Volume One focuses on the quality of life (Qol) of those with intellectual disabilities, commencing with a systematic review of established Qol measures to identify how these measures have been utilised and the factors that have been explored. In the resulting papers, environmental factors were considered more frequently than individual characteristics. Further research is needed for the continued development of Qol measures in order to provide services with a pragmatic way of documenting change and encourage continued focus on the individual. The empirical paper focuses on the health related quality of life (HrQol) of individuals with rare genetic disorders (Angelman, Cornelia de Lange and Cri du Chat syndromes). The variable of health, HrQol and level of challenging behaviour (CB) was explored. Individuals were found to have a high prevalence of health problems, which in turn was associated with lower HrQol. Understanding the progression of health problems and the impact in those with intellectual disabilities can aid early recognition and treatment. Volume Two contains five clinical practice reports including a service evaluation, case study and single case experiment. The reports cover a range of disorders and theoretic approaches and provide details of assessment, formulation, treatment, evaluation and reflections.

In global terms, Saudi Arabia is a rapidly developing country. As such, its food industries have yet to fully implement the food safety management systems common in the EU. In the hospitals sector, the Ministry of Health intends to implement Hazard Analysis Critical Control Points (HACCP) system to provide safe meals for patients, staff and hospital visitors. The aim of this study was to evaluate the readiness of the Saudi Arabian hospitals to implement HACCP by assessing the pre-requisites programmes in their foodservices departments. An audit form was used in four hospitals in Riyadh. Questionnaires were also used to assess self-reported behaviour, knowledge and attitudes of 300 foodservices staff. Lack of training was known to be a major omission in the pre-requisite programs (PRP’s) of all hospitals. Therefore a bespoke food safety training program was developed and delivered to food handlers in the participating hospitals. An assessment was then made to determine whether this intervention had any effect on their knowledge, attitude to food safety and self-reported behaviour. The results show that, the prerequisite programs were not implemented properly in the participating hospitals. Also, foodservices staff had a poor knowledge with regard to food safety. However, staff knowledge was significantly improved following the training (p. value < 0.05) and their level of knowledge remained stable after six months. Participants’ behaviours and attitudes also improved after the training. This indicates that, training has a positive impact on food handlers knowledge, practices and attitude.

The goal of this thesis is to (i) systematically review all epidemiologic studies reporting on the relationship between occupational exposures and adverse pregnancy outcomes among nurses and physicians, (ii) compare the risk of adverse pregnancy outcomes between singleton newborns of nurses, midwives, and physicians and those of women in other occupations (reference groups) and (iii) investigate the risk of adverse pregnancy outcomes among parents exposed to welding fumes or metal dust. Data were obtained from all epidemiologic studies reporting on the relation between occupational exposures and adverse pregnancy outcomes among nurses and physicians, the 1990–2006 Finnish Medical Birth Register, and the Finnish Prenatal Environment and Health Study (FPEHS). Occupational exposure to anaesthetic gases was associated with spontaneous abortion and congenital malformation among nurses and physicians. Chemotherapy agents were associated with spontaneous abortion among nurses. There was moderate to substantial heterogeneity in the studied relations. In the FHCPS, singleton newborns of nurses have increased risk of low birth weight, post-term delivery, and small-for-gestational-age compared to those of teachers (reference group). Maternal employment as a midwife was not related to adverse pregnancy outcomes. The risk of high birth weight and post-term delivery were lower among singleton newborns of the physicians compared to those of other upper-level employees (reference group), but the risk of SGA and LGA did not differ between the newborns of physicians and those of the reference group. In the FPEHS, paternal exposure to welding fumes only was related to small-for-gestational-age. Maternal exposure to metal dust only was related to low birth weight and pre-term delivery and the joint effect of welding fumes and metal dust was related to small-for-gestational age. In conclusion, maternal employment as a nurses and parental occupational exposure to welding fumes or metal dust may increase the risk of adverse pregnancy outcomes.

