases. Evaluation of food-borne disease (FBD) risk to urban consumers in developing countries has been hampered by a lack of data on the composition of urban diets, and a lack of methodologies to systematically assess risk along food value chains which are typically informal, unregistered, and unregulated. This research used a value chain risk assessment approach (VCRA) to evaluate food-borne infectious disease risks along dairy value chains supplying Moshi Municipality, the regional capital of Kilimanjaro, Northern Tanzania. Our findings demonstrated that by far the most frequently consumed products were unpackaged milk and mtindi (fermented milk). While there was some role for urban livestock keepers in supplying these products to their communities directly, most of the milk and mtindi sold within Moshi originated with milk produced by smallholder farmers in rural areas surrounding the towns. Both the milk and mtindi value chains involved similar value chain nodes and actors, with a large degree of overlap between the formal and informal sectors and little to no formal education or training on milk handling and hygiene for chain participants. VCRA identified the bulking, wholesale and retail stages of the value chain as potential hotspots for introducing infectious disease risk. Consumers were well informed about many of the FBD risks posed by milk, and took active steps to mitigate these risks by boiling before consumption; however they perceived mtindi as posing a lower risk and were unable to mitigate risks with any preparatory step as mtindi is consumed as purchased. The highest risk to consumers was estimated to be posed by mtindi rather than milk, particularly mtindi made from leftover unsold milk, as this milk had a high risk of contamination. More studies are needed to investigate the infectious hazards present in both mtindi and other fermented milk products which are consumed widely across the region. The practice of valorising leftover ASPs as alternative products for human consumption may represent a particular source of FBD risk to urban consumers in developing countries.

This thesis examines the dynamic of infectious diseases after natural disasters. Methods from epidemiology and geography intersect in the nexus of this research to form new insights into the risk of infectious disease in the aftermath of natural disaster and catastrophe. In the past decades, natural disasters have increased in frequency and magnitude, and with climate change progressing as it is, this trend is expected to continue. It is thus important to gain a fuller understanding of the dynamic between natural disaster and disease, and challenge the persisting problems in disaster and disease response efforts. Two approaches were taken to determine the risk of disease after disaster. Firstly, by pooling data from previously published literature, a form of meta-analysis was conducted to gain insight into risk patterns as well as to define relevant confounding factors that held significance in determining vulnerabilities of affected populations. For this analysis, a new tool was applied to identify relevant research, and this tool is expected to be useful in future study of the subject. Secondly, a set of empirical studies were conducted to determine the association between types of natural disasters, geographic region, and four distinct disease profiles. Cholera, malaria, tuberculosis, and the co-infection with HIV and tuberculosis served as examples for the types of diseases commonly observed after disasters (diarrhoeal diseases, vector-borne diseases, and acute respiratory infections). Logistic regression models were used to find the odds ratios for above average diseases at different tiers of disaster magnitude. It was shown in this research that the relative risk of infectious disease after natural disasters was 3.45, indicating a higher probability of disease after disasters. Specific results show that disasters affecting higher numbers of the population typically lead to increases in new infections. Most interestingly, tuberculosis relapses showed significant increases after natural disasters, especially meteorological and hydrological disasters.

