Prostate cancer has emerged as the most frequently diagnosed cancer, except for non-melanoma skin cancer, among men in many Western countries in the last decade. In the United Kingdom (UK), prostate cancer accounts for nearly a quarter of all new male cancer diagnoses. Increasing age and some genetic and ethnic risk factors have been identified but few modifiable risk factors are known. The introduction of Prostate Specific Antigen (PSA) testing has increased the detection of previously undiagnosed disease but its contribution to the observed increases in prostate cancer incidence is not clear. Considerable variations in the incidence of prostate cancer have been observed in different geographic regions and socio-economic groups across the UK but it is not known whether, or to what extent, these may be attributed to differential uptakes of PSA testing. Prostate cancer is the third most common cause of cancer death in men but many cases do not progress. There is therefore an important clinical need for better prognostic markers so that the increasing numbers of men with prostate cancer can be appropriately managed. This thesis begins with a descriptive epidemiological study using cancer registry incidence data from the West of Scotland from 1991 to 2007. The aim was to determine whether the incidence of prostate cancer was continuing to rise and to describe any demographic or socio-economic patterns that might suggest particular at-risk groups. To understand whether any socio-economic differentials in incidence might be due to PSA testing, I examined Gleason grade-specific prostate cancer incidence by socio-economic groups over time. Socio-economic circumstances were measured using census-derived Carstairs scores. Overall (age adjusted) prostate cancer incidence increased by 70% from 44 per 100,000 in 1991 to 75 per 100,000 in 2007, an average annual growth of 3.59%. This pattern was driven by significant increases in both low and high grade cancers with no convincing change in their proportions over time. Incidence was inversely associated with deprivation with the highest rates among the most affluent groups. To explore the role of potentially modifiable risk factors on prostate cancer incidence, the Midspan and Collaborative prospective cohort studies were analysed. An analysis of the relationship between cholesterol and prostate cancer incidence was conducted on the Midspan cohort, which comprises 12,926 men who were enrolled between 1970 and 1976 and followed up to 31st December 2007. Cox Proportional Hazards Models were used to evaluate the association between baseline plasma cholesterol and Gleason grade-specific prostate cancer incidence. Following up to 37 years’ follow-up, 650 men developed prostate cancer. Their baseline plasma cholesterol level was positively associated with hazard of high grade (Gleason score ≥8) prostate cancer incidence (n=119). The association was greatest among men in the 4th highest quintile for cholesterol, 6.1 to <6.69 mmol/l, Hazard Ratio 2.28, 95% CI 1.27 to 4.10, compared with the baseline of <5.05 mmol/l. This association remained significant after adjustment for age, body mass index, smoking and socio-economic status. Evidence on the possible role of tea and coffee consumption in the development of prostate cancer remains limited to a small number of studies with short follow-up and small numbers of cases. Therefore to understand the relationship of tea and coffee consumption with overall as well as grade-specific prostate cancer, a prospective cohort study of 6016 men was carried out, who were enrolled in the Collaborative cohort study between 1970 and 1973 and followed up to 31st December 2007. Three hundred and eighteen men developed prostate cancer in up to 37 years’ follow-up. I found a positive association between consumption of tea and overall risk of prostate cancer incidence (p=0.02). The association was greatest among men who drank ≥7 cups of tea per day (HR 1.50, 95% CI 1.06 to 2.12) compared with the baseline of 0-3 cups per day. However, I did not find any significant association between tea intake and low (Gleason < 7) or high grade (Gleason 8-10) prostate cancer incidence. Higher coffee consumption was inversely associated with risk of high grade disease (HR 0.46, 95% CI 0.21-0.99) but not with overall risk of prostate cancer. These associations remained significant after adjustment for age, Body Mass Index, smoking, social class, cholesterol level, systolic blood pressure and alcohol consumption. Although survival of prostate cancer patients has improved over time, little is known about the major prognostic factors. To understand the socio-economic differences and major determinants of survival, an investigation was carried out using cancer registry incidence data from the West of Scotland from 1991 to 2007, linked with General Registrar Office (Scotland) death records up to 31st December 2008. Socio-economic circumstances were measured using the Scottish Index for Multiple Deprivation (SIMD). Age, sex and deprivation specific mortality rates were obtained from General Registrar Office for Scotland (GRO(S)). One, three and five year relative survival was estimated using the complete approach. Survival gradients across deprivation quintiles were estimated using linear regression, weighted by the variance of the relative survival estimate, using STATA software (StataCorp, version 11). Five year relative survival increased from 58.2% to 78.6% in men over the same period (an average deprivation adjusted increase of 10.2% between six years periods). Despite substantial improvements in survival of prostate cancer patients, there was a deprivation gap (that is, better survival for the least deprived compared with the most deprived) between the three time periods. The deprivation gap in five year relative survival widened from -4.76 in 1991-1996 to -10.08 in 2003-2007. Age, Gleason grade and socio-economic status appeared as significant determinants of survival. There is some evidence that systemic inflammation may be associated with survival in patients with prostate cancer although its relationship to tumour grade and socio-economic circumstances has not been previously studied. I therefore investigated the association between inflammation-based prognostic scores and survival, using the modified Glasgow Prognostic Score (mGPS) and Neutrophil Lymphocyte Ratio (NLR) as well as Gleason grade. The patient cohort within the Glasgow Inflammation Outcome Study who had a diagnosis of prostate cancer was included in this study. The mGPS is a categorical score constructed by combining serum C-reactive protein and albumin levels, while the NLR is obtained by calculating the ratio of neutrophils to lymphocytes. The relationship between mGPS and NLR and five-year relative survival was explored after adjusting for age, socio-economic circumstances and Gleason grade. Of the 897 prostate cancer patients in the Glasgow Inflammation Outcome Study, 422 (47%) died during a maximum follow-up of 6.2 years. Systemic inflammation had a significant prognostic value. The mGPS predicted poorer 5-year overall and relative survival independent of age, socio-economic circumstances, disease grade and NLR. Raised mGPS also had a significant association with excess risk of death (mGPS 2: Relative Excess Risk = 2.08, 95% CI 1.13-3.81) among aggressive, clinically significant prostate cancer (Gleason score 8-10). Prostate cancer patients with a raised mGPS had significantly higher risks of death overall as well as for high grade disease. Inflammation-based prognostic scores can potentially predict patient outcome and a further prospective study is warranted to assess their clinical value.

