Background Road traffic crash (RTC) injuries affect 20 to 50 million people worldwide every year, causing premature death or disability as well as incurring large costs to individuals and society. In the UK, the number of RTC casualties is underestimated if based solely on police records, as many casualties are unreported to the police. “Safety” (speed and red light) cameras have shown to be an effective way of combating RTCs and in 2000 a national scheme was rolled out in the UK. Aim and objectives The overall aim of the study was: To investigate the epidemiology, cost and prevention of RTC injuries in the Strathclyde police region of Scotland. The specific objectives of the study were: 1. To establish the overall epidemiology and accuracy of reporting of RTC injuries in Strathclyde. 2. To determine the epidemiology of RTC injuries and the effectiveness of safety cameras at the camera sites in Strathclyde with special reference to different road users, RTC types and severity, before and after camera installation. 3. To estimate the economic burden of hospital admissions due to RTC injuries in Strathclyde and at the camera sites before and after installation. Methods Nine years (1997 to 2005) of police road casualty records (STATS19) and National Health Service hospitalisation records (SMR01) from the Strathclyde region were linked. The linkage resulted in nearly 11,000 police casualty records relating to approximately 30,000 hospital and death records. Unlinked RTC hospital and police casualties (nearly 9,000 and 70,000 respectively) were also utilised in the analysis. The study employed a range of epidemiological and economic methods. These included descriptive epidemiology (evaluating distributions of linked and unlinked records, length of stay and cost analysis), analytical epidemiology (examining associations using chi square and logistic regression models) and interventional epidemiology (before and after study). The economic evaluation utilised weighted mean costs. The focus of analysis was threefold: 1. Epidemiology of RTC, injuries and accuracy of police recording, 2. Epidemiological impact of safety cameras, 3. Cost of road traffic crashes a) in Strathclyde and b) at safety camera sites. Results Epidemiology of RTC injuries in Strathclyde: Older age and less protected road users (i.e. pedestrians and two-wheeled vehicle users) had a higher risk of a more severe outcome in RTCs. Head injuries were more common among pedestrians and pedal cyclists, while car occupants more often suffered injuries to the thorax and abdomen/lower back/lumbar spine. Accuracy of police reporting: 45% of RTC hospital admissions were not recorded by police. Casualty characteristics significantly associated with underreporting were: no third party involvement, older age, casualties from early in the study period, type of road user (especially pedal cyclist), hospitalisation as a day case and female gender. Seriously injured casualties recorded by police (STATS19) declined in frequency more than the RTC hospitalised injuries (SMR01) (38% and 21% respectively). Linked SMR01 casualties that were coded “slight” by the police increased by 5% over time, while linked SMR01 casualties coded “serious” declined by 27%. Safety camera impact: Compared to the rest of Strathclyde, there was a significantly greater downward linear time trend of RTC incidence at the camera sites. The impact of cameras on RTCs over time appeared stable. Cameras seemed to be effective in reducing the incidence of serious or fatal RTC injuries, as well as injuries associated with multiple-vehicle and non-junction RTCs. Cost of RTC casualties in Strathclyde: Total inpatient costs were conservatively estimated at £7.3 million yearly (linked records). Head and lower extremity injuries incurred the highest total costs (28% and 34% respectively). Pedestrian injuries, constituting 36% of the total, incurred 44% of total costs. Casualties from deprived areas, and pedestrians in particular, incurred higher hospital costs than other road user groups. Cost of RTCs at safety camera sites: 17% of all injured before safety camera installation were hospitalised, while 13% of casualties after installation were hospitalised. The mean costs of (surviving) casualties admitted to hospital declined by 24% after installation and the mean daily cost declined by 55%. Conclusions RTC injury incidence in Strathclyde declined over the study period, which is in line with expectations of developed countries. Young and elderly people as well as unprotected road users carry a disproportionately great RTC injury burden. Many hospitalised RTC casualties were not recorded by police and there appears to have been an increasing tendency over time for police officers to report injuries as slight rather than serious. National (UK) statistics of RTCs should be interpreted with caution in the light of these findings and routinely linking police and hospital data would enhance the quality of RTC casualty statistics. Linking police and hospital RTC records provide a more comprehensive source for road traffic analysis than any of the sources separately. Routine data linkage would also facilitate the evaluation of time trends in relation to national road casualty reduction targets. The study indicates that the most costly RTCs occur in areas with high levels of deprivation, a history of pedestrian RTCs, elderly and child casualties, roads with many non-junction RTCs and 30 mph speed limits. The evaluation of safety cameras strongly suggests that they are effective in reducing both road casualty incidence and severity and that the reduction in incidence is sustained over time. Additionally, safety cameras in Strathclyde may have contributed to a saving of over £5 million. Cameras thus fulfil an important public health, as well as law enforcement, function and should continue to play a central role in traffic calming. This study has demonstrated the value of utilising multiple data sources in the road traffic injury field.

