Those who misuse alcohol are a burden on health services, the economy and society generally. Compared to their peers, British adolescents report some of the highest levels of alcohol use in Europe. Community organisations can potentially play an important role in the delivery of policy interventions aimed at reducing alcohol misuse. However, little is known about British adolescents’ engagement with these organisations, and related activities, and therefore the role that participation in community activities plays in adolescent alcohol use. This thesis presents findings from an investigation into young people’s participation in organised activities (OAs), such as sports and special groups. While the research was primarily motivated by psychological theories of adolescent risk taking their application was in an ecological framework that identified broader social and environmental determinants of behaviour. An explanatory mixed method design was used. This consisted of two longitudinal studies using data from the Avon Longitudinal Study of Parents and Children (ALSPAC), two cross-sectional studies of male young offenders and non-offenders and a qualitative study involving practitioners involved with the care and management of vulnerable young people. Findings revealed that individual-level characteristics associated with risk-taking behaviours predicted OA participation and that more vulnerable young people participated less in OAs. The analysis of qualitative data indicated that there were barriers to youngsters’ participation in OAs at multiple levels. Longitudinal analyses showed that those participating in sport OAs were more likely to report alcohol use compared to adolescents who did not participate in any OA and participants in non-sport OAs. Cross-sectional analyses showed that young offenders in team sports reported lower levels of hazardous alcohol use compared to young offenders who did not participate in any OA. Qualitative work explored how OA participation might impact vulnerable young people’s alcohol use and showed that the structures of organisations were important for how practitioners worked and the mechanisms identified. These findings highlighted OA participation inequalities among British adolescents and the importance of community contexts for future adolescent alcohol use interventions.

Obstructive sleep apnoea (OSA) and insomnia are the two most prevalent sleep disorders. Their respective treatments Continuous Positive Airway Pressure (CPAP) and Cognitive Behaviour Therapy for insomnia (CBT-I), are effective, but at the same time challenging. It is this challenge that may translate to poor adherence, which ultimately leads to a reduction in treatment effectiveness. The evaluation of these treatments should not fall short of understanding effectiveness by only considering efficacy; the effort to establish what influences adherence makes up a large part of that goal. The aim of this thesis is to contribute to the literature by adopting a biopsychosocial approach (BPS). That is, the consideration of biomedical, psychological and social factors and how they interact to influence behaviour. The implications for both CPAP and CBT-I adherence literature were tested in the context of four experimental studies. Semi-structured interviews were conducted with 11 CPAP users, with 5 individuals completing the three required interviews prior to, at 1 week and 3 months after treatment initiation. The core themes emerging from a thematic analysis were ‘internal conflict around acceptance and adherence’, ‘integration of CPAP into life’ and ‘motivators and resources for CPAP use’. The interviews with 11 individuals having completed a CBT-I program revealed three important issues: ‘Making sense of CBT-I’, ‘Ongoing evaluation of components’ and ‘Obstacles to implementation’. Both studies reveal potential psychological and social factors contributing to adherence to CPAP and CBT-I, which need to be considered in a BPS framework. A patient-level meta-analysis of three randomised placebo-control studies showed that the relationship between CPAP adherence and improvements in daytime sleepiness was caused by both physiological (high use of real CPAP reduced sleepiness more than high use of placebo and more than low use of real CPAP) and psychological effects (high use of placebo was superior to low use of placebo), possibly as a result of an expectation of benefit. The results support the importance of considering both biomedical and psychosocial factors and their interactive effects on adherence. The translation of the BPS approach to clinical practice will be facilitated by the development of brief, reliable and valid measures to assess psychological iii and social variables in addition to the existing biomedical tools. The Stage of Change Scale for Insomnia (SOCSI) assessing components of the transtheoretical model (stage of change, self-efficacy, decisional balance and processes of change), was constructed and cognitively pre-tested in 13 individuals completing CBT-I. The reliability and validity of this comprehensible scale was subsequently examined in the context of a sleep restriction trial. Insomnia-related symptoms at post-treatment and follow-up, which were significantly different from baseline in the 27 individuals with insomnia, were associated with actigraphdetermined adherence to the agreed bed window. The SOCSI was deemed a valid tool with participants in the self-identified action/maintenance stage revealing significantly better adherence, higher motivation and self-efficacy than those in the contemplation and preparation stage. Test-retest reliability of the SOCSI was excellent and the content analysis of open-box responses revealed information for further validation of decisional balance and processes of change scales. This thesis provides novel information about the variables that influence adherence to CPAP and CBT-I. It distinguishes itself from previous efforts by acknowledging the need for the adoption of a BPS framework. This approach is necessary to successfully advancing not only the CPAP and CBT-I adherence literature individually, but potentially the adherence field in general.

