Whilst national guidelines have recommended abstinence before 18 years of age, in the North West of England, the use of alcohol is common practice by 15 years. The related harms amongst young people (such as violence, regretted sex, hospital admission) place significant burdens on public and individual health. Public health data are vital in order to monitor levels of harm and evaluate prevention strategies. This PhD submission presents a series of peer-reviewed journal articles (and other supporting publications) which evidence how I have used original research to further understand alcohol misuse and its impacts on at-risk groups such as underage drinkers, heavy episodic drinkers and those who may have been drinking alcohol during pregnancy. I have used a number of novel methodologies to explore alcohol consumption and further understand the need for early intervention. Firstly, we used simultaneous surveys of parents and children to understand both the child’s consumption and their parents’ understanding of their child’s consumption. Secondly, we used English hospital admission data to explore for the first time the prevalence of Foetal Alcohol Syndrome and related disorders. Thirdly, we initiated a feasibility study to understand the potential reach of a community-based alcohol brief intervention and liver blood test. Finally, we used a combination of breathalyser readings and nightlife surveys to increase the accuracy of surveys of nightlife users. The articles presented in this PhD provide a significant contribution to public health knowledge on the epidemiology of alcohol consumption and related harm, as well as discussing the evidence base for effective prevention strategies. This submission considers the methodologies, findings and impacts of my research. The work for all publications was undertaken during my employment at Liverpool John Moores University.

Mass gatherings such as the Olympic Games pose unique challenges for interorganizational collaboration. Such events often bring together organizations that collaborate irregularly or have never engaged in joint working. They involve interaction and collaboration among multiple and diverse agencies aiming at delivering a service to a large clientele, which can often prove challenging. This study used the 2012 London Olympic Games as the empirical setting to examine the interagency collaboration among the multiple and diverse public health and safety organizations involved in one of the world's largest mass gatherings. A single, holistic and exploratory case study design was used and data were collected before, during and after the Games through 39 semi-structured interviews with key informants, direct observations of field exercises and documentary analysis. Data collection commenced in May 2011, 14 months before the actual Games, and was completed in October 2012, two months after the completion of the Games. Template analysis was used to thematically analyze the interviews' transcripts, the fieldnotes from observations and the documents. Findings discuss interagency collaboration in mass gatherings along three main activity domains: leadership, communication and learning. In each domain, a number of challenges and facilitators emerged influencing interagency collaboration. Regarding the leadership domain, the lack of engagement of the leading organization and the ambiguous interoganizational decision-making processes negatively influenced collaboration. Shared micro-level leadership and the use of interorganizational linkages enabled collaborative working. Experienced positional leaders of each organization enabled the decision-making process at the interagency operational level by exercising a range of interpersonal leadership capabilities including flexibility and the ability to negotiate. Codified frameworks at the organizational level also provided leaders with common ground to assist them manage the complex interorganizational processes. Within the second domain, the complex intraorganizational structure of the involved agencies and the high density of information transmitted were associated with a dysfunctional communication experience. Findings revealed that the crafting of boundary-spanning roles and intense face-to-face interaction positively contributed to interagency collaboration. Online information systems and formal intersectoral dissemination of reports were essential in gaining common situational awareness. The implicit cultural rules in the form of communication etiquette shaped how interorganizational collaboration was perceived. Finally, sharing the acquired knowledge was a necessary step to create an enabling collaborative environment among interacting organizations. Experiential learning was identified as a significant factor which helped promote joint understanding and partnership work. Informal interpersonal exchanges and formal knowledge transfer activities facilitated knowledge sharing across interorganizational boundaries, helping to break down silos. The study outlines challenges and strategies that shaped interagency collaboration in the context of mass gatherings. Practical implications arising from this study inform the ways organizers of mass gatherings, public health and safety agencies and professionals can engage in effective partnerships and joint working.

