In this thesis I advance a socio–representational perspective on sexual and reproductive health as constructed by indigenous Mexican adolescents. The social and psychological literature on health among indigenous populations and on adolescent sexual health is reviewed. It is argued that a socio–psychological perspective is needed to understand the resources through which contemporary indigenous youth, a population overlooked by research, make sense of their sexual and reproductive health. In generating the theoretical tools to tackle this issue, I adopt a dialogical approach to social representations theory to sharpen Jovchelovitch’s (2007) model of knowledge encounters by proposing a typology of potential outcomes of these encounters. The empirical research involved female and male indigenous adolescents in two social contexts: rural and urban. In–depth individual interviews, focus group discussions and unstructured observations were employed for data elicitation. Results from the interpretative thematic analysis performed are presented through a ‘funnelling’ approach whereby the interdependent engagements of indigenous adolescents with their social context, their partners and specific health beliefs are discussed by highlighting nuanced differences in relation to social context and gender. Key findings are related to the understanding of romantic relationships in terms of stability and continuity, which impacts on the way that sex and contraception are perceived and experienced. Results also reveal that, in dialogue with others, adolescents come to identify alternative ways of positioning themselves with regards to customary discourses about sexual health. Focus group discussions are further examined through a dialogical analysis of interactions that aim to identify, in sociodialogue, the outcomes of knowledge encounters initially proposed. A further data–driven outcome is subsequently added to the typology and analytical categories are refined. Implications for health promotion in terms of the reflexion entailed in dialogue are offered in the conclusion chapter.

This dissertation presents the findings of a project where, following investigation and assessment, a million tonnes of sand and gravel at a contaminated former US Air Force Base was excavated for use as aggregate. The process required on-site screening for petroleum hydrocarbons of over 7,000 soil samples and provided an opportunity to assess the efficiency of the investigation, assess the application of geophysics of hydrocarbon contaminated sites, and look at the role of aggregate extraction in the contaminated land industry.

This thesis consists of five elements which, when taken together, articulate the journey of personal and professional development I have undertaken as an action researcher, and convey the emotional context of this type of work. The foundation for my development journey was the undertaking of a three year action research study which aimed to improve the care for older people on two rehabilitation wards in an acute NHS trust. Analysis of findings provided theoretical explanations of what helped and hindered staff from engaging in practice change,with the report presenting a neat and straightforward process of investigation. My experience of undertaking the study was, however, far from the neat and straightforward process articulated, with it being a complex, difficult and painful undertaking which had a personal impact on me. The thesis progresses from the research report to explore and critically reflect on my personal experience of undertaking the action research study, and engages with the experience of other action researchers through a secondary analysis of the literature. Through this work the emotional context of action research is highlighted for all those involved in the process. It is argued that attention to emotions throughout the action research process is essential for both participants and researchers to ensure that the care and support required to manage them can be provided, and to enable such emotions to be used as data that can further inform the field of study. Although the importance of recognising the emotional context of action research is articulated in this thesis, there is a dearth of literature in relation to it. It is concluded that more needs to be written on this aspect of practice so that those new to action research can be made aware of the importance of the emotional components inherent within it, and can ensure that appropriate strategies are in place to enable them to engage with, learn from, and utilise such emotions to further inform their work. The messages in this thesis will be of relevance to those considering, undertaking, supporting and supervising action research studies. In addition, due to the similarities of action research processes, contexts and topic areas to other methods of practice change, they will also be relevant to those involved in general practice development activity.