Background: No exact and reliable data exists on the characteristics and needs of people with mental health problems in England living in specialist housing services (SHSs). Aims: To describe the cohort of service users’ with mental illness aged 18 to 65 living in various types of SHSs (care homes, supported housing, and Shared Lives schemes) as well as their housing satisfaction, taking into account their social inclusion, and social networks. Pathways into SHSs were accounted for: delayed discharge, referrals and move-on accommodation where applicable. Method: Semi-structured interviews were conducted - using interview schedules designed for the purpose of this study - with 86 service users and 40 managers of SHSs within 7 areas of England. Analysis: Based on a mixed-methods approach: each interview was coded and string variables were turned into quantifiable ones; anonymised quotes from service users and managers were included in the body of the text. Main analysis is quantitative, with a secondary qualitative study, using framework analysis. Results: Differing support levels influenced service users’ experiences and pathways into SHSs, as well as the outlooks of managers. Analyses revealed several aspects mediating housing satisfaction. Many service users were not very well integrated in the community although managers held different views. Some service users were very much reliant on staff and had small social networks. Discrimination was still persistent and recent policy initiatives, in terms of funding, housing, benefits and employment held a negative impact. Preferences of service users were for the most part not taken into account. Conclusions: Further research is needed with regard to BME groups as well as other SHSs settings like Shared Lives schemes. Data should be more systematically collected and in more detail and barriers to employment should be tackled. Better advocacy and information for service users should be established.

Listeriosis is a rare but severe food‐borne disease caused by the opportunistic, bacterial pathogen Listeria monocytogenes. The elderly, those who are immunocompromised and pregnant women and their unborn or newborn infants are disproportionately affected. Listeriosis has a high case fatality ratio (up to 44%) and is the commonest cause of death ascribed to a food‐borne pathogen in the United Kingdom (UK). The number of cases of listeriosis in England and Wales reported to the Health Protection Agency (HPA) ‐ the arms length governmental body mandated with protecting the health of the population ‐ increased from an average of 110 cases per year between 1990 and 2000 to an average of 192 cases per year between 2001 and 2009. The epidemiology of listeriosis appeared to change with the observed increase almost exclusively among non‐pregnancy related cases, aged ≥60 years presenting with bacteraemia in the absence of central nervous system infection (CNS). Given the potential severity of listeriosis and that, as a predominantly foodborne disease, these infections are largely avoidable, there was a public health imperative to investigate the observed increase. Disease presentation, concurrent conditions, medications, deprivation, diet and mortality risk factors amongst non‐pregnancy related listeriosis cases and ethnicity amongst pregnancy related cases were investigated using national surveillance data. The increased incidence of bacteraemic cases occurred in those with cancer, particularly digestive organ malignancies (Odds ratio (OR) [95% confidence interval (CI)]: 16.7 [3.8 – 73]) and, to a lesser degree, those with conditions that necessitate treatment with stomach acid inhibiting medication (3.2 [1.5 – 6.6]). Ethnicity and/or deprivation were found to be important drivers for infection. Compared to the most affluent areas, disease incidence was 38% (95% CI: 16 to 65) higher in the most deprived areas of the country. Cases were more likely than the general population to purchase foods from convenience stores (OR [95% CI]: 5.37 [3.53 – 8.17]) or from local services ‐ bakers (3.40 [2.39 – 4.86]), butchers (1.62 [1.11 – 2.34]), fishmongers (5.05 [3.19 – 7.99]) and greengrocers (1.92 [1.32 – 2.78]) ‐ and their risk profile changed with increasing deprivation. The proportion of pregnancy related cases classed as ethnic increased significantly from 2001 to 2008 (chi‐square test for trend; p=0.002). The increase in the proportion of pregnancy related