Background: Kuwaiti female adolescents have a substantial prevalence of physical inactivity and unhealthy diet leading to epidemic proportions of obesity. Additionally, rates of tobacco smoking and substance abuse are increasing among them. There is a lack of health promoting interventions to deter such behaviours in this population and therefore a knowledge-based intervention in a school setting was investigated. Methods: The study included 128 adolescent females between the ages of 14 and 18. They were randomly selected and allocated to an intervention group (n= 64) and a control group (n= 64). The intervention consisted of six educational sessions for each of the following: physical activity (PA), healthy nutrition, prevention of tobacco smoking, prevention of substance abuse, bone health, and sun protection. Both groups were assessed before and after the intervention in weight measurements, physical fitness, PA by accelerometry in a subsample, and self-reported behaviours. The self-reported behaviours included PA, dietary behaviours, tobacco smoking, substance abuse, and sun exposure and protection. In addition, the knowledge of each health topic was assessed immediately before the session and a week after. A mixed model repeated measures analysis of variance (ANOVA) was used for analysis following an intention-to-treat approach. Results: Physical fitness including flexibility, abdominal muscles strength, body balance and cardiorespiratory endurance (VO2max) were significantly improved in the intervention group compared to the control group. The intervention group also had significantly increased energy expenditure, light PA, walking time, moderate PA, and moderate-to-vigorous PA, while had decreased sedentary time and elevator use. They also had improved a range of dietary practices by increasing consumption of breakfast, dairy, and water. Furthermore, their health knowledge of each topic was significantly increased. Weight measurements did not show any significant change. Tobacco smoking and substance abuse were scarcely reported which could be due to cultural sensitivity. Conclusion: A health promotion intervention in school was successful in increasing physical activity and physical fitness, and improving dietary practices in adolescent females in Kuwait. Thus, such interventions are promising and should be invested in and expanded in this population. These interventions should also be supported by socio-environmental changes including families, youth organisations, and health policies.

Background and Rationale: Urban regeneration programmes are well placed to address social inequalities, and improve residents' quality of life and thus, are increasingly regarded a form of population health intervention. Within such programmes, the central role of communities is becoming increasingly recognised as important, with policy makers highlighting the need for activities that foster community empowerment and community involvement in programmes’ delivery. A motivating factor for this emphasis on community empowerment is the envisaged health gains it can produce. Existing literature has demonstrated that community empowerment is linked to positive health (specifically mental health) however, little is known about this link within an urban regeneration context and the value of allocating resources to foster community empowerment as an outcome of urban regeneration programmes. Previous attempts to value community empowerment as an outcome of urban regenerations have failed to fully capture and measure this complex, multi-faceted outcome or its theorised links to health. This thesis crosses disciplines, addressing issues of public health, urban planning and health economics. However, as outlined in Chapter 1, its leading discipline is health economics, drawing on methodology from the field to make a contribution to the evolving focus of public health economic evaluation. Specifically, the thesis demonstrates how health economic methodology can be adapted or expanded upon to aid the challenges researchers face when trying to identify, measure and value complex, non-health outcomes (such as community empowerment) for inclusion in economic evaluations of population health interventions (such as urban regeneration), which, as discussed at length in Chapter 5, present numerous challenges for techniques previously used solely within the health sector, and commonly in controlled settings (randomised controlled trials). Methods: The thesis initially outlines the policy context of the study (community empowerment in urban regeneration), defines what is meant by community empowerment and the study’s overall health economics focus in Chapter 1. Chapter 2 continues this introduction to the study’s context by highlighting how community empowerment relates to other concepts, whether it is viewed as an outcome or a process and how this impacts on efforts of measuring the concept and through a rapid scoping review, summarises what is known in the current evidence base on community empowerment and its links to health. It clearly highlights that community empowerment is a context specific concept and that in order to identify, measure and value it within an urban regeneration context, investigation of its specific, quantifiable ‘elements’ within this context must be identified. This is presented in Chapters 3 and 4. Firstly, a systematic review with narrative synthesis was then conducted (Chapter 3) to identify whether urban regeneration interventions can lead to a sense of empowerment and key community empowerment elements within this context. Then in Chapter 4, analyses of cross-sectional data from Glasgow’s GoWell neighbourhoods regeneration study (n=4254) was used to further test the causal relationship between community empowerment and self-reported health. The final part of the thesis (Chapters 5-8), firmly centres these initial findings into the health economics focus of the thesis to demonstrate how discrete choice experiments could be used to value a non-health outcome such as community empowerment for future inclusion in economic evaluations of population health interventions. It outlines the challenges of conducting economic evaluations of population health interventions and the importance of health economics as a discipline for decision-makers (Chapter 5). Then in Chapters 6-8 it presents the conceptualisation, design and results of a UK representative population discrete choice experiment survey (n=311) and how its results can value community empowerment as a potential outcome (using the payment vehicle ‘time’) for use in economic evaluation of population health interventions within urban regeneration. Results: The thesis identifies that community empowerment can result from urban regeneration interventions and that there are specific community empowerment ‘elements’ within this context which can be used to start conceptualising how to measure and value this concept and its links to health. The thesis also demonstrated that this was not always a positive relationship between urban regeneration and community empowerment and that a sense of disempowerment could be felt by the affected communities. These elements were sense of inclusion, sense of belonging, residents’ time commitment, a sense of trust in stakeholders, availability of stakeholder help and support and, availability of information about the regeneration programme (Chapters 2-3). Regression analysis of the GoWell data (Chapter 4) highlighted significant associations between community empowerment and improved general health and mental wellbeing. The discrete choice experiment’s (shown in Chapters 6-8) mixed logit model analyses demonstrated that there is an overall value for community empowerment activities within urban regeneration. The general populations respondents strongest preferences were shown for the delivery of community empowerment activities which require less time commitment, offer opportunities to participate, fully explain decision making processes, increase social interactions with their neighbours, have help and support from stakeholders and, keep them informed of the regeneration programme. Respondents’ strongest preferences were for delivery of community empowerment attributes that increase sense of belonging and feeling informed about the regeneration programme. Conclusions: The thesis provides valuations for attributes of community empowerment which can be used to inform future resource allocation decisions related to the cost-effectiveness of community empowerment generating activities as part of the delivery of urban regeneration programmes. Progress on the application of economic evaluation methodology to public health has been challenging, thwarted by complexities due to broad ranging costs and outcomes that are not readily suited to established economic evaluation techniques. The thesis contributes to the growing field of public health economic evaluation by highlighting the use of stated preference techniques, specifically discrete choice experiment methodology as a tool for measuring and eliciting values for the non-health outcomes of population health interventions for inclusion in economic evaluations. Failure to capture and include all benefits or costs of these multi-sector interventions which seek to look beyond health gains could lead to under or over estimation of their value and total effectiveness. This could ultimately result in poor investment decisions. To conclude, this study has contributed to current evidence by providing a means for identifying, measuring and valuing community empowerment both as an outcome in its own right and as an interim surrogate outcome linked to health. Thus, it has begun to address and tackle the research gaps identified in previous studies (outlined in Section 1.2.2). It has valued individual elements of CE within urban regeneration programmes which can be used by policy makers for decisions regarding future investment in CE and has further evidenced claims that community empowerment is linked to health within this context. Therefore, the thesis is able to recommend investment for community empowerment promoting activities in the delivery of urban regeneration programmes as a pathway to mental health gains.