Background: The HIV/AIDS epidemic has contributed to a drastic increase in the number of orphans and vulnerable children in sub-Saharan Africa. However, little is known about the mental health of these children in low prevalence areas such as Ghana. The thesis investigated the relationship between orphanhood, parental HIV/AIDS status and mental health. It further examined the mediating effects of identified risk and protective factors on the relationship between orphanhood/parental HIV/AIDS status and psychological difficulties. Finally, the thesis identified pathways through which HIV/AIDS impacts children by exploring the interactive and cumulative effects of the various risk and protective factors on psychological difficulties. Method: The thesis employed cross-sectional, quantitative interviews that involved 291 children aged 10-18 years and their caregivers that compared children who have lost their parents to AIDS, those who have lost their parents to other causes, those who are living with HIV/AIDS-infected caregivers and children from intact families in the Manya Krobo district in Ghana. ANOVAs, T-tests, General Linear Models, Log-linear Analyses, Chi-Squares and Bivariate Correlations were used to analyze the data that were obtained from both the children and their caregivers. Results After controlling for relevant socio-demographic factors, both children and informants’ reports showed that children orphaned by AIDS and those living with infected parents showed higher delinquency (p <.01), peer problems (p <.001), hyperactivity (p <.01) and lower self esteem (p <.001) than other orphans and children from intact families. AIDS orphans, other orphans and those living with HIV/AIDS-infected parents all reported significantly more depression (p <.001) and relationship problems (p <.001) than those for intact families. Conduct problems as indicated by informants’ reports were generally, significantly higher for orphans and vulnerable children compared to children from intact families. Over 70% of both AIDS orphans and children living with infected parents showed internalising symptoms that were above clinical cut-offs for abnormality. AIDS orphans and children living with infected parents reported more stigma, abuse, child labour and lower levels of SES and lower perceived social support. These factors independently, strongly mediated the relationship between orphanhood, parental HIV/AIDS status and mental health. The interactive and cumulative effect of engagement in child labour and being physically abused heightened the risks for depressive symptoms from 38% to 66%. Neglect and psychological abuse increased the risks for symptoms of Reactive Attachment Disorder from 26.6% to 67.3%. The cumulative effect of stigma and either child labour or physical abuse substantially increased the likelihood of delinquency symptoms to approximately 67%. Conclusion: The findings demonstrated that both AIDS orphans and children living with HIV/AIDS-infected parents showed heightened psychosocial symptoms. The present evidence also highlighted the interactive, cumulative, co-occurrence of contextual factors and HIV/AIDS unique exposures to create heightened vulnerabilities for psychological difficulties among children. The findings call for a comprehensive intervention programme that addresses factors specific to HIV/AIDS and contextual variables.

Background and Aims: Judicial antibiotic prescribing and appropriate use of healthcare resources are public health priorities. Preschool-aged children that attend day care frequently consult general practitioners (GPs) and receive antibiotics, despite experiencing mainly self-limiting and/or viral infections. North-American surveys indicate that day care providers unnecessarily exclude children with infections, and make exceptions to exclusion on the basis of antibiotic treatment. Commentators suggest that this may lead to unnecessary consultations and inappropriate antibiotic requests. This study’s main aim was to explore whether UK-based day care providers’ management of infections encourages parents to unnecessarily consult GPs, and inappropriately seek antibiotics. A secondary aim was to describe the content and nature of written day care sickness exclusion policies. Questionnaire Methods and Results: Questionnaires were distributed to 329 day care providers in three socio-demographically contrasting areas of South-East Wales, to gather descriptive data regarding sickness exclusion policies. 216 (66%) responses were received. Policies were mostly self-written, diverse in content and detail, and often non-evidence-based. Qualitative Methods and Results: Day care providers’ management of infections, and the influence this had on parents’ consulting and antibiotic-seeking behaviours, were explored through semi-structured interviews with 24 purposefully selected day care providers, and 28 opportunistically-selected parents that used their services. Interviews underwent inductive thematic analysis. All day care providers encouraged parents to consult GPs for self-limiting infections, and often inappropriately advised antibiotic treatment through written policies and verbal communication. Some parents felt that day care attendance increased their tendency to consult for symptoms they would usually manage themselves. The purpose of consultation was often to expedite return to day care, rather than alleviate concern. Parents understood that antibiotics were unlikely to be beneficial, but still sought and received treatment in order to appease day care providers’ requirements. Conclusion: Day care providers’ inappropriate advice to parents, together with non-evidence-based exclusion policies, contribute to unnecessary GP consultations and inappropriate antibiotic-seeking behaviour.