cases that were ethnic was most marked in 2006, 2007 and 2008, when the incidence was higher than expected given the underlying population (Relative risk (RR) [95% CI]: 2.38 [1.07 – 5.29], 3.82 [1.82 – 8.03] and 4.33 [1.74 – 10.77], respectively). A wide range of underlying conditions appeared to increase the risk of infection, most notably diseases of the liver (RR [95% CI]: 22.4 [17.7 – 28.4]), systemic connective tissue disorders (18.3 [12.6 – 26.6]), neoplasms of the lymphoid, hematopioetic, and related tissues (17.6 [15.1 – 20.6]), psychoactive substance (alcohol related in 96% of reports; 12.3 [9.4 – 16.1]) and renal failure (12.2 [9.8 – 15.1]). Associated medications, including cytotoxic drugs (RR [95% CI]: 320.9 [228.5 – 450.7]), drugs affecting the immune response (18.5 [11.6 – 29.5]) and corticosteroids (11.1 [8.5 – 14.6]), and food groups, most notably smoked salmon (OR [95% CI]: 4.82 [2.99 – 7.76]), other cold cooked fish (22.32 [15.85 – 31.44]), camembert (4.80 [2.32 – 9.90]), hard cheese other than cheddar (2.37 [1.69 – 3.30]), blue cheese (2.24 [1.47 – 3.43]), also appeared to be associated with increased risk of infection. Underlying conditions, particularly malignancies of the breast (OR [95% CI]: 3.2 [1.7 – 6.2]) and respiratory and intrathoracic organs (3.9 [2.2 – 7.1]), alcoholism (2.7 [1.6 – 4.3]), cardiovascular diseases (1.4 [1.01 – 1.9]), treatment to reduce stomach acid secretion (1.6 [1.1 – 2.3])and increasing age (cases ≥80 years versus less than 60 years; 3.1 [2.3 – 4.2]) increased the risk of death amongst cases. This cohesive body of work redefines the population at risk of listeriosis and indicates that there is added value in actively targeting appropriate food safety advice at a range of vulnerable groups other than pregnant women, to whom information has previously been routinely and preferentially disseminated.

This thesis explores the relationship between social comparisons and health and wellbeing as a possible explanation for health inequalities. This is because, although inequalities in health have been observed in Britain since occupational and mortality statistics were first published in 1851 (Macintyre, 1997), the underlying reasons remain a subject of much debate. This thesis adds to the debate by focusing on one of the most influential arguments in recent decades; that, in developed countries, perceptions of place as a class context in the socioeconomic hierarchy is a psychosocial risk factor related to ill health (Wilkinson, 1992; Wilkinson, 1996). However, despite being implied as the central mechanism in his psychosocial pathway, surprisingly, Wilkinson has given little attention to the process of social comparisons. His reliance on large scale epidemiological data to make inferences at an individual level is unsatisfactory since it offers no understanding of the dimensions of people’s social comparisons and how this may be linked to health and wellbeing. The main aim of this study was, therefore, to investigate the scope and nature of social comparisons amongst people living in proximal socio-economically contrasting neighbourhoods, their perceptions of class and inequality and how this might impact on health and wellbeing. In-depth interviewing was the main methodology, supplemented with media analysis and participant observation in order to gain an understanding of the study areas. A total of 33 interviews were conducted with parents from Drumchapel and Bearsden. These areas were chosen because they were strikingly different class contexts, Drumchapel representing a working class area and Bearsden a middle class area. As Wilkinson focuses on between-class comparisons, the selection of these proximal neighbourhoods provided a good opportunity to investigate the extent to which people make comparisons between classes. Insofar as lay theories map on to explanations of health inequalities, this study found little support for Wilkinson’s assertion that perception of place in the social hierarchy is the determining factor in relation to health and wellbeing. Firstly, unlike his suggestion that social comparisons are more common with decreasing social class, the process was found to be a widespread social phenomenon which people across the hierarchy utilise for both self-evaluation and self-enhancement. Secondly, in contrast to Wilkinson’s focus on a single economic hierarchy, this study found compelling evidence that people often utilise complex