In 2011, 19.2 million households in the United Kingdom had access to the Internet. Online social networks (OSN) such as Facebook, Twitter, MySpace, Bebo and YouTube have proved to be the most popular Internet activity (Office of National Statistics, 2011). 49% of these users have updated or created an OSN profile and are making over 24 million visits a month (Dutton, 2009). These websites are often directed at a broad market i.e. people without disabilities. Unfortunately people with disabilities, especially those with physical impairments, often have a greater risk of experiencing loneliness than people without a disability as a result of their mobility, access and or communication impairments. Conventional communication methods such as face-to-face communication, telephone communication and text message communication are often difficult to use and can limit the opportunities for people with disabilities to engage in successful socialisation with family members and friends (Braithwaiteet al, 1999). Therefore people with disabilities can often see online communication, especially OSNs, as an attractive alternative. Previous studies such as Braithwaite et al(1999), Ellis and Kent (2010) and Dobransky and Hargittai (2006) suggests that OSNs are opening a new world to individuals with disabilities. They help these individuals, especially those exhibiting lifelong physical challenges to carry out social interaction which they would otherwise not be able to do within the analogue world. However due to inaccessible features presented in the technology for example features requiring JavaScript, hard-coded text size and Captcha (AbilityNet, 2008; Cahill and Hollier, 2009 andAsuncion, 2010) access to OSNs is often difficult. The overarching purpose of this PhD research is to understand the experiences and challenges faced when people with the physical disability cerebral palsy (cp) use OSNs. It is estimated that 1 in 400 children born in the UK is affected by cp (Scope Response, 2007). The disability can present itself in a variety of ways and to varying degrees. There is no cure for cp, however management to increase social interaction especially through technological innovations is often encouraged (United Cerebral Palsy, 2001; Sharan, 2005 and Colledge, 2006). Previous studies such as AbilityNet (2008), Cahill and Hollier (2009), and Boudreau (2011) have explored mainstream OSNs use from the perspective of users with disabilities, i.e. blind and visually or cognitively impaired, but have placed great emphasis on investigating inaccessibility of OSNs without involving these users. Other studies such as Manna (2005) and Belchiorb et al (2005) have used statistical methods such as surveys and questionnaires to identify Internet use among people with unspecified disabilities. Conversely Asuncion (2010) has taken a broader approach involving OSN users using high-level taxonomies to classify their disabilities, and Marshall et al (2006) focused on a specific disability type, cognitive impairments, without considering the variety of limitations present within the disability. Other studies such as Pell (1999) have taken a broader yet more specific approach and looked at technology use, especially computer and assistive technology among people with physical disabilities, where only 7 out of 82 surveyed had cp. Whereas Braithwaiteet al (1999) focused on individuals with disabilities, where most were classified has having a physical disability. However the study does not explicitly look at OSNs but rather at online social support within forums for people with disabilities. Studies such as these have not involved the users; defined what constitutes disability or focused on cp without encompassing other disabilities, making it impossible to identify the requirements of OSN users with cp. Initially this PhD research explored the experiences and challenges faced when individuals with cp use OSNs. Fourteen interviews were carried out consisting of participants with variations of the disability. The study identified the reasons for OSN use and non-use and also discovered key themes together with challenges that affected their experiences. This work was followed by an in-context observational study that examined these individuals context of use. The study identified the OSNs and assistive technology used, tasks carried out and users feelings during interaction. As a result of these studies it was determined that changing OSNs prevented and or slowed down these users ability to communicate online. Previous work within human-computer interaction and other disciplines such as software engineering and management science, change is often discussed during software development and is restricted to identifying scenarios and tools that assist change management within information technology (Jarke and Kurkisuonio, 1998). Studies such as these have not considered change deployment or its affect on users, though within HCI such an understanding is limited. Other disciplines i.e. psychology and social sciences have looked at change deployment. Theorists such as Lewin (1952), Lippett (1958) and Griffith (2001) attempt to offer solutions. However no one theory or approach is widely accepted and contradictions, adaptations and exclusions are continually being made. Conversely Woodward and Hendry (2004) and By (2007) have attempted to contend with these difficulties specifically stress as a result of change, believing that if change agents are aware of what an affected individual is thinking during the on set of change it will help to minimise or prevent damage. Studies such as these have focused on software development or organisational change from the perspective of developers or employees, they have not considered OSNs or individuals with cp. To fill this gap a longitudinal OSN monitoring and analysis study was carried out. The study identified how OSN changes are introduced, their affect on users, and the factors that encourage change acceptance or non-acceptance. The study was divided into three studies: two studies investigating realworld examples of OSN change by observing the actions of change agents (Twitter.com and Facebook.com) and their users reactions to the change process. A third study that asked OSN users about their experiences of OSN change was also carried out. A by product of these studies was a unique way of displaying OSN change and user acceptance on a large scale using a infographic and an inductive category model that can be used to examine OSN change. The findings from the five studies were then distilled alongside identified change management approaches and theories to develop an five-stage process for OSN change for change agents to follow. The process defined the requirements for OSN change including the change agent responsibilities before, during and after the change.

