Background: The prevalence of obesity is higher in adults with intellectual disabilities (ID) than in the general population, with increased rates of secondary health risks and increased mortality rates. Multi-component weight loss interventions have been advocated by current UK clinical guidelines for all adults without ID. Such interventions incorporate dietary changes that produce an energy deficit, increased levels of physical activity and the use of behavioural approaches to promote and sustain changes in physical activity and dietary patterns, followed by a weight maintenance intervention. However, UK clinical guidelines have reported that the evidence base for the treatment of obesity in adults with ID is minimal. New evidence in this area of research could be used for the development of accessible weight management interventions for adults with ID and lead to a sustainable clinically significant weight loss. Methods: Study 1: A systematic review aiming to evaluate the clinical effectiveness of weight management interventions in adults with ID and obesity using recommendations from current clinical guidelines for the management of obesity in adults. Full text papers published between 1982 to 2011 were sought by searching the Medline, Embase, PsycINFO and CINAHL databases. Studies were evaluated based on 1) intervention components, 2) methodology, 3) attrition rate 4) reported weight loss and 5) duration of follow up. The assessment of the quality of the studies and interventions was based on the criteria of the Centre for Reviews and Dissemination (CRD) (University of York) and the PRISMA checklist. Study 2: The evidence base for the development of weight maintenance interventions in adults with ID is limited. This study presents the findings of the second phase of a multi-component weight management programme for adults with ID and obesity (TAKE 5). A total of 31 completers of the 16 week weight loss intervention of the TAKE 5 programme were invited to participate in a 12 month weight maintenance intervention. The TAKE 5 weight maintenance intervention included monthly one to one sessions and monthly phone calls, using the recommendations of the Glasgow and Clyde Weight Management Service (GCWMS) and of the National Weight Control Registry. The intervention provided a dietary advice based on the estimated energy requirements of each participant, advice to improve physical activity and behavioural approach techniques to facilitate changes in physical and dietary patterns. Participants’ body weight, BMI, waist circumference (WC) and levels of physical activity were measured before and after the intervention. Paired t tests were used to assess differences in anthropometric and physical activity measurements. Study 3: 52 participants of the TAKE 5 weight loss programme were individually matched by baseline characteristics (gender, age and BMI) with two participants without ID of the GCWMS programme. Non parametric significance tests were used for comparisons between groups in terms of weight and BMI change and rate of weight loss. In addition, data from the 52 completers with ID of the TAKE 5 weight loss intervention were used to perform a univariate logistic regression analysis for the identification of socio-biological predictors for absolute weight loss and clinically significant weight loss at 16 weeks. Study 4: Semi-structured interviews were used to explore the experiences of 24 carers that supported participants of the TAKE 5 weight loss programme. The transcripts were analysed qualitatively using the qualitative data software analysis package, ATLAS ti 5.2 software. Thematic analysis was used to examine potential themes within data. Results: Study 1: Twenty two studies met the inclusion criteria. The interventions were classified according to inclusion of the following components: behaviour change alone, behaviour change plus physical activity, dietary advice or physical activity alone, dietary plus physical activity advice and multi-component (all three components). The majority of the studies had the same methodological limitations: no sample size justification, small heterogeneous samples, no information on randomisation methodologies. Eight studies were classified as multi-component interventions, of which one study used a 600 kilocalorie (2510 kilojoule) daily energy deficit diet. Study durations were mostly below the duration recommended in clinical guidelines and varied widely. No study included an exercise program promoting 225-300 minutes or more of moderate intensity physical activity per week but the majority of the studies used the same behaviour change techniques. Three studies reported clinically significant weight loss (≥ 5%) at six months post intervention. Study 2: 28 participants completed the TAKE 5 weight maintenance intervention. Most of the participants (50.4%) maintained their weight (mean weight change=-0.5kg; SD= 2.2) within ± 3% from initial body weight at the end of the weight maintenance intervention. There was no statistically significant change in BMI and WC at 12 months from BMI and WC at the end of the 16 week weight loss intervention. There was no statistically significant decrease in the time spent in sedentary behaviour and no statistically significant increase in the time spent in light and in moderate to vigorous physical activity. At the end of the weight maintenance intervention participants spent less days walking (at least 10 minutes) than at the end of the end of the weight loss intervention (P<0.05). Study 3: There were no significant differences between participants with ID and participants without ID in the amount of weight loss (median:-3.6 vs. -3.8, respectively, P=0.4), change in BMI (median: -1.5 vs. -1.4, P=0.9), success of achieving 5% weight loss (41.3% vs. 36.8%, P=0.9) and rate of weight loss across the 16 week intervention. Only, initial weight loss at four weeks was positively correlated with absolute weight loss at 16 weeks (P<0.05). Study 4: Three themes emerged from the analysis: Carers’ perceptions of participants’ health; barriers and facilitators to weight loss; and carers’ perceptions of the weight loss intervention. Data analysis showed similarities between the experiences reported by the carers who supported participants who lost weight and participants who did not. Lack of sufficient support from people from the internal and external environment of individuals with ID and poor communication among carers, were identified as being barriers to change. The need for accessible resources tailored to aid weight loss among adults with ID was also highlighted. Conclusions: Study 1: Weight management interventions in adults with ID differ from recommended practice and further studies to examine the effectiveness of multi-component weight management interventions for adults with ID and obesity are justified. Study 2: The TAKE 5 weight maintenance intervention can effectively support adults with ID maintain their weight. Assessment of the cost effectiveness of the TAKE 5 weight management programme is justified. Study 3: The TAKE 5 multi-component weight loss intervention in its current structure can be equally effective for adults with ID as in adults without ID and obesity. A study with a larger sample could facilitate the identification of sociological and biological predictors for weight loss in adults with ID. Study 4: This study identified specific facilitators and barriers experienced by carers during the process of supporting obese adults with ID to lose weight. Future research could utilise these findings to inform appropriate and effective weight management interventions for individuals with ID.