This research explores the relationship between risk factors associated with cannabis use in young people. This thesis addresses the assessment of cannabis use and its association with risk factors and implicit associations, and the suitability of these for targeting at-risk cannabis users, and how theories of drug instrumentalization and normalization frame cannabis use behaviour in young people in contact with drug services using a mixed-methods approach. Additionally, this research addresses the implications for indicated prevention and the targeting of young people considered at risk for developing problematic cannabis use behaviours. This PhD reviews the scientific literature on cannabis use, with an emphasis on prevalence and use behaviours alongside associated risk and protective factors. Cannabis markets and potency, along with policy implications, are also explored. Furthermore, this PhD aims to understand how cannabis use behaviour assessment impacts on the identification of risk, and the subsequent implications for identifying those who might benefit from further support. Frequent, habitual cannabis users and their relationship with risk factors, including implicit cognitions, and use behaviour assessment are explored. Additionally, cannabis users in touch with drug services and their use behaviour are explored through frameworks of drug use instrumentalization and normalization. Lastly, the main findings of this dissertation are surmised and future research and policy implications are discussed. This PhD illustrates the importance of cannabis use behaviour assessment in identifying young people at-risk for developing problematic use behaviours. This thesis provides evidence that suggests that psychopathology, and the over-instrumentalization of use as a self-medication, coping mechanism may be associated with the development of problematic use outcomes. These findings are contextualised within the current cultural and political environments in the United Kingdom and discussed in regards to their suitability for indicated prevention.

No description available.