The motivation for this research was the publication in 1995 of the Calman-Hine report. This provided a strategic framework for the delivery of cancer care by creating a network of cancer care centres in England and Wales to enable patients to receive a uniformly high standard of care. The report acknowledged the fact that although the evidence on optimal cancer care used to prepare the report was based on two key sources (i) medical literature and (ii) audit data provided by UK cancer registries, they did not lend themselves to controlled experiments as most information came from retrospective analyses; hence they were subject to a number of possible flaws and biases. Yet the report recommended some key structural changes to be implemented. The focus of the research described in this thesis was centred on the recommendation of a multidisciplinary team (MDT) review of patients prior to a treatment decision, both in general cancer units as well as in specialised cancer centres. Given the mandate to implement these recommendations, the research questions addressed were “can the current configuration support this recommendation?”, “what evidence was there to support the effectiveness of the MDT?” and “was there a model of care to support the service delivery of cancer care?” A literature review established that there was no existing template upon which MDT services could be set up. This research therefore set out to develop an MDT model to support operational delivery of care in the setting of a cancer centre. The clinical specialty in which this research was undertaken was that of lung cancer. The research successfully developed a conceptual model. However, in the process, a number of operational and practical constraints were identified within the revised service configuration designed to deliver high quality cancer care through the incorporation of the MDT service, and this ultimately limited the extent to which the model could be deployed in the particular clinical setting. Nevertheless, the modelling process did enable a range of core issues to be identified, enabling design solutions to be formulated and tested, thereby confirming the effectiveness of the MDT model. In particular, the adoption of a soft modelling approach was shown to be beneficial in addressing operational problems. By engaging clinical and other end-users right from the start in the modelling process, the models did become operationally accepted, allowing resistance to change to be overcome and the solution to be integrated into the business process. MDT services are now well established, both in cancer units and cancer centres and published data on their effectiveness in the treatment of lung cancer, although not conclusive; demonstrate an increase in resection rates. However, assessing the long-term impact of MDTs on lung cancer outcomes remains a topic for future research.

