Food welfare for low-income women and children in the UK is an unexplored area of food policy. The current food welfare scheme for low-income women and children in the UK is called Healthy Start, and this replaced the previous Welfare Food Scheme in 2006. The main changes were that Healthy Start was intended to be more health focussed and aimed to influence behaviour change by providing a voucher that could be spent on fresh (and later frozen) fruits and vegetables, milk or infant formula. The previous scheme only provided milk and infant formula. In addition it was intended that there would be more interaction with health professionals as part of the scheme. Little is known about why the Welfare Food Scheme changed to Healthy Start and what influenced the initiation, formation and implementation of Healthy Start. Nor is there substantial information on how Healthy Start operates in practice. The objectives of this thesis were to consider what influenced the development of Healthy Start and to consider how Healthy Start as a policy relates to Healthy Start in practice. After mapping how Healthy Start was developed, what is known about the scheme, undertaking a literature review on subject specific literature, research questions were developed to direct the line of inquiry. A theoretical literature review explored methods of policy analysis that could inform the overarching methodology. Models of policy analysis and literature on the policy process were developed to better understand the policy process that informed Healthy Start. To address the research questions, three phases of research were undertaken. The first was a policy analysis of publically available policy documents using Kingdon’s concept of policy streams to make sense of the process; the second was a series of semi-structured interviews with policy participants to add detail to the first phase. A recurring issue was the role of the Health Professional in delivering Healthy Start, and a case study with health professionals who deliver Healthy Start in one Borough of London was developed to further explore this issue. The findings indicate that the shift from the Welfare Food Scheme to Healthy Start was largely influenced by political factors, with inadequate consideration of public health objectives and practical components of behaviour change. A lack of training and support for health professionals who are gatekeepers of the scheme was apparent at all points of the policy process. By tracking the development of the Healthy Start scheme and its place within food welfare this research highlights the need for more thorough consultation and thoughtful development if complex schemes crossing welfare and food policy are to be successful.

Implementation of protocols and guidelines is an important strategy used by hospitals in their fight against healthcare-associated infections (Pratt et al., 2007), yet their use remains a challenge (Boaz et al., 2011; Grimshaw et al., 2001). This thesis addresses the topic of behavioural change through exploring how protocols and guidelines are used on hospital wards to manage the risk from Clostridium difficile infection, the difficulties ward staff faced with their use and what happened in practice as difficulties were experienced. A qualitative study was conducted using a single case study methodology (Yin, 2009) with one acute NHS hospital in the UK. Methods used included nonparticipant observation (184 hours), informal conversation, interviews (49) and document review. An adapted version of the topic guide developed by Michie et al. (2005) based on their theoretical framework of behavioural change was used in the interviews. Data collected was analysed inductively using NVivo 8 and compared against Michie et al’s (2005) framework. The findings illustrate that nurses and doctors were detached from protocols and guidelines. Instead they relied heavily on informal sources of knowledge to guide their practice. Examples include experiential knowledge, common sense, intuition, ‘‘rules of thumb’’ and “mind lines’’ (Gabbay and le May, 2004, 2011). They also took account of preferences, their perceptions of risk, social norms and other contextual issues. Four emergent themes illustrate the complexity of factors hindering and assisting the use of protocols and guidelines into practice. These are ambiguity, organisational issues, professional frustrations and perceptions of contamination. Variations in practice were widespread as protocols and guidelines were ‘worked around’ and improvisations were made as ward staff struggled against a tide of organisational constraints, unrealistic conflicting priorities and difficulties with protocol ambiguity. The way that difficulties were being solved on the ward means that the underlying causes were not being addressed as concerns were not brought to the surface. Professional frustrations such as feeling overwhelmed and powerless acted as barriers to nurses’ reflection. The study has empirically expanded Michie et al’s (2005) behavioural framework whilst exploring the dynamics and complexity of categories influencing the use of protocols and guidelines through a ‘thick’ description of the study findings. This study has made a conceptual contribution to the literature by identifying that Michie et al’s (2005) framework does not seem to take into account tacit and experiential knowledge, professional knowledge, how sense is made of information from the local context or the process of reflection as part of learning. Recommendations are made to address the findings from this study.