This PhD submission presents a series of peer-reviewed journal articles (and other supporting publications) that synthesise an original programme of research that examined the ways in which the media platforms (magazines, television, marketing, Social Network Sites (SNS)) young people (11-21 years) engage with portrayed alcohol, it’s use and related practice. Young people’s own perspectives, interpretations and experiences were also explored, in order to better understand the role of the media in shaping young people’s drinking cultures, practices and related identity making, in ways that are gendered. The underlying theory is presented, the methodological approach employed critically reviewed, and researcher positionality considered. Published findings are then presented that highlight how entertainment media, marketing and peer content on SNS act as important sources of information through which young people learn what is socially acceptable and normative drinking practice for men and women, and how to ‘do’ and perform gender through alcohol-related practice. The research found that although mediated gendered norms around alcohol are reflected and reproduced in young people’s attitudes, beliefs, and behaviours, young people also appropriated and rejected alcohol-related messages within their own identity making. The use of the media and social media platforms (e.g. SNS) in disseminating health messages on alcohol to young people and young people’s acceptability of such approaches is also addressed. How the research has contributed to knowledge and the implications of the research for public health, gender studies and policy are also considered. The articles presented in this PhD, supporting documents, conference presentations and public engagement, provide a coherent, significant and novel multi-disciplinary contribution to knowledge on the role of the alcohol, media, and alcohol marketing in young people’s drinking cultures, and practices, and in shaping their identities. All the research conducted for the publications was undertaken during employment at the Public Health Institute, Liverpool John Moores University.

The purpose of this multi-partnered project was the production of a fully integrated POC system, combining automated nucleic acid extraction in a centrifugally operated microfluidic disk (the LabDisk), with loop mediated isothermal amplification (LAMP) and optical detection, capable of detecting the sexually transmitted pathogens Neisseria gonorrhoeae, Chlamydia trachomatis, Mycoplasma genitalium and Trichomonas vaginalis in clinical urine and swab samples. LAMP is a novel nucleic acid amplification method, designed to amplify target nucleic acid in a highly specific and rapid manner, under isothermal conditions. The work detailed in this thesis presents the development of a rapid total nucleic acid extraction process, based on the capture of target nucleic acid by magnetic silica beads, optimised for use on the LabDisk platform. The extraction process was capable of the purification of target nucleic acid from a clinical sample within 5 minutes, and was robust when challenged with a range of inhibitory compounds potentially encountered in samples for STI testing. The system was capable of tolerating N. gonorrhoeae (1 x 105 CFU/ml) urine suspensions containing samples containing 50% total blood volume, 1x108 E. coli cells per ml, and 10mg/ml of BSA, without any effects on the downstream amplification time of the N. gonorrhoeae specific LAMP assay. A freeze dried lysis buffer pellet was developed, that was able to increase the sample volume, thereby decreasing the time to detection, whilst minimising the stored fluid volume on the LabDisk. LAMP assays were designed for the detection N. gonorrhoeae and M. genitalium, and the limits of detection and specificity of the assays were evaluated. The N. gonorrhoeae ORF1 assay was able to detect a minimum of 20 copies of the N. gonorrhoeae genome per reaction, whilst the M. genitalium pdhD assay was capable of detecting 16 genome copies. The tolerance of the ORF1 LAMP assay to urea, and blood, was found to be 1.8M, and 20% reaction volume, respectively. The increased tolerance of the LAMP assay to these inhibitors in comparison to PCR demonstrates the suitability of LAMP when processing urine samples for STI’s. To our knowledge this is the first application of LAMP technology for the detection of these organisms, and the first attempt at commercialising a fully integrated molecular diagnostics system based on LAMP.

Receiving personalised feedback on body mass index and other health risk indicators may prompt behaviour change. Few studies have investigated men’s reactions to receiving objective feedback on such measures and detailed information on physical activity and sedentary time. The aim of my research was to understand the meanings different forms of objective feedback have for overweight/obese men, and to explore whether these varied between groups. Participants took part in Football Fans in Training, a gender-sensitised, weight loss programme delivered via Scottish Professional Football Clubs. Semi-structured interviews were conducted with 28 men, purposively sampled from four clubs to investigate the experiences of men who achieved and did not achieve their 5% weight loss target. Data were analysed using the principles of thematic analysis and interpreted through Self-Determination Theory and sociological understandings of masculinity. Several factors were vital in supporting a ‘motivational climate’ in which men could feel ‘at ease’ and adopt self-regulation strategies: the ‘place’ was described as motivating, whereas the ‘people’ (other men ‘like them’; fieldwork staff; community coaches) provided supportive and facilitative roles. Men who achieved greater weight loss were more likely to describe being motivated as a consequence of receiving information on their objective health risk indicators. They continued using self-monitoring technologies after the programme as it was enjoyable; or they had redefined themselves by integrating new-found activities into their lives and no longer relied on external technologies/feedback. They were more likely to see post-programme feedback as confirmation of success, so long as they could fully interpret the information. Men who did not achieve their 5% weight loss reported no longer being motivated to continue their activity levels or self-monitor them with a pedometer. Social support within the programme appeared more important. These men were also less positive about objective post-programme feedback which confirmed their lack of success and had less utility as a motivational tool. Providing different forms of objective feedback to men within an environment that has intrinsic value (e.g. football club setting) and congruent with common cultural constructions of masculinity, appears more conducive to health behaviour change.