Although speech and language therapy practitioners commonly place great weight on standardised, static assessment, the procedures may not be fully representative, and reveal little about the child’s learning potential or the direction that intervention should take. Vygotsky’s theories, particularly his notion of the Zone of Proximal Development, underpin a range of approaches within the complementary assessment paradigm known as Dynamic Assessment (DA) (Vygotsky 1986). The term is used for assessments consisting of ‘active intervention by the examiners and assessment of examinees’ response to intervention” (Haywood and Lidz 2007 P1) The current project investigated the application of Dynamic Assessment to a population of children with previously identified Language Impairments. As in parallel studies of intelligence, both manifest skills of language, and underlying processes used in manipulating and constructing language as a tool, were elucidated. The contribution that such an assessment can make to extending the understanding of language impairment, and in devising intervention programmes was investigated. This thesis describes the development of a Dynamic Assessment task requiring implicit knowledge of syntactic structure. The construction of the procedure was a novel adaptation and combination of established DA methodologies that are described and evaluated in Chapter 1. The task, which is essentially a sentence anagram, comprised 12 items specifically selected to assess particular grammatical structures reported in Chapter 2 to be problematic in children with Specific Language Impairments (SLI). The details of the task construction are reported in Chapter 3. The measure was employed on 24 children aged 8-10, with identified language impairment, and the results are reported in Chapter 4. Inter-rater reliability of the test measure was 88%, and the sensitivity of the test to change over time was demonstrated. Information about participants’ ability to transfer learning between items, their ability to use less directive prompts, their strategy use, and their metalinguistic and metacognitive awareness was extracted, and reported to the speech and language therapists working with the children. Evaluation of the test is discussed in Chapter 5. The thesis also reports on an investigation of the role of the information derived from the DA in informing intervention programmes (Chapter 6). The same cohort of 24 children with SLI was randomly allocated to two groups. Reports from the DA were used to inform the ongoing language intervention of one of the groups of children. In Chapter 7 the outcomes of therapy from that group were compared to the outcomes of the group receiving regular intervention. Differences between groups were nonsignificant although the gains achieved by subgroups of children were predicted, and in particular children making little progress in their ongoing therapy were shown to derive most benefit from the modified intervention. The information was rated as useful by participating SLTs who altered the nature of their intervention strategies. Discussion of the results and identification of factors such as emotional and behavioural issues that affect progress in intervention are discussed in Chapter 8. Implications for further development of the DA paradigm are discussed, and conclusions are summarized in Chapter 9.

In this thesis, a synthesis is presented of the knowledge models required by clinical informa- tion systems that provide decision support for longitudinal processes of care. Qualitative research techniques and thematic analysis are novelly applied to a systematic review of the literature on the challenges in implementing such systems, leading to the development of an original conceptual framework. The thesis demonstrates how these process-oriented systems make use of a knowledge base derived from workflow models and clinical guidelines, and argues that one of the major barriers to implementation is the need to extract explicit and implicit information from diverse resources in order to construct the knowledge base. Moreover, concepts in both the knowledge base and in the electronic health record (EHR) must be mapped to a common ontological model. However, the majority of clinical guideline information remains in text form, and much of the useful clinical information residing in the EHR resides in the free text fields of progress notes and laboratory reports. In this thesis, it is shown how natural language processing and information extraction techniques provide a means to identify and formalise the knowledge components required by the knowledge base. Original contributions are made in the development of lexico-syntactic patterns and the use of external domain knowledge resources to tackle a variety of information extraction tasks in the clinical domain, such as recognition of clinical concepts, events, temporal relations, term disambiguation and abbreviation expansion. Methods are developed for adapting existing tools and resources in the biomedical domain to the processing of clinical texts, and approaches to improving the scalability of these tools are proposed and evalu- ated. These tools and techniques are then combined in the creation of a novel approach to identifying processes of care in the clinical narrative. It is demonstrated that resolution of coreferential and anaphoric relations as narratively and temporally ordered chains provides a means to extract linked narrative events and processes of care from clinical notes. Coreference performance in discharge summaries and progress notes is largely dependent on correct identification of protagonist chains (patient, clinician, family relation), pronominal resolution, and string matching that takes account of experiencer, temporal, spatial, and anatomical context; whereas for laboratory reports additional, external domain knowledge is required. The types of external knowledge and their effects on system performance are identified and evaluated. Results are compared against existing systems for solving these tasks and are found to improve on them, or to approach the performance of recently reported, state-of-the- art systems. Software artefacts developed in this research have been made available as open-source components within the General Architecture for Text Engineering framework.