The high-resolution molecular characterisation of the Cryptosporidium species and subtypes biquitous in environmental samples can provide important information regarding their potential public health significance. The purpose of this study was to develop, evaluate and apply sensitive screening and DNA recovery methods to environmental Cryptosporidium for molecular characterisation. A systemic literature review as undertaken to identify methods of subtyping Cryptosporidium species recovered from environmental samples. Prior to molecular characterisation, the recovery and detection of oocysts from water is by immunomagnetic separation and immunofluorescence microscopy. However, this method is not currently suited for screening large numbers of faecal samples. A commercially available faecal parasite concentrator protocol was modified and evaluated for the enhanced detection of Cryptosporidium oocysts. Once recovered from samples, DNA must be released from the oocyst bound sporozoites before molecular methods can be applied. Commonly used oocyst disruption methods were identified and using samples containing high numbers of oocysts, evaluated by microscopy and a SYBR Green real-time polymerase chain reaction (PCR) developed from the internal stage of a previously published nested small subunit ribosomal DNA PCR. The eight best methods were then evaluated with low numbers of oocysts in the presence of immunomagnetic beads to replicate field samples, using the published nested PCR and SYBR Green real-time PCR. The enhanced screening and optimal DAN recovery combined with microsatellite multilocus fragment analysis was applied in a study investigating the species and subtypes of Cryptosporidium recovered from water, non-clinical farmed and wild animal faeces as well as clinical human and cattle samples from within a single water catchment. Several human pathogenic Cryptosporidium subtypes were identified in addition to the unprecedented finding of Cryptosporidium as the predominant species in the catchment surface water. This study demonstrated the potential application of the developed methodology in the public health investigation of environmental Cryptosporidium.

Despite structured enforcement of food safety requirements known to prevent foodborne disease outbreaks, catering businesses continue to be the most common setting for outbreaks in England and Wales. Limited published evidence suggests that the way catering businesses are managed and operated may contribute to food safety control failures which in turn can result in an outbreak. The purpose of this study, funded by the Food Standards Agency1,2 was to identify the underlying management factors that may contribute to or prevent outbreaks in the catering industry. A matched case control study compared the management and operational practices of 148 catering businesses associated with foodborne outbreaks with 148 control catering businesses. High response rates were achieved: case businesses 90%, and control businesses 93%. To minimise false inferences from chance associations analysis followed a predefined hypothesised causal pathway. Hazard analysis critical control point systems and formal food hygiene training were found not to be protective and food hygiene inspection scores were not useful in predicting which businesses were likely to be associated with outbreaks. Larger small medium sized (SME) businesses were more likely to be associated with outbreaks compared to micro SME businesses. Operational and management practices did not differ significantly between case and control businesses when adjusted for SME size. SME size was not explained by other staff employment and management variables. However, businesses associated with Salmonella outbreaks were significantly more likely to use regional egg suppliers, the only significantly independent operational practice associated with Salmonella outbreaks. Regional egg suppliers were also more likely to supply businesses associated with outbreaks that were attributed to food vehicles containing eggs. Businesses associated with egg outbreaks were less likely to use eggs produced under an approved quality assurance scheme suggesting that the underlying risk associated with using regional suppliers may relate to the use of contaminated eggs.

Certain mould genera were found to predominate and built form was observed to be associated with mould concentration. PIV reduced the indoor humidity and it reduced the likelihood of mould reoccurring in the intervention homes.