The incidence of oral cancer continues to rise in the UK and in Scotland, with a steady increase in oral cavity cancer rates and a rapid increase in oropharyngeal cancer rates in the last decade. These rates are projected to increase further over the next decade, so there is a pressing need to optimise oral cancer prevention strategies. Tobacco and alcohol use are recognised as the major modifiable risk factors for developing oral cancer (both oral cavity and oropharyngeal). In addition, there is a significant increased risk for oral cancer among lower socioeconomic groups, males, and older age groups. Recently there has been recognition of the role of human papillomavirus in the aetiology of oropharyngeal cancers. The major behavioural risk factors (tobacco and alcohol) implicated in oral cancer risk are also associated with a wide range of diseases affecting oral and general health and are thus termed 'common risk factors', increasing the public health benefit should they be tackled. Given the pivotal role in oral cancer and wider disease prevention of reducing tobacco and alcohol use, there is a clear need to optimise the role of primary care dental professionals in delivering behavioural interventions. However, there are uncertainties about the best evidence for particular strategies and approaches to assess risk factors, advise and/or refer in the dental practice setting, with a particular lack of clarity in terms of the specific form and content of such interventions (for example: duration, tailoring to need, who delivers). In addition, the barriers and facilitators to implementation in primary care dental practice - from both the dental professional and patient perspectives - is relatively under-explored. This thesis describes studies undertaken to address these gaps in the knowledge and evidence-base. First a systematic overview was undertaken of systematic reviews and published (international) clinical guidelines. This aimed to identify the evidence on the best practice for the assessment of the major behavioural risk factors associated with oral cancer and for delivering effective behaviour change preventive interventions (in relation to, for example: advice, counselling, signposting/referral to preventive services) by dental professionals in primary care dental practice setting. This evidence was then explored via a study in primary care dental practices in Scotland utilising qualitative in-depth interviews with dental professionals, to identify barriers and facilitators to implementation, and to gather suggestions to inform the development of interventions to support dental professionals in delivering prevention. Finally, a small qualitative survey of patients attending primary care dental practice was conducted to explore barriers, facilitators, and acceptability of risk factor assessment and preventive interventions from the patients' perspective. The overview shows a lack of direct evidence from the dental practice setting (one high-quality systematic review relating to tobacco prevention and none relating to alcohol). However, relatively strong evidence and recommendations from other primary care (medical/pharmacy) settings were identified and synthesised, which could potentially be adapted and adopted by dental professionals. Overall the findings show that robust risk factor assessment is an important first step in any prevention intervention. There is a clear indication of the effectiveness of a "brief", in-person, motivational intervention for sustained tobacco abstinence and reduced alcohol consumption. The lack of detail particularly in relation to duration made it difficult to make a conclusion regarding precise specification of the duration of element of the "brief" interventions. For tobacco users, though longer (10-20 minutes) and intensive (more than 20 minutes, with follow-up visits) interventions have shown to be effective in increasing quit rates compared to no intervention, very brief (less than 5 minutes) interventions in a single session also showed comparable effectiveness to the longer brief or intensive interventions. While, for alcohol users, 10-15 minutes multi-contact interventions were most effective, compared to no intervention or very brief intervention or intensive intervention; brief interventions of 5 minutes duration were also reported to be equally effective. Thus, very brief or brief advice of up to 5 minutes, should be trialled for tobacco and alcohol respectively in a dental practice setting, tailored to patient motivational status. Exploring use of the dental team is supported, as effectiveness was generally independent of primary care provider (i.e. general practice physician or nurse). The qualitative studies on feasibility showed time and resources to be the major barriers from the dental professional perspective. Dental professionals also reported social barriers for a) using cancer as a term to frame preventive consultations and b) in delivering alcohol advice which may not be welcome by patients. Professionals were willing to receive training to overcome confidence issues in approaching behavioural aspects of both main risk factors. Patients however generally supported explicit conversations on oral cancer, and were amenable to alcohol as well as smoking advice, provided their stage-of-change (motivational readiness) was incorporated. The use of formal risk assessment tools to frame discussions was broadly supported by patients and professionals alike. Recommendations are made for testing a model of preventive consultation that draws from this best available evidence and addresses barriers for professionals and patients alike to help shape practice and support this important area of public health going forward.

The statistical inference of socio-economic variables in public health is key to the design of interventions to address the many health inequalities that exist across the world. However, such inferences are achieved commonly using a small standardised library of statistical methods. Meanwhile other fields such as computer science and systems biology have seen the development of many new methods allowing for more varied and useful analyses. Here we present analyses in three important contextual areas of socio-economic variables in public health, bringing in modern and sophisticated methods in order to develop highly useful and flexible results and further expand the library of statistical methods in public health. In the first, we further develop and apply a non-linear temporal model to analyse the spread of health aspects such as mood and weight over US adolescent friendship networks by a process known as social contagion. The use of this model improves our ability to more realistically reflect patterns we expect to see result in the data from contagion. This was achieved using analysis of the Add Health dataset. In the second, we use the flexibility and complex features of Gaussian processes to analyse two different aspects of pregnancy in rural South Africa using the Agincourt HDSS dataset. First, the modelling of fertility-patterns over combinations of variables where some have established models and others do not, allowing us to incorporate such variables into our model without risking the enforcement of unjustified assumptions. Second, analysing social contagion of pregnancy risk behaviour where no social network data exists, demonstrating how the use of sophisticated methods can enable us to attempt complicated research questions. Finally, in the third we build three possible Bayesian belief network models of household food security in the Agincourt study area. The structural features of these models make them potentially highly useful causal tools that enable us to model a wide range of interventions on our system. Through these analyses we demonstrate the importance of expanding the library of statistical methods in public health to include the many modern and sophisticated methods being developed in other fields, whilst also producing findings and tools of great robustness, flexibility, and utility.