multiple status hierarchies that can include material and non-material factors like speech, social mannerisms, moral respectability, education, and family upbringing when making social comparisons. In this respect, though Wilkinson’s call for income redistribution policies is admirable, it would not necessarily eliminate feelings of relative deprivation because status differences can exist even in the most economically equal societies. Thirdly, whilst factors like globalisation, the rise in consumerism, and expansion of the mass media have made people more aware of inequalities in society, comparisons with ‘similar others’ like neighbours, friends, family members, and work colleagues were found to be still the most salient reference groups. Further support for this was that status distinctions within classes (e.g. between ‘old’ and ‘new’ money in Bearsden and ‘rough’ and ‘respectable’ in Drumchapel) were more important than those between classes. Lastly, and most importantly, there was little indication that a psychosocial explanation is at the forefront of people’s minds in accounting for health inequalities. To begin with, none of the participants spontaneously suggested a psychosocial mechanism; instead, those in Drumchapel were more likely to suggest material/structural factors whilst Bearsden participants tended to advocate behavioural/cultural explanations. Furthermore, although there was evidence to suggest that ‘some’ people may be vulnerable to similar negative effects of social comparisons they perceived as impacting on others (including anxiety, stress, pressure and depressive state), such effects appeared to be minimal since they were reported to occur only at particular periods in people’s lives. The fact that this thesis was centred on Wilkinson’s psychosocial hypothesis is testimony to the enormous contribution he has made to the health inequalities debate. However, in examining the association between social comparisons and health and wellbeing, the conclusion drawn from this study is that the role of social comparisons in the psychosocial mechanism may have been exaggerated.

Injuries are among the leading causes of death and disability in the world and a major public health concern. Young persons with learning disabilities have a higher rate and different pattern of injuries when compared with young persons without learning disabilities, but little is known regarding adults. The aim of this study was to determine the incidence and types of injuries experienced by a community-based cohort of adults with learning disabilities (n = 511). Face-to-face interviews were conducted with participants and their carers two years after they had first been recruited into a longitudinal study. The measures were based on those previously used with a large population-based sample (n = 6,104) in the Scottish Health Survey (2003). Results were compared between the adults with learning disabilities and the general population. Incidence of at least one injury that required medical or nursing attention or treatment in a 12-month period was 20.5% (105), of which 12.1% (62) was due to falls. The standardised incident injury ratio for adults with learning disabilities aged 18 - 64 years, compared with the regional general population aged 18 – 64 years, is 1.63 (95% confidence interval (CI) = 1.55 – 1.71). The types and causes of injuries experienced differed from those found in the general population. Incident injury was predicted by having epilepsy (odds ratio (OR) 1.809), and not having autism (OR 0.153). Incident fall injury was predicted by urinary incontinence (OR 1.976), whilst Down syndrome reduced risk (OR 0.416). Carers of adults with learning disabilities (n = 446) were less likely to experience at least one injury in a 12-month period overall, but they were significantly more likely to experience harmful injury from another person (p = 0.048), and less likely to experience injury through the use of a tool, implement or equipment (p = 0.045), when compared with the regional general population. These findings are first steps towards understanding the considerable burden of injuries, accidents and falls in the learning disabilities population, and towards informing interventions to prevent injuries and falls in adults with learning disabilities in the future. The types and causes of injury experienced by carers of adults with learning disabilities are also reported for the first time.