Background Public health interventions need to both improve health and reduce health inequalities, whilst using limited health care resources efficiently. Well-established ethnic differences in cardiovascular disease (CVD) raise the possibility that CVD prevention policies may not work equally well across ethnic groups. The aim of this thesis was to explore whether there are ethnic differences in the potential impact of two CVD prevention policy choices – the choice between mass and targeted screening for high cardiovascular risk, including the use of area deprivation measures to target screening, and the choice between population and high-risk approaches. Methods Cross-sectional data from the Health Survey for England 2003 and 2004 were used. Three sets of analyses were carried out – first, calculation of ethnic differences in the utility of area deprivation measures to identify individual socioeconomic deprivation; second, investigation of ethnic differences in the cost-effectiveness of mass and targeted screening for high cardiovascular risk; third, analysis of ethnic differences in the potential impact of population and high-risk approaches to CVD prevention. Results Area deprivation measures worked relatively effectively and efficiently at identifying individual socioeconomic deprivation in ethnic minority groups compared to the white group. In ethnic groups at high risk of CVD, cardiovascular risk screening programmes were a relatively cost-effective option, screening programmes targeted at deprived areas were particularly cost-effective, and population approaches were found to be an effective and equitable way of preventing CVD despite potential underestimation of their impact. Discussion This thesis found that ethnic minority groups in the UK are unlikely to be systematically disadvantaged by a range of CVD prevention policies that have been proposed, or implemented, for the general population. Additional CVD prevention policies, in particular those based on the population approach, should be implemented.

Older people are often portrayed as a disadvantaged and silent group in society, whose views have been largely ignored. Demographic studies suggest the number of people over 75 years of age, as a percentageo f the population in coming years is likely to substantially increase, which will place greater demands on healthcare services. In the last two decades, health policy has focused on delivering high quality services based on individuals' needs, with a greater emphasis placed on individuals being involved in decisions about their care. This policy direction has facilitated a change in power relationships between patients and professionals and will require providers of healthcare to focus on delivering 'patient-centred' care at times and places that meet individual's needs and expectations. The aim of this researchw as to evaluatet he current medical model provision of NHS podiatry with the biopsychosocial model which claims to provide 'holistic', patient-centredc are. An important aim of this research was to provide a greater and more informed understandingo f what older people communicate about their 'lived' experiences, the significance of those experiences on care-seeking and their expectations of appropriate podiatry care. The research was undertaken with older people living in east Gloucestershire, who were 75 years old or over, and had requested NHS podiatry. The study was underpinned by a qualitative methodology, strengthened by a desire to change current clinical practice and inform health policy. The research methodology included involvement of participants in an innovative reminiscence technique, and as a consequence the 'podiatry patient career' was constructed. The texts generated from the participants were examined using an interpretative phenomenological analysis to ensure a 'person-centred' focus because it was imperative to hear the voices of the 'Participants' and not just the medical model 'patients' narrative. A portrait was revealed of older people who were conscious of their position in the life course and their own mortality, together with the effect this had on how they conducted their lives. The participants' raised consciousness of their 'self' affected their expectations, feelings, and interaction with others. For many of the participants there appeared a vicious circle of impending frailty that led to a diminishing circle of contacts which had an effect on their wider social activities and relationships. At this stage, participants perceived a resolution of their foot-care needs to be of great value and importance in maintaining their well-being which, assisted by the podiatrist, resulted in a handing over of the responsibility for their care. The conclusion is that neither model delivers 'person-centred' care to meet participants' expectations and foot-care needs. A new model is presented where differing and changing priorities, at different times of the participant's lived world will be relevant to meet their expectations and needs. The research concluded that the requirement for podiatry care can be taken as an early indicator of failing independence. The importance of the participant podiatrist relationship was also identified as cental to the delivery of 'person-centred' podiatry. The research findings depict older people who want to be involved in their care rather thm being 'a burden to the state. Recognition is also given to the changing nature of caring relationships in the next decade, and how NHS podiatry services will have to profoundly transform if they are to deliver a holistic, person-centred service in the future.