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This thesis includes theoretical contributions to organisational studies and medical sociology, drawn from a three levelled ethnographic case study of commissioning by General Medical Practitioners in the setting of the English National Health service. In order to locate these levels as interrelated structures, the concept of “field” (Bourdieu, 2005, Fligstein, 2001, Fligstein and McAdam, 2012, Lewin, 1997 [1951]) is used. Jens Beckert (2010) has developed a framework in which cognitive frames, networks, and rules are in a relationship of irreducible interdependency. The definitions of analytic categories in the extant framework are under-developed. In this thesis, the framework is empirically applied to add definition to the analytic category “cognitive frame”. Beckert’s Framework and Weick’s (Weick, 1995, Weick, 2000, Weick et al., 2005) Sensemaking Perspective are intersected to develop a reciprocal relationship between the two theories. By conceptualising cognitive frame as a sensemaking process, insight is gained in three different but overlapping facets: wider contexts, temporality, and distributed sensemaking. At the level of an industry a cognitive frame can be described as a sensemaking type, which will have constituent sensemaking styles associated with that industries internal networks. When rules require organisations from separate industries or sectors to form partnerships then actors with different sensemaking types will be required to interact within one network. Organisational development techniques can be used to support and align sensemaking in both of these circumstances. Sensegivers may have an important role in pacing, including suspending, sensemaking. The thesis also contains insights for medical sociology in respect of how and why GPs commission as they do. These relate to the impact of belonging to the NHS family; differing permutations of changes to the profession (hybridisation, restratification, and the delimitation of autonomy) in GP networks; GP compliance with rules; and the characteristics of an inner-city GP workforce.

People living with advanced disease face challenges to their being-in-the world; these are attributable to both the nature and progression of their illness and the level and variability of their care needs. Recent policy initiatives and literature promote community care for patients with advanced disease, and there are a plethora of different health services that may be involved in care provision for people in the last year of their lives. The current research takes a phenomenological approach, informed primarily by the work of van Manen, to explore the lived experiences of patients and their spousal-carers in relation to the multiple services that are involved in their care. In-depth, semi-structured interviews with twelve patients with advanced disease, and eight spousal-carers were conducted. These interviews employed the Pictor technique to support people in reflecting on, and communicating, their experiences of care situations. Pictor is an innovative technique that is used with lay-participants for the first time in this research. The technique encourages people to reflect on relationships and personal experiences, and then to communicate these through the creation and discussion of a visual chart. The digitally recorded data were transcribed verbatim and analysed using interpretive phenomenological methods, supported by Template Analysis, which allowed the hierarchical coding of themes. The research findings indicate that advanced disease affects people in many different ways; participants’ perceived meaning of illness is instrumental in how they view and engage with health care services. The lived experience of this phenomenon is discussed as an ‘unhomelike-being-in-the-world’, and ‘striving for poise’. The varied experiences of participants are illuminated and further explored with a focus on key relationships with health care providers. Here, it is argued that consideration of ‘authentic relationships’ is a valuable resource in supporting people affected by advanced disease.

