Background: Strong evidence has been provided by several researchers on the influence that structure and social factors have on health. However, there is relatively little information about the mechanisms by which the structure shapes health-related practices and the place there is for agency in this process. Therefore, this thesis explores the mechanisms through which the structure influences the space for agency that men and women from different social groups have over their health-related practices in their daily lives in a strongly neoliberal economically high-income country such as Chile. Design and objectives: Following a critical realist approach, this thesis uses mixed methods to answer the research question. The contextual analysis aims to comprehend the wider political and economic forces related to the Chilean neoliberal regime that underlie people’s health-related practices. It is based on a bibliographical review and quantitative analysis of secondary data. The extensive analysis focuses on the extension of health-related practices and their statistical association with structural variables. Finally, the intensive analysis explores the meanings and values people give to health and to their health-related practices. It is based on the analysis of fifty-seven in-depth interviews conducted with twenty-nine people living in Santiago de Chile. Results and conclusions: By combining intensive and extensive approaches with a contextual analysis of Chilean society, this thesis concludes that there are different mechanisms through which the structure influences the space for agency that people have over their health-related practices in Chile. These mechanisms affect people differently according to their socioeconomic level and gender. They are related to people’s economic, social and cultural capital, all of which are unequally distributed in Chile. The analysis shows that these mechanisms are a consequence of a structure with high levels of inequalities consolidated by the Chilean neoliberal policy regime.

This thesis analyses the issue of competition for hospital services, introduced in the UK by the NHS reform in 1991. The work is structured around two main questions: whether efficient contracts for hospital services can be devised by economic theory, and whether efficiency and productivity have actually changed since the introduction of the reform. For data reasons, the focus of this second part is on Scotland only. Chapter 1 is a general introduction to the work. Chapter 2 performs the theoretical analysis. The economic literature on hospital contracts in discussed first, and a model is then developed which takes into consideration the existence of waiting time and its effect on patients’ utility. The conclusions cast some doubts on the possibility of defining an optimal contract, and emphasise the possible drawbacks of the prospective payment systems suggested by the reform. Chapters 3 to 5 are devoted to the empirical analysis. As one of the main aims of the reform was to improve efficiency, this is the focus of the research, and the approach is the estimation of production frontiers, reviewed in Chapter 3. The data are a sample of 53 acute hospitals in Scotland between 1991/92 and 1996/97 (the beginning and the end of the reform). Two methods of estimation are used because of their complementarity: the non- parametric DEA and Malmquist indexes are the subject of Chapter 4; the econometric estimation of stochastic distance functions is in Chapter 5. The results show an improvement in productivity whereas the improvement in technical efficiency is controversial and not related to the working of the reform (represented by hospitals’ trust status). Furthermore, a change in the technology of production and in what hospitals produce is found, which casts some doubts on the beneficial effects of the reform. The general conclusions are in Chapter 6.

Biomedical imaging techniques play an important role in visualisation of e.g., biological structures, tissues, diseases and medical conditions in cellular level. The techniques bring us enormous image datasets for studying biological processes, clinical diagnosis and medical analysis. Thanks to recent advances in computer technology and hardware, automatic analysis of biomedical images becomes more feasible and popular. Although computer scientists have made a great effort in developing advanced imaging processing algorithms, many problems regarding object analysis still remain unsolved due to the diversity of biomedical imaging. In this thesis, we focus on developing object analysis solutions for two entirely different biomedical image types: uorescence microscopy sequences and endometrial histology images. In uorescence microscopy, our task is to track massive uorescent spots with similar appearances and complicated motion pattern in noisy environments over hundreds of frames. In endometrial histology, we are challenged by detecting different types of cells with similar appearance and in terms of colour and morphology. The proposed solutions utilise several novel locality sensitive models which can extract spatial or/and temporal relational features of the objects, i.e., local neighbouring objects exhibiting certain structures or patterns, for overcoming the difficulties of object analysis in uorescence microscopy and endometrial histology.

This thesis explores mental health literacy (MHL) and mental health difficulties in at-risk populations. Young people, particularly males, are vulnerable to the onset of mental health difficulties, failing to access support and increased risk of suicide. Supporting people with mental health difficulties and improving prognosis is an important area of public health concern. Chapter one is a systematic review of gender differences in MHL of young people (ages 12-25 years). 14 studies were identified and critically assessed. The nature of gender differences in MHL of young people is complex but most consistently reported in depression. Females tended to have higher levels of MHL than males. The implications for public health interventions and future research are discussed. Methodological components of MHL research, such as the use of case vignettes are also considered. Chapter two is a qualitative research study of male professional footballers’ lived experiences of mental health difficulties and help-seeking using interpretative phenomenological analysis. One superordinate theme emerged from the data; Survival. This is discussed through six subordinate themes and alongside existing literature pertaining to identity, transition, personality and emotional development. The clinical implications of the findings are discussed, as well as suggestions for future research. Chapter three is a reflective paper considering the use of Cognitive Analytic Therapy as a tool for reflexivity in qualitative research. The opportunities and limitations of this approach are considered, alongside reflections on the research process.