Progression of chronic kidney disease (CKD) in diabetes can be slowed by strict blood pressure and blood sugar control, prescription of medicines that modify the renin-angiotensin system and lifestyle changes, such as smoking cessation. Because of the large numbers of people with diabetes whose condition progresses (and eventually require dialysis or transplantation), it is possible that the management of their diabetes remains sub-optimal. The overall purpose of this thesis is to develop, test and evaluate an educational package to help people self-manage their risk of CKD progression. This thesis contains a case study, a critical review of literature, the main research study and an artefact (the self-management package). The case study developed from a three-month observation period in six general practitioner (GP) practices. The literature review evaluates the effect of patient education and selfmanagement on diabetes control and outcomes. The research project develops and evaluates the self-management package. Development of the package was informed by the findings of the case study and literature review, and also through interviews with 15 people at high risk of CKD progression. The resulting self-management package comprises written information; a 20-minute DVD filmed with patients; a fridge magnet (with key messages); a monitoring diary; and a blood pressure machine if required. Testing of the package was undertaken in the same six practices mentioned above, with one additional control practice. Patients with Type 1 or Type 2 diabetes at risk of kidney disease were included. Data on renal function (serum creatinine, eGFR and proteinuria), systolic and diastolic blood pressure (BP), glycated haemoglobin (HbA1c), body mass index (BMI) and smoking status were collected at six time points, before, during and after the intervention. Outcomes in patients in the participating surgeries who did receive a pack (n=116) were compared with patients in the control group (n=61). At time point 4 mean systolic BP in the intervention group was 129.2 ± 19.2 mmHg vs. 134.6 ± 15.0 mmHg in the control group (p=0.057). At time point 5 there was mild significance (p=0.053) in mean diastolic BP. At the end of the study (time point 6) the intervention group had a mean systolic BP of 132.1 ± 14.2 mmHg vs. 136.2 ± 16.4 mmHg and mean diastolic BP of 74.9 ± 8.5 mmHg vs. 77.6 ± 9.1mmHg in the control group (p=ns). There were no significant differences in HbA1c and BMI at any time period. The results of the research project have shown the importance of self-management techniques to control blood pressure, which in turn can slow the rate of CKD progression and reduce cardio-vascular risk. Following evaluation by patients, the self-management package has been amended and strategies for local and national dissemination of the package have been put in place.

Eight schools, located in Scotland were involved in this study. Four different types of data were collected in the following order: first, 183 semi-structured interviews with a range of staff and pupils across the schools, the interviews covering questions relating to health education, promotion and ethos including quality of relationships; second, a school audit of health education and health promotion in all schools; third, Researcher observations for all schools; and, fourth, questionnaire data collected from 446 pupils across the schools. The Health Promoting School (HPS) concept is based on the belief that schools have the potential to influence their students' health and health behaviour through the school's social organisation, culture and physical environment, as well as through the formal curriculum. To date, there is little empirical evidence to test the effectiveness of the HPS, at least evidence that adjusts for known predictors of the behaviours, a standard set by the more advanced area of 'school effects' research on educational outcomes. This thesis will add to that evidence base. The aims of this study have three main components: first, to quantify 'school effects' on a range of pupils' health behaviours comprising current smoking, weekly alcohol drinking, ever tried drugs and physical activity: second, to assess the extent to which the health behaviour profile of schools are related to health promotion activity as evidenced by an audit: third, to select and analyse qualitative data from three case study schools. The purpose of the second and third aims is to investigate the extent to which school processes are associated with 'school effects' on pupils' health behaviours, triangulating data from different methodologies. The questionnaire data indicated that a strong school effect existed for smoking and drinking to a lesser degree, but not for drugs or physical activity. This addressed the first aim of this study and, in addition, provided the means by which three case study schools were selected. These were the two schools with the lowest (added value) and highest odds (lost value) for smoking after adjustment for known predictors of the health behaviours. Plus, a third school which was significantly different from the school with lowest smoking and located in the same town, as this eased interpretation of the results. Relating to the second aim, the pattern of the 'school effects' on smoking were triangulated with data from three different data sources. First, in the audit, higher levels of action on health education and health promotion were associated with lower (adjusted) rates of smoking. Second, the three case study schools were used to explore the Researcher's observations; the school with added value for smoking was rated more highly than the two with lost value. Regarding the third aim, based on qualitative data from a range of staff and pupils, the analysis showed that the school with added value had progressed furthest towards functioning as a whole school, performing best across all the areas explored. These findings theoretically triangulated with the schools low smoking rates according to the HPS concept. These results confirm the importance of school processes on students' health behaviour, particularly smoking, and support a school-wide or "Health Promoting School" approach to improving health behaviours.