A detailed account of the hippocampal anatomy has been provided. This thesis will explore and exploit the use of 3T MRI and the latest developments in image processing techniques to measure hippocampal and hippocampal subfield volumes, hippocampal metabolites and morphology. In chapter two a protocol for segmenting the hippocampus was created. The protocol was assessed in two groups of subjects with differing socioeconomic status (SES). This was a novel, community based sample in which hippocampal volumes have yet to be assessed in the literature. Manual and automated hippocampal segmentation measurements were compared on the two distinct SES groups. The mean volumes and also the variance in these measurements were comparable between two methods. The Dice overlapping metric comparing the two methods was 0.81. In chapter three voxel based morphometry (VBM) was used to compare local volume differences in grey matter volume between the two SES groups. Two approaches to VBM were compared. DARTEL-VBM results were found to be superior to the earlier ’optimised’ VBM method. Following a small volume correction, DARTEL-VBM results were suggesitive of focal GM volumes reductions in both the right and left hippocampi of the lower SES group. In chapter four an MR spectroscopy protocol was implemented to assess hippocampal metabolites in the two differing SES groups. Interpretable spectra were obtained in 73% of the 42 subjects. The poorer socioeconomic group were considered to have been exposed to chronic stress and therefore via inflammatory processes it was anticipated that the NAA/Cr metabolite ratio would be reduced in this group when compared to the more affluent group. Both NAA/Cr and Cho/Cr hippocampal metabolite ratios were not significantly different between the two groups. The aim of chapter 5 was to implement the protocol and methodology developed in chapter 2 to determine a normal range for hippocampal volumes at 3T MRI. 3D T1-weighted IR-FSPGR images were acquired in 39 healthy, normal volunteers in the age range from 19 to 64. Following the automated procedure hippocampal volumes were manually inspected and edited. The mean and standard deviation of the left and right hippocampal volumes were determined to be: 3421mm3 ± 399mm3 and 3487mm3 ± 431mm3 respectively. After correcting for total ICV the volumes were: 0.22% ± 0.03% and 0.23% ± 0.03% for the left and right hippocampi respectively. Thus, a normative database of hippocampal volumes was established. The normative data here will in future act as a baseline on which other methods of determining hippocampal volumes may be compared. The utility of using the normative dataset to compare other groups of subjects will be limited as a result of the lack of a comprehensive assessment of IQ or education level of the normal volunteers which may affect the volume of the hippocampus. In chapter six Incomplete hippocampal inversion (IHI) was assessed. Few studies have assessed the normal incidence of IHI and of those studies the analysis of IHI extended only to a radiological assessment. Here we present a comprehensive and quantitative assessment of IHI. IHI was found on 31 of the 84 normal subjects assessed (37%). ICV corrected IHI left-sided hippocampal volumes were compared against ICV corrected normal left-sided hippocampal volumes (25 vs. 52 hippocampi). The IHI hippocampal volumes were determined to be smaller than the normal hippocampal volumes (p<< 0.05). However, on further inspection it was observed that the ICV of the IHI was significantly smaller than the ICV of the normal group, confounding the previous result. In chapter seven a pilot study was performed on patients with Rheumatoid Arthritis (RA). The aim was to exploit the improved image quality offered by the 3T MRI to create a protocol for assessing the CA4/ dentate volume and to compare the volume of this subfield of the hippocampus before and after treatment. Two methodologies were implemented. In the first method a protocol was produced to manually segment the CA4/dentate region of the hippocampus from coronal T2-weighted FSE images. Given that few studies have assessed hippocampal subfields, an assessment of study power and sample size was conducted to inform future work. In the second method, the data the DARTEL-VBM image processing pipeline was applied. Statistical nonparametric mapping was applied in the final statistical interpretation of the VBM data. Following an FDR correction, a single GM voxel in the hippocampus was deemed to be statistically significant, this was suggestive of small GM volume increase following antiinflammatory treatment. Finally, in chapter eight, the manual segmentation protocol for the CA4/dentate hippocampal subfield developed in chapter seven was extended to include a complete set of hippocampal subfields. This is one of the first attempts to segment the entire hippocampus into its subfields using 3T MRI and as such, it was important to assess the quality of the measurement procedure. Furthermore, given the subfield volumes and the variability in these measurements, power and sample size calculations were also estimated to inform further work. Seventeen healthy volunteers were scanned using 3T MRI. A detailed manual segmentation protocol was created to guide two independent operators to measure the hippocampal subfield volumes. Repeat measures were made by a single operator for intra-operator variability and inter-operator variability was also assessed. The results of the intra-operator comparison proved reasonably successful where values compared well but were typically slightly poorer than similar attempts in the literature. This was likely to be the result of the additional complication of trying to segment subfields in the head and tail of the hippocampus where previous studies have focused only on the body of the hippocampus. Inter-rater agreement measures for subfield volumes were generally poorer than would be acceptable if full exchangeability of the data between the raters was necessary. This would indicate that further refinements to the manual segmentation protocol are necessary. Future work should seek to improve the methodology to reduce the variability and improve the reproducibility in these measures.