Background: Emergency medical admissions in the United Kmgdom have been rising for many years. This rise has resulted in increasing pressures on hospitals' resources, with consequent difficulties in coping with peaks of admissions. This rise has not been intended or planned. The epidemiology of emergency medical admissions is poorly understood. Aims: To investigate the epidemiology of emergency medical admissions in Glasgow in terms of time, person and place. To explore variations in Glasgow's general practices' and hospitals' emergency medical admission rates. Literature review: Articles relating to variations in emergency medical admission rates were identified by searching bibliographic databases, cross referencing from known articles, consulting other researchers and hand searching of journal indexes. Relevant articles were included in a systematic review of the epidemiology of varying rates of hospitals' emergency admissions. Articles that postulated causes of the rise of emergency admissions or factors associated with varying admission rates were also reviewed. A summary of mechanisms whereby hospitals might cope with pressures of emergency admissions concluded the literature review. Published evidence of variations of rates of hospital emergency admission was limited. Most articles were found to contain postulated associations with variations in hospitals' emergency admissions. While many published mechanisms for hospitals to adapt to pressures from emergency admissions were identified, only a minority of these had been formally evaluated. 3 Setting: Greater Glasgow Health Board residents (813,029 adults at June 1997). Data obtained from the Health Board's Community Health Index (CHI). Subjects: 537,798 Greater Glasgow Health Board residents admitted to Glasgow hospitals7 medical beds between 1980 and 1997 (43,236 patients in 1997). Data obtained from Scottish Morbidity Record database one (SMRl). Methods: Anonymised CHI and SMRl datasets linked by patients' general practitioners' codes, using a computer database package. Standardised emergency medical admission rates were calculated by the database. Computerised maps of standardised emergency medical admission ratios were plotted for Glasgow7s postcode sectors to show geographical variations. Correlation and logistic regression were used to explore variations in standardised emergency medical admission ratios. Outcome measures: Crude emergency medical admission rates. Standardised emergency medical admission ratios adjusted for patients7 age, sex and Carstairs7 deprivation categories. Results: The numbers of emergency medical admissions doubled between 1980 and 1997. Emergency medical admission rates increased steeply with increasing age of patients, more than doubling for every two decades. Men above 40 years had approximately 20% higher age specific emergency medical admission rates than women. Emergency medical admission rates were more than twice as high amongst patients from Glasgow's most deprived areas, compared with the most affluent. Cardiovascular disease (ICD10 chapter IX) discharge diagnoses were commonest (27.2% in 1997)' followed by the non-specific diagnoses in ICDlO chapter XVII (21.0%). The non-specific diagnoses mainly comprised chest pain (9.6%) which was the commonest reason for admission. Between 1980 and 1997, non-specific diagnoses (ICD10 chapter XVII) increased at twice the rate of all other ICDlO chapters of diagnoses. There were two areas of Glasgow that had raised standardised emergency medical admission ratios (adjusted for patients' ages, sex and deprivation). These corresponded to the catchment areas of two acute hospitals, which had substantially higher adjusted emergency medical admission ratios than had the other three. There was a 2.51 fold variation between the top and bottom deciles of Glasgow's general Practices' crude emergency medical admission rates. After adjustment for their patients' age, sex and deprivation characteristics, this reduced to a 1.87 fold variation. Additional adjustment for general practices' admitting hospitals (along with their patients' age, sex and deprivation) accounted for a total of 84% of the inter-practice variation in crude emergency medical admission rates. Fundholding general practices had modestly raised emergency medical admission rates (odds ratio 1.06.) There were no associations between practices' rates of emergency medical admissions and any other measured practices' characteristics (including numbers of partners, practices' sizes or dispersions, immunisation and cytology rates). Conclusions: This large study discovered epidemiological associations between emergency medical admission rates and patients' sex and socioeconomic deprivation that had not previously been shown. It showed that emergency admission rate variations between general practices were only partly accounted for by patient characteristics. Apart from fundholding status, difference between practices were not related to variations in their rates of emergency medical admissions. However, a substantial part of the variation between general practices could be attributed to differences between their admitting hospitals.