The dominant political ideology emphasises the patient as a consumer and partner in health care. Correspondingly, the move towards patient-centred nursing, based on the principles of humanism and individualism, emphasise the central role patients' should play in the nurse-patient encounter. Additionally, changing social and demographic trends highlight the importance of medication as a health care issue. Thus, current health care policy and practice contexts highlight the importance of patients' participation in health care as consumers and partners and, nurses' ability to make an effective contribution to educating patients about medication as part of their role in health education and promotion. However, despite the significance of this context, little is known about the extent and manner of patient participation, or the contribution that nurses make to this important health promotion activity. Therefore the purpose of this study is to extend knowledge in this area by describing and explaining patient participation in medication interactions, as it occurs within the reality of the clinical context. In order to study patient participation in medication interactions in the reality of the clinical context, a case study approach was adopted. Three case sites were sampled and included: 1) an acute medical ward, 2) a community hospital rehabilitation unit, and 3) a community mental health service. Data collection methods employed to explore and describe patient participation in medication interactions included: non-participant observation, audio-recording of nurse-patient interactions, nurse interviews, patient interviews, reflective field notes, focus groups and documentation. The data analysis framework included the use of conversation analysis for nurse-patient interaction data and content analysis for other qualitative data. The findings indicate that patient participation can be understood at least in part by the communicative practices and choices that nurse and patients/clients make. More specifically a range of conversational strategies were employed by nurses to initiate and control conversations and by doing so inhibited patients' participation. However a comparison of findings across sites indicates that there were both differences and similarities in the extent to which nurses facilitated and inhibited patient participation. A number of influencing factors were identified that helped to explain these findings. These include: power, nurses' communicative style, knowledge, skills and experience, patients' age, acuity of illness and level of knowledge, and the organisation and philosophy of care. The findings from the study make a unique contribution to the body of knowledge in a number of ways. First, as the only study to describe patient participation in medication interactions between nurses and patients, it identifies that participation can occur at an interactional level, as well as a more practical level via, for example, the potential to self medicate and independently manage medications. Related to this, it has also contributed to the conceptual clarity and development of the concept of patient participation. This study has highlighted that patient participation may be realised and understood more fundamentally, at the level of the nurse-patient interaction, in contrast to previous research that conceptualises participation as making choices and involvement in decisionmaking. Furthermore, by the successful use of conversation analysis, this study has also advanced knowledge about potential ways to investigate patient participation at the level of nurse-patient discourse. Finally, this study provides a contribution to advancing theoretical explanations of patient participation through the construction of a framework of explanatory factors influencing patient participation. A framework for enabling participation has been developed based on the specific conclusions and principles for action drawn from the findings and from the philosophy of Freire (1972; 1983), which acknowledges an individual's potential to be empowered and assume control. The framework proposes that addressing attitudinal, interactional, relational, educational and contextual issues, might facilitate patient participation. Implications and recommendations reflect the practice and education requirements needed to implement such a framework.

Within healthcare, the concept of specialisation remains both poorly defined and under-debated in the literature. This research analyses the concept of specialisation and assesses the maturity of the concept of the diabetes specialist podiatrist; tracing the origins, change over time and current status of podiatric specialisation in diabetes. Literature pertaining to the legal implications of specialist practice, settings and titles is reviewed and a definition of specialisation within the context of healthcare is proposed. The initial concept analysis led to refinement of research questions which directed further enquiry. Because answers to the research questions lie within the knowledge and experiences of key actors, managers and individual podiatrists who have held specific posts; a qualitative methodology featuring focus group and key actor interviews was utilised. The meaning of podiatric specialisation in diabetes, how diabetes evolved as a podiatric specialty, the impact of specialist titles and the longer-term, wider implications which accompany specialisation were explored. In presenting analysis of the data, the researcher focuses on theory which illuminates the findings. The centrality of Weber’s concept of charismatic authority to the development and contemporary face of specialist practice is illustrated by the data; thus it represents a guiding theoretical concept within the author’s thesis. Documentary analysis was used as a triangulation strategy, in a bid to corroborate findings elicited through interview techniques. The documentary data also illustrates both the scale of and the context within which podiatric specialisation in diabetes evolved – not in isolation, but rather as one of many specialist foci.

Multiple sclerosis (MS) is a chronic autoimmune disease characterised by inflammatory attacks on the central nervous system. Fatigue is a common symptom in MS, yet its aetiology, exacerbating factors, and manifestation in everyday life are unclear. Given its role in regulating inflammation, energy metabolism and stress responses, cortisol is a relevant psychobiological target for MS fatigue research. The primary aims of this thesis were to examine diurnal fatigue patterns and contextual effects of daily stressors and mood in people with relapsing-remitting MS (RRMS); explore cortisol secretory activity in RRMS in everyday life; and investigate associations of cortisol with fatigue at baseline and change in fatigue 6 months later. Data were collected in an ecological momentary assessment study incorporating repeated real-time selfreports and salivary cortisol assessments over 4 consecutive weekdays in an RRMS group (n = 38) and healthy control group (n = 38), matched for age and sex. Statistical analysis was predominantly by multilevel modelling. The analysis presented in the first empirical chapter (Chapter 3) demonstrated that RRMS fatigue typically follows an increasing (but decelerating) within-day fatigue trajectory, distinct from linear trajectories in controls. Fatigue was sensitive to stressor and mood fluctuations within-subjects in both groups. The analysis presented in the second empirical chapter (Chapter 4) described larger cortisol awakening responses in RRMS compared to controls, but similar diurnal cortisol slopes. Cortisol reactivity to daily life stressors was apparent in both groups, mediated by self-reported distress. A systematic review was conducted (presented in Chapter 5) showing attenuated diurnal cortisol variability is most-frequently associated with fatigue across clinical populations; cortisol output appeared less relevant. However, the analysis presented in the final empirical chapter (Chapter 6) showed greater cortisol variability in the morning (larger cortisol responses to awakening) was associated with RRMS fatigue. Flatter diurnal cortisol slopes were associated with fatigue in controls. Chronic stress and depressive symptoms did not moderate associations, and there was no relationship between cortisol and change in fatigue 6 months later in either group. The original research presented confirms MS fatigue is not a stable symptom experience in everyday life, is sensitive to psychosocial contextual factors, and is associated with cortisol, potentially via pro-inflammatory immune mediators.