In the UK, dietary fibre intake is below the recommended level of 30 g/day. The manipulation of behavioural change is challenging, hence finding alternative ways to improve diet is important. The development of functional foods such as bread with added functional ingredients such as β-glucan and black tea may be more feasible and acceptable than changing to a new eating pattern. β-Glucan and black tea are often eaten separately, however there may be a food-matrix interaction between starch, protein (gluten), tea (poly)phenols and β-glucan when added together in a bread. We hypothesise that β-glucan and black tea will be digested slowly and display a blunted postprandial glycaemia. Some undigested residues will reach the colon, where it will be metabolised to short chain fatty acids (SCFA). SCFA, particularly propionate, have the potential to increase satiety by stimulating G protein receptors, however the effects on food intake need to be tested. This project described: i) development of a functional bread containing black tea, BT; β- glucan, βG; β-Glucan and black tea, βGBT) and compare it to normal white bread (WB) (study 1); ii) determination of bread palatability, perceived satiety and subsequent energy intake following ingestion (study 2); iii) determination of postprandial glucose and insulin responses, and appetite hormones (CCK, PYY and GLP-1) among healthy volunteers (study 3 – in vivo study). In study 1, the breads were developed and tested for starch functionality, antioxidant potential and in vitro fermentability mimicking human colonic fermentation. βG and βGBT breads reduced early (10-min) in vitro starch hydrolysis and this could be due to action of β-glucan that ‘protected’ some of the starch granules (microscopic study) against amylolysis. Digestion with α-amylase increased antioxidant potential and total (poly)phenols content of BT and βGBT breads compared with WB. In vitro propionate concentration did not increase significantly when fermented with β-glucan. High inter- individual variation was observed for individual SCFA production. The addition of black tea had no apparent effect on SCFA production. Study 2 is a randomised, crossover study design conducted in healthy volunteers. Breads were given as breakfast and perceived satiety (perceived fullness, hunger, satiety, desire to eat and prospective food intake) was measured postprandially for 3 h. Ad libitum lunch was given after 3 h and energy intake estimated. BT bread was the most acceptable among all breads. βG and βGBT breads showed adverse taste, texture and palatability but showed similar overall acceptability as WB and BT breads. Female subjects showed lower preference for taste, texture and palatability of βG and βGBT compared with WB. βG and βGBT had positive effects on perceived satiety as follows: 1) decreased hunger; 2) increased fullness; and 3) decreased desire to eat. However, eating βG and βGBT at breakfast did not reduce energy intake at lunch compared with WB. Study 3 was similar to study 2. Only βG bread showed significantly lower glucose TAUC0-180 min compared with BT and βGBT but has no apparent effect on insulin response. No significant changes were observed for CCK and GLP-1 responses for all breads. However, βG and βGBT showed lower PYY TAUC0-180 min compared with BT. In vitro starch hydrolysis did not correlate with in vivo postprandial glycaemic responses. In conclusion, these studies suggest that breads with β-glucan and/or black tea have positive effects on perceived satiety in vivo and show good overall acceptability. However, there is no clear evidence that they affect appetite regulation. Breads containing 7 g β- glucan per 50 g of available carbohydrate reduced in vivo glucose response without altering insulin responses. There was no additional effect of adding black tea together with β-glucan to bread on the in vivo postprandial glycaemic response. It is too early to generalise the results from in vitro batch fermentation and starch hydrolysis and this needs to be considered when planning future dietary interventions looking at both in vitro and in vivo studies. Overall this study concluded that adding soluble dietary fibre to bread is feasible in controlling glycaemic responses and may help increase daily dietary fibre intake.