NDM-producing bacteria are associated with extensive antimicrobial resistance (AMR). This thesis reports on detailed molecular analysis, including whole genome sequencing, of Acinetobacter spp. and Vibrio cholerae isolates. A study of clinical Acinetobacter baumannii isolates from India, demonstrated spread of a single strain containing blaNDM-1 but with evidence of significant genetic plasticity between isolates. A novel plasmid, pNDM-32, was fully characterised in isolate CHI-32. This contained multiple AMR genes including blaNDM-1 and the aminoglycoside methyltransferase gene armA. A repAci10 replicase gene was identified but no conjugation machinery and the plasmid could not be transferred in conjugation experiments. A single isolate of Acinetobacter bereziniae from India contained plasmid, pNDM-40-1, harbouring blaNDM-1, which was closely related to plasmids from NDM-producing Acinetobacter spp. isolated in China, and was readily transferred into Escherichia coli and Acinetobacter pittii by conjugation. Five blaNDM-1 positive Acinetobacter spp. isolated from a faecal screening study in Pakistan also included three, clonal, Acinetobacter haemolyticus isolates harbouring a similar plasmid. Three environmental V. cholerae strains from India and a blood isolate from a traveller returning to the UK from India were found to include three distantly related strains. 2 isolates of a single strain contained an IncA/C plasmid, pNDM-116-17, harbouring AMR genes including blaNDM-1. In one isolate pNDM-116-17 had become integrated into a chromosomal region containing a SXT-like element. In the other isolates blaNDM-1 and other AMR determinants were localised to a large plasmid, pNDM-116-14, with a novel replicase and a full complement of conjugative transfer genes, and a novel genomic island, SGI-NDM-1. Most previous studies have focused on Enterobacteriaceae. Thecurrent work contributes to an understanding of the full extent of the genetic diversity of blaNDM-1 contexts, and their dissemination. Such knowledge should help to infer factors which contribute to the spread of AMR in bacterial pathogens.

Chronic kidney disease (CKD) is insidious and most cases are diagnosed through opportunistic serum creatinine (SCr) testing before symptoms develop. However, efforts to accurately assess prevalence have been hampered by the lack of a universally agreed definition of SCr thresholds for the diagnosis of CKD. At the turn of the millennium, two crucial developments occurred. The first was the description of the Modification of Diet in Renal Disease estimated Glomerular Filtration Rate (eGFR) which closely correlated to cumbersome measured GFR and could be used instead in daily clinical practice. The second was the publication of the Kidney Disease Outcomes Quality Initiative (KDOQI) clinical practice guideline for the evaluation, classification and stratification of CKD detailing a new definition of CKD based on GFR thresholds. Together, these two developments formed the basis of CKD as we know it today. Prevalence of CKD varies, and accurate prevalence estimates are difficult to obtain especially with respect to fulfilling the chronicity criterion (reduced eGFR ≥ 90 days). Traditional risk factors for CKD are well described and non-traditional risk factors such as socio-economic status (SES), health literacy and rurality are gaining interest. SCr sampling patterns in the community mean that most individuals with CKD are tested routinely every year. This information may not be considered in its entirety by primary care providers (PCP) which may explain inaccuracies in PCP CKD registers. Accurate identification is important to direct evidence based clinical interventions to this patient group. In chapter 2, a novel algorithm for detecting CKD and confirming chronicity from a laboratory database was developed to identify a CKD cohort of the population served by NHS Ayrshire & Arran. Data linkage of additional laboratory data, Scottish Morbidity Records for co-morbidity, statin dispensing information from Prescribing Information Scotland, area SES, rurality and deaths from Information Services Division Scotland enriched the cohort. Patients on renal replacement therapy were identified and excluded through the Scottish Renal Registry. Multiple imputations were applied where appropriate to address missing values. There were 21,037 individuals from 2010 to 2012 fulfilling the definition of CKD stage 3 – 5. Prevalence of adults with CKD was 5.6% – 5.8%. Average age (± SD) of the cohort was 75 ± 11 years. 64.6% were female and average eGFR for the cohort was 47.32 ± 11.53 mL/min/1.73m2. In chapter 3, laboratory ascertainment of CKD identified 7% more cases than PCP CKD registers. Furthermore, around 25% of patients on PCP CKD registers may be wrongly coded as having CKD. There was a 3.9-fold variation in CKD prevalence amongst PCPs, ranging from 2.8% - 11.0%. Variation fell to 3-fold with laboratory ascertainment, ranging from 3.0% - 9.1%. This fell further with age and gender stratification. Stratified laboratory CKD prevalence was positively associated with SES and rurality, a novel finding, but in multivariate linear regression, only SES, in addition to age and gender, were significant predictors for CKD prevalence. Chapter 4 explored the association between SES, eGFR and all-cause mortality. One-way ANOVA demonstrates a linear relationship between eGFR and SES (F (4,15078) = 2.52, p = 0.039) with a mean difference in eGFR of 0.83 mL/min/1.73m2 between the lowest and the highest SES quintile. However, linear regression modelling found proteinuria, hypertension, peripheral arterial disease, age, gender and serum albumin to be significant predictors for eGFR, but not SES. After adjustment for age and gender imbalance, survival demonstrated substantial influence by SES, but weakened in effect with full adjustment with only Scottish Index of Multiple Deprivation (SIMD) quintile 3 demonstrating a 13% increased risk (HR 1.13, 95% CI 1.03 to 1.24) with no progressive increase in risk associated with lower levels of SES. As a quality of care marker, the dispensing of statin was examined in chapter 5. Having another diagnosis where statins are indicated, male gender, higher serum albumin, CKD stage 3B and age between 65 – 80 were associated with higher odds ratio for statin dispensing. 64% of the cohort was dispensed a statin in 2010, but the proportion fell by 5% to 58% in 2012. This fall in dispensing disproportionately affected younger and less co-morbid CKD patients who were all eligible for a statin. SES and gender did not appear to be a factor in falling dispensing rates. Average LDL levels were lower in the statin group by (mean difference) 0.78 mmol/L (95% CI 0.74 to 0.81) in 2010 and 0.93 mmol/L (0.90 to 0.97) in 2012. 37.2% of all statin prescriptions was for Simvastatin 40 mg. Statins reduce cardiovascular events and mortality in CKD. However, in older patients typical of CKD, evidence is lacking. Chapter 6 examines survival in those dispensed a statin. Those dispensed a statin were younger, more likely to be male, had higher serum albumin and more co-morbid. After full adjustment, statin dispensing was associated with a 24% lower risk of death (HR 0.76, 95% CI 0.71 to 0.83) overall, 18% benefit for primary prevention (no prior coronary heart disease or cerebrovascular disease) (0.82, 0.74 to 0.91), 32% benefit in secondary prevention (0.68, 0.60 to 0.77), 22% benefit in younger (< 76 years) CKD patients (0.78, 0.67 to 0.92) and 22% benefit in the older (≥ 76 years) CKD patients (0.78, 0.71 to 0.85) over 4.5 years follow-up. To illustrate absolute risk reduction, the number needed to treat to avoid one death for all patients is 15.8 (95% CI 12.3 to 22.2) and 12.4 (9.3 to 18.5) for older CKD patients. This thesis demonstrates that centralised ascertainment of CKD is better at case finding, than existing PCP CKD registers. The linkage of additional, routinely collated healthcare data can develop CKD registers into a powerful tool for monitoring quality of care, efficacy of therapy and hypothesis generation which can, and should be, integrated into clinical IT systems with the appropriate information governance oversight in place.