The aim of this research was to examine nurses' and health care assistants' perspectives of infection control practice on one hospital ward and use this as the basis for the development, implementation and evaluation of an education and support programme for improving practice on the ward. In Phase I of the study, nurses and health care assistants were interviewed using a semistructured interview schedule to explore their views and anxieties about infection control practice and identify their priorities for practice development. Qualitative and quantitative analysis of these data revealed that respondents' concerns related primarily to the use of Contact Precautions for patients with Clostridium difficile associated diarrhoea (CDAD) and Methicillin resistant Staphylococcus aureus (MRS A). Structured observations of practice were employed to confirm the prevalence of the issues raised in relation to this and provide an understanding of their context. The findings of Phase I informed the design of an intervention to improve practice. This involved the development of a practice guideline on Contact Precautions and the availability of practical instruction and support during its implementation. In Phase II of the study, participant observations of practice were conducted to gain an understanding of nurses' and health care assistants' behaviour and in particular, their responses to the supportive intervention. Their perceptions of its impact on their practice were ascertained in Phase III using semi-structured interviews. Qualitative analysis of these data revealed that participants experienced great difficulty understanding and implementing infection control recommendations. Factors that may help explain this include nurses' and health care assistants' knowledge and skills in infection control, their personal belief systems and self-preservation instincts. In addition, the recommendation to use Contact Precautions for patients with infectious conditions such as CDAD and MRS A may itself counteract attempts to promote the routine use of infection control precautions in clinical practice. It is suggested that in relation to infection control, there may be a need to radically re-think the ways in which health care workers are educated and supported in practice. Moreover, it is argued that until the ambivalent evidence base relating to the use of Contact Precautions is resolved, messages about infection control are likely to generate confusion amongst health care workers.

Previous research has shown that children with a parent with a chronic medical condition may face psychosocial difficulties. This thesis presents a series of studies to explore how children adjust to their parents’ Multiple Sclerosis (MS). Study 1: A systematic review of the literature showed a number of factors linked to children's adjustment and also that adolescents might be at increased risk of psychosocial problems compared to younger children with a parent with MS. Study 2: Following the systematic review, a qualitative interview study, is presented, with 15 adolescents with a parent with MS which showed how adolescents view their increased responsibilities and also the importance of the parent without MS to provide practical and emotional support. Study 3: Mixed methods were used in order to develop a questionnaire (Perceptions of Parental Illness Questionnaire, PPIQ) to measure adolescents’ beliefs about their parents’ MS. To assess the psychometric properties of the newly developed questionnaire, 104 adolescents completed the PPIQ together with standardised measures of emotional and behavioural adjustment and illness-related impairment. The PPIQ appeared to be valid and reliable. Study 4: Finally, the data of the questionnaire development study was used in a longitudinal design study in which 56 parents with MS, 40 partners without MS and 75 adolescent children were included. The findings showed that parents’ anxiety and depression symptoms, parents' emotional expression and adolescents' views about MS were associated with adolescents' adjustment. MS characteristics (e.g. MS severity, type, time since diagnosis, relapses) and adolescents' reports on parent-adolescent communication were not associated with their adjustment. Family environment and adolescents’ illness beliefs are important factors to be incorporated in future interventions to support adolescents’ adjustment to parental MS.