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This study investigated the hospital admission process in relation to two areas associated with known patient related risks, venous thromboembolism (VTE) risk assessment and medicines reconciliation in an English teaching hospital Acute Medical Unit (AMU). National guidance was available at the time of the study for both of these aspects of care. Government targets with associated financial penalties were set for VTE risk assessment in 2010, there were no similar targets for medicines reconciliation. NHS ethics approval was granted. A novel mixed methodology was used involving direct observations of the patient admissions process, interviews with staff and an audit of case notes. Data were collected over four one-week periods between 2009 and 2011, 36 staff were observed admitting 71 patients, 44 staff were interviewed (25 VTE, 19 medicines reconciliation) and 930 sets of case notes were audited. The observations showed that at the start of the study guidance was rarely followed for both VTE risk assessment and medicines reconciliation. Staff were unaware of its existence and ignorant of the both the associated risks and the level of guideline compliance within the organisation. There were low levels of compliance with local and national VTE guidance until national financial sanctions were introduced when significant increases in the rates of both VTE risk assessment and appropriate prescribing of prophylaxis were seen, however inappropriate prescribing also rose. Observations showed poor medication history taking and prescribing practices, during the study the proportion of items with a prescribing error increased, however the interviews showed that staff did know how to establish an accurate medication history and were aware of the potential problems. A national financial sanction was associated with the effective implementation of VTE guidance however it remains to be seen whether standards can be maintained in a complex high pressure environment. Organisations must also be aware of the potential for unexpected adverse outcomes. Prescribing errors may be reduced if a mechanism can be found to ensure that theoretical knowledge is routinely translated into practice, however greater pharmacy involvement before the admission prescription is written should also be considered.

Physiological systems are well recognised to be nonlinear, stochastic and complex. In situations when only one time series of a single variable is available, exacting useful information from the dynamic data is crucial to facilitate personalised clinical decisions and deepen the understanding of the underlying mechanisms. This thesis is focused on establishing and validating data-driven models that incorporate nonlinearity and stochasticity into the model developing framework, to describe a single measurement time series in the field of biomedical engineering. The tasks of model selection and parameter estimation are performed by applying the variational Bayesian method, which has shown great potential as a deterministic alternative to Markov Chain Monte Carlo sampling methods. The free energy, a maximised lower bound of the model evidence, is considered as the main model selection criterion, which penalises the complexity of the model. Several other model selection criteria, alongside the free energy criterion, have been utilised according to the specific requirements of each application. The methodology has been employed to two biomedical applications. For the first application, a nonlinear stochastic second order model has been developed to describe the blood glucose response to food intake for people with and without Diabetes Mellitus (DM). It was found that the glucose dynamics for the people with DM show a higher degree of nonlinearity and a different range of parameter values compared with people without DM. The developed model shows clinical potential of classifying individuals into these two groups, monitoring the effectiveness of the diabetes management, and identifying people with pre-diabetes conditions. For the second application, a linear third order model has been established for the first time to describe post-transplant antibody dynamics after high-risk kidney transplantation. The model was found to have different ranges of parameter values between people with and without acute antibody-mediated rejection (AMR) episodes. The findings may facilitate the formation of an accurate pre-transplant risk profile which predicts AMR and allows the clinician to intervene at a much earlier stage, and therefore improve the outcomes of high-risk kidney transplantation.

This research uses mixed methods to critically analyse health regulation systems in England, in a macro and micro sense. The qualitative side of the research involves interviews with key staff members from four NHS Trusts and two Clinical Commissioning Groups. These semi-structured interviews offer unique specific insights from the key actors, from varying perspectives in the process. The quantitative element of the research focuses on trends and correlations of the data sets used by particular arm’s length bodies operating in the policy area. Specific arm’s length bodies operating in the health policy arena, which are assessed in the research, include the Care Quality Commission, Monitor and Dr Foster Intelligence. The findings and conclusions centre on the deficiencies that are present in the current regulatory regime, what is occurring in this area, and why this is occurring. Following the Grounded Theory Approach, the research develops inductive theory, from the data, culminating in a “Feedback Loop Theory of Regulation”. Key words: NHS, regulation, mixed methods, arm’s length bodies, feedback loop theory, grounded theory, Care Quality Commission, Monitor, and Dr Foster Intelligence.

The NHS has to meet the Climate Change Act targets of an 80% reduction to their carbon emissions by 2050. Investigation into the components of the carbon footprint of mental health care is needed to understand how services can meet these targets. This thesis first seeks to understand what is known about the carbon footprint of mental health care through two systematic reviews and two national surveys. Second, existing methodologies for estimating carbon footprints are examined to assess whether an approach is available that is ‘fit for purpose’ in mental health care. The approach needs to be applied feasibly within a clinical context and the results need to be sufficiently robust to reliably inform decisions about service design. The aim of this research is to provide an approach that service providers can use to estimate the carbon footprint of services and then use the information obtained to inform service design. This thesis defines the boundaries of assessment to ensure a consistent approach. It suggests an approach to data collection that includes financial and activity data. It presents a review of the available methods for converting this data to carbon equivalents and finds a potential five-fold range associated with carbon footprint estimates of medication. The approach developed within this study is termed the combined approach. The combined approach is then evaluated using a scenario analysis, a four-year retrospective cohort analysis and a prospective care modelling analysis to assess whether it is fit for purpose according to specified criteria. It is concluded that the combined approach is fit for the purpose of assessing how the carbon footprint of a service changes over time. However, due to the use of financial data and the problems with estimating the carbon footprint of medication, this approach has significant weaknesses, which limits its wider use.