Background: Almost all intellectual disabilities research is conducted in urban areas, and very little is known about the population of adults with intellectual disabilities living in rural areas. It is important to know whether there are significant rural-urban differences, in order to provide appropriate services and address inequalities. In particular, the general rural population is known to be disadvantaged with respect to access to healthcare and social exclusion. Adults with intellectual disabilities are also disadvantaged in these areas, and therefore adults with intellectual disabilities living in rural areas may have a double disadvantage. Method: A sample of adults with intellectual disabilities living in a rural area on the West Coast of Scotland participated in a face-to-face semi-structured interview; their medical notes were also accessed. Demographics, healthcare, access to services, daytime opportunities, access to community facilities, recent contact with others, the quality of personal relationships, and area deprivation by postcode were measured. Data were already available for a pre-existing urban sample. Data were analysed using direct comparison and binary logistic regression. Results: A representative sample of adults with intellectual disabilities from rural (n=39) and urban (n=633) areas were compared. There were no significant rural-urban differences over a wide range of variables including: age, gender, ethnicity, level of intellectual disabilities, mental ill health and common co-morbidities such as mobility, visual impairment, incontinence and epilepsy. Both direct comparison and binary logistic regression showed the rural sample to have had significantly more contact with primary (Odds Ratio = 4.02, 95% CI 1.56 -10.35, P = 0.004) and secondary health care (OR = 3.93, 95% CI = 1.81 – 8.55, P = 0.001.) Participants from rural areas were significantly more likely to have any regular daytime opportunity (Odds Ratio = 10.8, 95% CI = 2.3 – 51.5) including employment (OR = 22.1, 95% CI = 5.7 - 85.5) and attending resource centres (OR = 6.7, 95% CI = 2.6 – 17.2) than were participants from urban areas. They were also more likely to have been on holiday (OR = 17.8, 95% CI = 4.9 – 60.1); however, were less likely to use community facilities on a regular basis. Participants from urban and rural areas had a similar number of contacts with other people in a wide range of situations, but the quality of relationships may have been less close in rural areas. Finally, rural participants lived in significantly less deprived areas (Mann Whitney U = 7826, Z = -3.675, P ≤ 0.001). Conclusion: There were no significant demographic and health differences between the rural and urban samples. The study was underpowered with respect to some of these findings, and some results may reflect a Type II error. Nevertheless this is an important negative finding. Contrary to original hypothesis, the rural sample was found to have better access to healthcare services, had better opportunities and lived in less deprived areas than adults with intellectual disabilities living in urban areas. However, the results suggest that the rural sample may not have held such positive or close relationships, and this may be important when considering the subjective experience of social exclusion. Additional qualitative sub-study: A qualitative sub-study investigated the difficulties experienced with recruitment to the original study. 10 semi-structured telephone interviews were held with professionals who had helped with recruitment. These were transcribed verbatim and anonymised, then analyzed using the Framework approach. A number of themes arose, including participant factors (interview anxiety, worry about negative feedback), the importance of the researcher (using a personal approach, meeting potential participants prior to recruitment) and motivators (enjoyment of the research interview (participant), obtaining a medical assessment (carer)). The themes were then used to generate strategies to improve recruitment to intellectual disabilities research: these include the research team applying a more personal approach, and considering motivators for both participants and carers. The findings of this study have implications in terms of both time and money. However, successful recruitment is essential to intellectual disabilities research, and the results can be used by intellectual disabilities researchers to review and improve their recruitment processes.

The objective of this thesis is to develop a standard, simple methodology for the assessment of health in areas near sources of pollution. This methodology should make use of readily available data and computing facilities. A literature review on previous studies on the subject was carried out in order to draw from existing experience. A total of twenty-five studies on health near sources of pollution were reviewed. These studies were carried out between 1982 and 1991, most of them in Britain, two in France. The types of pollution sources studied ranged from waste dumps to incinerators, to nuclear power stations. Each study was described, stressing on their respective backgrounds, building on geographical (study) areas, data, analysis and results. Brief synopses of the studies were next grouped, according to those using conventional epidemiological methods and more innovative ones. Finally, it was concluded from the review that the methodology intended should be descriptive, making use of routinely collected data, with a study area based on small geographical divisions (small areas) and taking into account socio-economic differences over its study area. In the absence of accurate data on pollution levels, and from the previous experience of one of the studies reviewed, circular study areas centred on the source of pollution and subdivided into rings were used, with distance of each ring to the centre as a proxy indicator of levels of pollution. The new methodology was found valid and the objective of the study was met. It compared favourably with previously reviewed methodologies. The methodology is intended to be used as a descriptive, exploratory tool, whose findings may warrant further analytic studies, which the method is not designed to, and can not, replace. The use of routinely collected data greatly facilitated the study, although caveats for future studies exist on them. Distance as a surrogate for exposure is seen as a simplistic approach, but in the absence of reliable exposure data it is a useful one. Standardization by Deprivation category has also been found useful to account for factors for which little data exist.