Background: Group B Streptococcus (GBS) is the leading cause of neonatal sepsis and meningitis. Currently, the UK recommends against universal antenatal screening to prevent early-onset GBS disease (EOGBS, < 7 days). Key gaps around GBS natural history, harms from screening and a lack of high-quality data to prove screening effectiveness make it difficult to ensure the benefits of GBS screening outweigh the harms. There is also a wider gap on policy-making processes for screening. The overall aim of this thesis is to address these gaps and examine whether the UK should introduce universal GBS screening as a result. Methods: In addition to a literature review, I used two approaches: systematic review/metaanalysis and ecological trend analysis. The systematic reviews synthesised evidence on the screening policy-making processes, mechanisms of EOGBS and adverse events from intrapartum antibiotic prophylaxis (IAP) to prevent EOGBS. In the absence of RCTs, I combined ecological data on the benefits and harms of GBS screening, then analysed their trends across time compared with other prevention strategies in regression analyses adjusting for context differences. Results: Evidence from 17 countries showed that most GBS screening recommendations were not developed by screening organisations and it is not known whether screening principles and the likely unseen harms of GBS screening were considered. Seventeen studies revealed that we do not fully understand the natural history of why some mothers, but not others, transmit GBS to their neonates, or which neonates will develop EOGBS. There was consistent evidence that heavy bacterial load was associated with transmission and progression to EOGBS. Neonates colonised with serotype III were also twice as likely to develop EOGBS compared with serotype Ia and II. However, the evidence was old and at high risk of bias. The selective culture test at 35 to 37 weeks gestation is not an accurate predictor of EOGBS and at least 99% of screen-positive and treated mothers (and their neonates) would be over-treated. Seventeen observational studies and 13 RCTs showed a wide range of potential harms from IAP, including cerebral palsy, functional impairment and antibiotic resistance. However, there was little high-quality and applicable evidence to quantify the frequency of adverse events. The three ecological trend analyses combining data from 59 geographical areas showed that EOGBS incidence decreased by approximately 0.02 per 1,000 livebirths per year in areas that most recently reported GBS screening, whereas it increased by approximately 0.01 to 0.02 per 1,000 livebirths in areas most recently reporting risk-based prevention. Areas that recently did not have GBS prevention displayed conflicting EOGBS trends. By contrast, there was no evidence that screening impacted annual early-onset sepsis trends compared with other, or no prevention strategies; however, this study did not have a sufficient sample size. The was no harmful impact of GBS screening on LOGBS trends compared with other, or no prevention. There was also no evidence that screening increased early-onset E. coli incidence and the percentage of GBS cases resistant to clindamycin and erythromycin, compared with risk-based or no prevention; again, these analyses did not have a sufficient sample size. The findings of these studies must be treated with caution as some results may be due to low statistical power and others were unstable across analyses. The findings also contain numerous limitations as covariates were poorly collected in most countries. Therefore, the evidence on the benefits and harms of universal GBS screening remains inconclusive. Conclusion: GBS infection is an important health condition and its persistence, poor screening tests and the IAP harms stress the need for a better understanding of the natural history of GBS and more effective prevention. Evidence on the harms and benefits of GBS screening is limited, therefore, screening should not be introduced in the UK. Ecological trend analysis was not an adequate method to inform GBS screening decisions, however, it may be useful for screening decisions on other conditions.

No description available.

INTRODUCTION: Having members within communities as ‘natural helpers’ may ensure good understanding of local health issues and better delivery of relevant messages. Lay Community Food Advisors (LCFA) may be an effective means to increase coverage of health promotion, empower individuals and communities, help to reduce social exclusion and address the gap in nutritional inequalities. LCFAs may increase awareness of healthy eating and help people translate advice into practice thereby positively influencing patterns of behaviour. However, there is limited evidence supporting these programmes, particularly from a Canadian perspective. Research objectives: To describe the context, drivers and (identify) strategic components of different programme models To determine the role of programmes in addressing healthy eating behaviour (across the socio-economic spectrum) To determine the wider role and impact of programmes in food and public health RESEARCH DESIGN AND METHODOLOGY: A qualitative, case study approach of three key LCFA programmes in Ontario with both exploratory and explanatory aspects. Data collection included key informant interviews using semi-structured questionnaires, overt participant observation and document review. Analysis: Thematic Analysis was utilised as an overarching approach to data analysis, NVivo qualitative tool was utilised for analysis of interviews. The Health Policy Triangle and Multiple Streams Framework were both used as frameworks for policy analysis. FINDINGS: Programme models have been shown to be able to deliver on policy priorities and enable increased capacity at multiple levels: individual, community, organisational and policy. Programmes show examples of being both universally accessible and targeted in their approach, addressing a combination of food literacy and community engagement strategies. Programmes raise tensions around lay helping and issues of access and utilisation of programmes. DISCUSSION: Programmes play a key role in meeting public health policy priorities. Programmes address food literacy set within a social and community context, but may be more challenged to address the underlying determinants of health and raise some tension around whether they can reduce or exacerbate inequalities. However, the absence of programmes can leave a greater gap. Though they remain for the most part downstream with some midstream activity, there are opportunities for more upstream effort. CONCLUSION: Though localised, programmes can address food and public health policy objectives beyond food skills alone. Programmes and their role need to be viewed more broadly, with connections to the wider food system and environment and how they can be both policy levers and policy influencers. As well, programmes should not be seen as the solution to a complex problem that needs more than behavioural intervention, they must complement other strategies to improve public health across the system.