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Aim: Within the field of obesity, evidence shows that weight regain following weight loss is extremely common, demonstrating that weight loss treatments are not effective. Considering that attachment history influences a person’s capacity for emotional regulation and that some people use food to self-soothe, increasing our understanding of the relationship between attachment style and obesity might inform better treatments. This study is comprised of two parts: the first part investigates whether attachment style predicts outcome in a 12-session group treatment for obesity and the second part explores the experience of that treatment. Design: The study utilises a mixed methods design with participants from a group treatment for obesity which comprises: the Attachment Style Questionniare (ASQ), completed by 52 group members, along with their body mass index (BMI) measures at the start and end of the treatment, analysed using a backwards multiple regression to test whether the 5 dimensions of the ASQ can predict participants’ change in BMI; and semi-structured interviews with 7 people from the same treatment analysed according to Interpretative Phenomenological Analysis (IPA) guidelines. Method: Data was collected from 52 people attending group treatment for obesity with an NHS service in South East England, which included the ASQ and BMI measures at Week 1 and Week 12 of treatment. The change in BMI was entered as the dependent variable for the regression in SPSS and the five attachment dimensions were entered as predictors. 7 people who had taken part in Part I of this research participated in interviews about their group experience. Transcripts were subjected to IPA. Results: Quantitative findings produced a model in which the ASQ dimension Confidence (in relationships) significantly predicted change in BMI in a negative direction (i.e. the participants who scored higher on Confidence lost less weight than those with lower scores). Confidence explained 8% of the variance (R2=0.08, F(1,50)=4.32, p<0.05). Qualitative findings produced four super-ordinate themes which included: the sadness at the course ending; the support and comfort felt from others in the group experience; the positive aspects of the group treatment; and the negative aspects of the group treatment. Other group members appeared to have a substantial impact on participants, whether positive or negative. Some accounts reflected the importance of others in feeling accepted and supported. Other accounts conveyed less of an emphasis on feeling part of the group and more on feeling separate. Conclusions: The quantitative results are inconclusive and possible reasons for this are discussed. The qualitative findings suggest that it is likely that group intervention for obesity could be improved by attention to attachment and by tailoring treatments more specifically to individuals.

This thesis develops statistical methodology for disease mapping, an increasingly important field of spatial epidemiology. Disease mapping has applications in public health by allowing for identification of areas which are at high risk of particular health problems. Such approaches are generally based on areal data, which involves partitioning the study region into a set of non-overlapping areal units and recording counts of disease cases within each areal unit. The majority of approaches assume a spatially smooth risk surface, but this may not be realistic, and there has been recent interest in developing methodology which allows for discontinuities in this structure. This can be done by identifying clusters of areal units with similar disease risks, and allowing for discontinuities between these clusters. The work presented in this thesis develops models to identify such clusters and also estimate disease risk. Three Bayesian hierarchical models are proposed; the first two are based on spatial data at a single time point, while the third extends into the spatio-temporal domain by modelling across multiple time points. Each model is applied to respiratory hospital admission data from the Greater Glasgow and Clyde Health Board area in order to identify clusters which have high disease risk.

This thesis explores the various roles that visual representations played in the theoretical understanding of, and practical approaches to, venereal disease in London’s medical marketplace from around 1780 to 1860. Venereal disease was understood in a variety of ways, and conceptualised within a number of different medical disciplines, such as pathology and dermatology. The analytic lens of visual representation allows the historian to explore the complexities of these understandings. This thesis therefore contributes to the literature on the historicising of disease. The period under discussion was one of enormous change in medical theory, practice and disciplinary organisation. Disease was being conceptualised as something physical within the body, meaning images of the disease took on new meanings. Furthermore, these representations played an important role in medical education of the period, as well as in the legitimisation of new disciplines. Within these new theoretical paradigms and institutional spaces, various new meanings were created for the visual representations, and their creators and users had to employ various strategies to limit their meaning and control their interpretations. This thesis utilises a variety of visual and material representations – atlas illustrations, wax moulages, paintings, casts, models and pathological preparations – to see how meaning was negotiated for these visual representations. Venereal disease is a particularly complex case, as it was considered difficult to depict, therefore debates and disagreements over how it was to be visualised reveal much about how the disease was conceptualised. Through five chapters, the thesis explores how these representations functioned within different spaces in London’s medical marketplace, such as public museums, private schools, hospitals and university medical departments.

The health experiences, and the lived experiences in general, of homeless young women have largely been overlooked. In seeking to redress this situation, the research findings presented in this thesis support those from other homelessness studies; the sample's health was poor. However, drawing upon a wider range of research traditions than is normally the case, conceiving health in terms of physical, mental and social well-being, and employing qualitative methods to facilitate verstehen of the epiphanies and processes involved in the outcome of 'homelessness', the meanings these lived experiences had engendered, and the lifeworld of 'homeless' young women, this study problematises the rather biomedical orientation of most homelessness and ill-health studies. The fundamental argument presented is that homelessness and poor health outcomes are products of the same iniquitous structures that affect a much greater population, yet the medicalisation of homelessness has served to obscure this and reinforce difference. Accordingly, the concepts of social exclusion, youth transitions and identity in late modernity provide a normative 'way of seeing' the experience of homelessness and its relationship with health. By simply conceiving the subjects of research as cognisant and purposive agents whose lived experiences are rooted in the structures and processes of exclusion inherent in late modernity, yet mediated by the affective body, the importance of acknowledging relativity, as a social concept in homelessness research is demonstrated. This is accomplished by exploring the sample's lived experiences as the contexts within which their health meanings and actions are informed and effected. It is shown that 'homelessness', portrayed by the sample as a stage of transition between the structured limitations of the past and their aspirations for the future, does not only produce negative health outcomes.