The focus of this thesis was to investigate, especially in the context of obesity, the interactions among sleep duration and quality, and adverse health outcomes. Three comprehensive studies are described in the thesis: 1. A cross-sectional epidemiological study examined factors that are associated with both short and long sleep duration among an older Chinese population, and also assessed whether there was a link between sleep duration and chronic conditions such as obesity, hypertension, and diabetes. This study showed that long sleep duration was associated with increased risk for obesity among women. Additionally, demographic, socio-economic, and medical conditions were associated with sleep duration. Identifying potential factors that affect sleep will inform future interventions for improving sleep with potential downstream effect on obesity and other chronic disorders. 2. A cross-sectional study of patients with extreme obesity indicated that the prevalence of sleep disturbance is high in this patient population. There was a positive association between sleep disturbance factors and depressive symptoms and quality of life among these individuals. The findings emphasise the importance of adequate assessment and treatment of sleep problems in this patient population. 3. A systematic review and meta-analysis assessed the effectiveness of lifestyle modification interventions on the treatment of obstructive sleep apnoea (OSA). Lifestyle interventions such as dietary and physical activity improved OSA parameters, but were insufficient to normalise them. The findings will inform the development of future interventions for OSA, and are likely to contribute to clinical guidelines for OSA management.

In the last 10 years there has been a growth in working collaboratively with sex offenders by focusing on goals, tailoring treatment to the needs of the client, and an emphasis on therapist features (Andrews & Bonta, 2003 ; Ward, 2002). This thesis explored how sex offender treatment workers are responding to working with sex offenders in light of the changes. The introduction covers the key concepts and theory relevant to the thesis, and highlights the aims. The second chapter is a systematic literature review investigating the impact of working therapeutically with sex offenders. The review highlighted the extent sex offender treatment workers are impacted by their work was inconclusive. The third chapter focused on critiquing the Trauma Symptom Inventory (TSI; Briere, 1995) as a potential tool that could be used to assess distress in sex offender treatment workers. The critique revealed that the TSI had good reliability and validity. The fourth chapter explored the experiences of sex offender treatment workers using semi-structured interviews. All participants reported enjoying their work despite experiencing some negatives (i. e., intrusive images, suspiciousness, and concerns about clients re-offending). This chapter also highlighted that sex offender treatment workers reported using a range of coping strategies to manage the work. In addition, it was found that sex offender treatment workers believed a genuine interest in the work, hope, optimism, self-efficacy, and circumstances outside of work were related to enhanced resilience. The last chapter of the thesis involved discussing the implications of the findings from each of the chapters.