This thesis identies, inter alia, the socio-economic factors that affect malaria incidence at both the household and district levels and investigates how these differ across rural and urban settlement-types. In addition, state level data for India are used to examine the effect of aggregate income relative to that of public health expenditure on malaria incidence. The household and district-level analysis focuses on the state of Uttar Pradesh and exploits the National Family Health Survey, which is the Demographic Health Survey (DHS) for India, for two time periods - 1992-93 and 1998-99 - and combines these data with the district-level census data for 1991 and 2001. A key theme of the micro-level analyses is whether household wealth exerts a negative impact on malaria incidence. Wealth is measured using the DHS data by constructing a consumer durable asset-index by Principal Components Analysis and malaria incidence was modelled using a probability model. The household-level analysis reveals that the relationship between socio-economic status and malaria incidence is not always negative. For example, owning a water pump, indicative of a higher socio-economic status, has a positive impact on malaria incidence and being of a lower caste has a negative impact. Variables that support the negative socio-economic status and health relationship include having an electricity connection in the house, having access to a protected public drinking water supply rather than an open source, and living farther away from open water sources. The aggregate (or panel data) analysis was undertaken using data for 15 states in India covering the time period 1978 to 2000. The aggregate analysis reveals that income has a negative impact on malaria incidence but direct expenditure on health is more effective in bringing about a decline in malaria incidence - an increase of a rupee in aggregate income per person reduces malaria incidence by 0.1 percent whereas an equivalent increase in real health expenditure per capita results in a 0.4 percent decline in malaria incidence. The research undertaken for this thesis is unique in using the DHS to identify the factors aecting malaria incidence and shows that these data are very useful in exploring the relationship between malaria incidence and a host of socio-economic factors in order to identify areas for effective policy intervention. Such a holistic approach is critical in controlling and, eventually, eradicating malaria rather than relying primarily on more direct treatment strategies based on insecticide-treated bed nets and drug therapy. The areas where public spending could be directed to attack malaria identied by the empirical analysis include education, particularly raising awareness on prophylactic measures through adult literacy centres, controlling the breeding of mosquitoes in open water collection sites such as public taps and around water pumps and improving water flow in agricultural fields to prevent stagnant water collection.

Public health guidelines for (leisure time) physical activity evolved in the United States from scientific research which began in Britain and spread to North America during the second half of the 20th Century. This dissertation examines the guidelines' scientific and social construction. Research questions centre upon what has become known as the 'threshold-intensity vs volume-energy expenditure debate': Is a minimum intensity of physical activity necessary to achieve significant beneficial health outcomes? Or can that effective 'dose' be achieved by accumulating a sufficient total volume of expenditure (kcals) -- regardless of its intensity? The research questions are: 1. Why were public health guidelines switched from a focus upon vigorous intensity to moderate intensity, and was the science base sufficiently sound and uncontested to justify that switch on scientific (and social scientific) grounds? 2. Why were the guidelines so focused on cardiovascular disease (CVD) to the relative exclusion of other health outcomes? 3. Did a small, influential group of investigators play a disproportionate (anomalous) role in shaping the 1996 US Surgeon General's Report on Physical Activity and Health? Conclusions: The US Surgeon General's Report switched public health focus from vigorous to moderate intensity activities on a proclaimed 'emerging consensus' of scientific evidence. However, the science base remained complex and contested. This 'consensus' was, in large measure, socially constructed by a small group of investigators who had gained influence within the American Heart Association, the Centers for Disease Control and Prevention, the National Heart, Lung and Blood Institute, and then the very taskforce selected to write the Report. This dissertation explores a new and relevant area of 'Regulatory Science' given current interest in sedentary lifestyles and illness, not least cardiovascular disease and obesity. Anomalies in scientific interpretation and policy making arose not from financial considerations, but primarily from motives of altruism and professional status.