Childhood obesity is a leading global public health issue. Chapter One of this thesis is a literature review of the evidence concerning the issue of childhood obesity and its management. The literature review describes this issue in terms of national and international prevalence and trends, health consequences and determinants. The literature review examines the evidence to guide effective management of childhood obesity. The role of parents in the management of childhood obesity has been identified as a promising area of research and specific attention is given to this issue. This thesis examined the effect of a family-based behavioural treatment programme for obesity in 7-11 year olds (The Malaysian Childhood Obesity Treatment (MASCOT) Study). The intervention is presented in Chapter Two. Families of obese 7-11 year olds in Kuala Lumpur were randomised to either an intervention (treatment) or control (no treatment) group. The sample was characterised by BMI z-score, health related quality of life reported by participants and their parents (PedsQL questionnaire) and objectively measured habitual physical activity and sedentary behaviour (Actigraph accelerometry). The intervention was delivered over a six month period and between group differences in changes over the six month period were examined at this time point. The sample size (n=107) was calculated as sufficient to detect an estimated difference in the reduction in BMI z-score of-0.25 in over six months between groups and the SD of the change in BMI z-score of 0.21, allowing for dropout (and with power=90%, significance=95%). The primary outcome was change in BMI z-score. This chapter also describes how the MASCOT treatment programme developed, and describes its content. The Malaysian Childhood Obesity Treatment Trial (MASCOT) was a single-blind RCT of a dietetic treatment for childhood obesity in children of primary school age (7 to11 years old) in Kuala Lumpur, Malaysia. The MASCOT comprising eight sessions, of an 8-hour family-centred group treatment programme is described, based on behavioural change techniques, covering topics on nutrition, physical activity and sedentary as well as parenting skills. All information was directed to parents, the main agent of change in which they were responsible for initiating and maintaining healthy lifestyle changes with their families. Outcomes were recorded at baseline and six months, consisting of primary outcome indicators (body mass index (BMI) z-score) and secondary outcome indicators (weight changes, health-related quality of life (HRQoL) and, habitual physical activity and sedentary behaviour) (Chapter Three). Analysis of the primary outcome found no significant group differences at the six month time point for BMI z-score (intervention: 0.0 (0.7) vs control: 0.1 (0.5), p=0.79). There were significant differences between the groups in favour of the intervention group in weight changes (intervention: 1.7(2.5) vs control: 3.5(2.0), p<0.001) and total parent score for HRQoL (intervention: 4.2(15.5) vs control -3.8(19.3), p<0.05). This thesis also reports complementary studies that examined: · the quality of life of obese children compared to pair-matched controls of healthy weight (Chapter Four) and · the physical activity levels and sedentary behaviour of obese children in the MASCOT study versus healthy weight children (Chapter Five) The study of quality of life (Chapter Four) found significant impairment in all HRQoL dimensions (Total score, Physical Health, Psychosocial Health) in the obese children compared to healthy weight children (p<0.001, respectively). In Chapter Five it was shown that obese children spent more time in sedentary behavior (intervention: 90.2% vs control: 87.5%, p<0.001) and less time in MVPA (intervention: 0.7% vs control: 1.2%, p<0.001) compared to healthy weight children. Chapter Six concludes the thesis by summarising its results and highlighting how they have contributed to the evidence base. Study strengths and limitations are described and those weaknesses would be improved by suggesting a few changes in the MASCOT programme for future research.