Section A explores capacity to consent to healthcare in adults with an intellectual disability in a broad context. It examines the legal understanding of capacity to consent as defined by the Mental Capacity Act (2005), before going on to use decision-making theory as a framework for exploring the psychological understanding of capacity to consent. It then examines the empirical literature on what influences capacity to consent to healthcare interventions and research in people with an intellectual disability, highlighting what further research is needed. Section B reports an empirical study, which follows up on some of the further research suggested by Section A. Background: Capacity to consent has been identified as one of the significant barriers to healthcare faced by people with intellectual disabilities. In order to improve understanding, the literature has attempted to investigate factors that influence capacity to consent to healthcare. Materials and Method: This study had 32 participants with learning disabilities, 22 carers and 3 nurse participants. It examined the correlations between verbal ability, decision-making opportunities and previous health experience, with capacity to consent to healthcare in people with learning disabilities, before exploring a regression model to show how the factors interacted. Results: Previous health experience and verbal ability significantly positively correlated with capacity to consent, whilst the correlation with decision-making opportunities was almost significant. However, the regression model showed that only verbal ability was a significant predictor. Conclusion: The study reveals the importance of looking at how factors that influence capacity to consent to healthcare interact with each other, rather than just acting individually. Further research is required to expand this model to include other variables. Section C provides a critical appraisal for the whole project, exploring what was learnt and what could have been improved on, as well as considering the implications for clinical practice and further research.

In recent years awareness of childhood obesity as a clinical and public health problem has increased. However, a number of important issues related to childhood obesity were unclear when this thesis began. The aims of this thesis were as follows: 1. To estimate the prevalence of obesity in British and Iranian children. 2. To assess the strengths and weaknesses of the body mass index (BMI) as a way of identifying obese children/estimating obesity prevalence. 3. To investigate the factors associated with early 'adiposity rebound'. 4. To identify risk factors for obesity in British children. This thesis showed that prevalence of childhood obesity in British and Iranian children was significantly higher than expected and that obesity prevalence in children increased during the 1990s. These results are consistent with reports of increased childhood obesity in the USA, Europe, and some other countries. Using BMI 95th centile as the definition of childhood obesity has moderately high sensitivity and high specificity, though a definition of BMI 92nd centile was shown in this thesis to be optimum. This thesis indicated that the typical age of AR in British children must be sometime between 5-7 years. Further research on the factors associated with timing of AR is recommended. A number of independent risk factors for childhood obesity are identified. Parental obesity, birth weight, fizzy drink consumption, and time spent in the car had the strongest association.

Physical activity (PA) (30 minutes of accumulated moderate intensity PA on most days) can protect against and enhance physical and mental ill-health. Despite this, 60% to 75% of the Scottish population do not meet the current PA recommendations. Those living in socially and economically deprived communities are particularly susceptible to chronic diseases related to sedentary lifestyles. Three studies were conducted as part of this research. Study One - Aim: To develop a reliable, valid, self-assessing, British, 7-day recall measure of occupational and leisure PA. Study Two - Aim: To pilot the procedures necessary to conduct the main study. Study Three - Aim: To assess the effects of a fitness assessment compared to a control intervention and an exercise consultation compared to a control intervention on PA, SOC and POC over 1 year in a community population high in social and economic deprivation. Methodology Three thousand residents of 2 socially and economically deprived communities were invited to volunteer for a fitness assessment or exercise consultation. Fitness assessment volunteers were randomly assigned into an experimental or control group (receiving PA information only) as were exercise consultation volunteers. This produced 4 groups; fitness assessment experimental (FAE, N=112) and control (FAC, N=113) and exercise consultation experimental (ECE, N=73) and control (ECC, N=72). Results For those not regularly active (contemplators and preparers), leisure PA initially increased and was maintained to 6 months before falling at 1 year post test. There were few group differences. Only the ECE group reported significantly higher levels of leisure PA at 1 year compared to baseline. SOC mirrored PA, with baseline contemplators and preparers mostly progressing into action, maintaining this to 6 months before regressing back to baseline SOC at 1 year for those not regularly active at baseline. Exercise consultations offered the best chance of study adherence and long-term SOC maintenance.