Childhood obesity is a global public health concern. In England, the prevalence of overweight/obesity increases from one fifth at the start of the primary school years to one third by the age of 10-11 years. This thesis examines the role of primary schools in preventing obesity. Stakeholder views are considered through a systematic review, and two qualitative studies investigating the perceptions of headteachers, parents and children. Data from a childhood obesity prevention trial (the WAVES study) are also used to examine the relationships between school policy/practice and pupil weight status/physical activity levels. Findings show that stakeholders support the school role in preventing obesity, and in helping families to lead healthier lifestyles, though limited expertise and resources are barriers. Although most schools actively promote health, there is much variation. For example, time allocated for physical education and breaks varies by school and has a significant impact on children’s physical activity levels, particularly for boys. In conclusion, school policies and practices can impact on children’s health, and schools are ideally placed to support families to prevent obesity. However, schools require support to perceive this role as a feasible and integral part of their function, rather than as an increasing burden of responsibility.

This thesis examines the effects of psychosocial factors and physical activity on antibody response to vaccination in healthy young, older, and HIV+ populations. Chapter Two found that a brisk walk prior to vaccination did not improve antibody response to pneumococcal or influenza vaccinations in young (18-30yrs) or older (50-64yrs) adults. Chapter Three examined whether a lifestyle physical activity intervention affected antibody response to pneumococcal vaccination in sedentary middle-aged women. There was no effect on antibody response, body composition or fitness measures, although there was an improvement in quality of life for the intervention group. Finally, Chapter Four investigated the relationship between psychosocial and physical activity status and antibody response to vaccination in HIV+ patients. Antibody response to some strains of the pneumococcal vaccine were predicted by higher physical activity levels (pn1, pn6b, pn18c), greater social support (pn3) and lower life events stress (pn1). However, the majority of analyses found that antibody response to vaccination was not affected by these measures. In conclusion, neither acute nor chronic walking interventions improve antibody response to vaccination, and only limited relationships are seen between psychosocial factors, physical activity status and antibody response to a variety of vaccinations.

Analytical methods based on gas chromatography in combination with electron capture negative ion/electron ionisation mass spectrometry were developed and validated for the separation and determination of legacy and emerging flame retardants (EFRs) in a wide range of samples including indoor air, dust, diet and human milk. A broad suite of EFRs and legacy flame retardants (FRs) including polybrominated diphenyl ethers (PBDEs) and hexabromocyclododecane (HBCDDs) were determined in indoor air and dust taken from offices and homes in Birmingham, UK. Comparison with previous data, suggests that temporal trends in contamination with EFRs and legacy FRs reflect changes in production and use of such compounds as a result of bans and restrictions on the use of legacy FRs. Using inter alia a simple, single compartment, steady state pharmacokinetic model, human exposure to FRs via air inhalation, dust ingestion and diet was estimated for different age groups and the relative importance of each exposure route to overall exposure assessed under different exposure scenarios. Concentrations of target EFRs were detected for the first time in UK human milk samples (n=35). Human exposure to EFRs and HBCDDs via diet was estimated for a population impacted by a rudimentary e-waste processing area in Vietnam.

Rationale: Hypoxaemia plays a role in the aetiology of abnormal skeletal muscle function in chronic obstructive pulmonary disease (COPD) via abnormal protein synthesis and mitochondrial function. Patients exhibiting exercise-induced desaturation (EID) have exercise intolerance, perhaps a consequence of muscle hypoxia. Ambulatory oxygen therapy (AOT) is indicated in these patients; however the evidence is derived from single assessment studies. This thesis explores the role of longer term AOT and whether it favourably alters skeletal muscle gene expression in patients with COPD and EID. Methods: A 12 week randomised controlled trial of AOT against air in 25 patients with COPD and EID was undertaken. Participants underwent skeletal muscle biopsies and exercise assessments. In parallel a systematic review of published literature from 1980-2014 for trials in which AOT was compared to placebo in COPD was completed. Results: The systematic review showed that AOT had no statistical effect on improving exercise capacity (6 minute walk or endurance shuttle walk tests); p=0.44 and p=0.29 respectively. Gene set enrichment analysis show the KEGG pathways of oxidative phosphorylation, PPAR signalling and fatty acid metabolism to be up-regulated following AOT (q < 2%) in the clinical trial of AOT versus Air. Conclusion: AOT has limited long term benefit in improving functional exercise capacity. It may however favourably alter gene expression in patients with COPD and EID.