There is increasing interest in how people manage the multiple demands of paid work, home and personal life, and the consequences that failure to achieve ‘balance' between these domains may have on health. There has been limited qualitative research exploring the meanings and connections people attach to gender, ‘work-life balance’ and health; this is particularly so for workers who do not occupy managerial or professional jobs. To fill this gap in the literature this qualitative study examined narratives about ‘work-life balance’ amongst women and men working in ‘non-professional’ jobs in a single organisation. Forty semi-structured interviews were carried out with women and men working in administrative, technical and manual jobs within a single organisation based in various cities across the UK. As with the wider labour market, jobs were largely segregated by sex; all the administrative workers were women, whilst all but one of the manual employees were men. The sample included people who worked full-time and part-time, along with participants who also had other employment or were in further education. The sample was diverse in relation to age and family situation. The study was framed within the context of Clark’s (2000) work/family border theory, which aims to explain how individuals balance paid work and family, and construct the borders between these domains. The thesis focused on paid employment, family, leisure, and reported experiences of work-life balance amongst the sample. It concludes by revisiting Clark’s work/family border theory, considering the importance of different domains and borders for this sample, and the role of gender within the theory. The accounts of work-life balance given by these participants differed from those reported in studies of professional employees. Whilst much of the literature problematises paid work as being the main source of conflict, within this sample experiences varied. Due to the relatively low-paid nature of the work carried out amongst the sample, in many instances the necessity of work in providing for self and family predominated over considerations of work-life balance. Borders surrounding the leisure domain were highly permeable, meaning this domain was often compromised by work and family demands. Participants generally held traditional attitudes to gender roles, particularly in relation to the domestic sphere. This influenced choices constructed around paid work, and experiences of work-life balance. Health was not a key concern, although high levels of strain in different spheres, particularly in relation to the home and family sphere, led to stress for some participants.

Cerebrovascular disease, has an enormous, and increasing, impact on global health. As well as causing clinical stroke, cerebrovascular disease is thought to be a major contributor to cognitive decline and dementia. Socioeconomic status (SES) is associated with risk of stroke. Those in the lowest SES group are estimated to be at twice the risk of stroke compared to those in the highest SES group. Those with low SES may also have a more severe stroke and a poorer outcome. It is imperative that the extent and mechanism of this association is clarified. This thesis aims to determine if the association between SES and stroke is explained by a greater prevalence of traditional vascular risk factors amongst those of low SES. It also explains the link with a novel risk factor, poor oral health. Lastly it addresses the long-term cognitive outcome in older people at risk of vascular disease. A systematic review and meta-analysis was undertaken to establish if vascular risk factors explain the association between SES and stroke incidence / post-stroke mortality. This demonstrated that lower SES was associated with an increased risk of stroke and that a greater burden of vascular risk factors in those with low SES explained about 50% of the additional risk of stroke. However this meta-analysis could not clarify what vascular risk factors are most critical. Low SES was also associated with increased mortality risk in those who have a stroke although study results were heterogeneous and this link was not readily explained by known vascular risk factors. A prospective study of 467 consecutive stroke and transient ischameic attack (TIA) patients from three Scottish hospitals was undertaken with the aim of establishing whether those with low SES carry higher levels of vascular risk factors, have a more severe stroke and have equal access to stroke care services and investigations. Stroke / TIA patients with low SES were younger and more likely to be current smokers but there was no association with other vascular risk factors /co-morbidity. Those who had lower SES had a more severe stroke. The lowest SES group were less likely to have neuroimaging or an electrocardiogram although differences were not significant on multivariate analysis. There was however equal access to stroke unit care. A secondary analysis of a prospective cohort study of 412 stroke patients was conducted. The aim was to explore oral health after acute stroke and assess if poor oral health explains the association between SES and stroke. Dry mouth amongst acute stroke patients was very common, however there was no association between oral health and low SES. There was an association of dry mouth with pre-stroke disability and Urinary Tract Infection. There was also a link with oral Candida glabrata colonisation, although the clinical relevance of this is uncertain. In the acute phase after stroke there was no convincing association of dry mouth with dysphagia or pneumonia. Therefore there was no association between SES and poor oral health as measured in this study but oral health may still be part of the explanation of the association between SES and acute stroke and this needs further investigation. Vascular disease is an important contributor to cognitive decline and dementia. Low SES may be associated with an increased risk of cognitive decline in later life and vascular disease may be a mediating factor. More effective prevention of vascular disease may slow cognitive decline and prevent dementia in later life, particularly in low SES groups. Lipid lowering with statins might be effective in preventing dementia but so far evidence from randomised control trials does not show benefit from statins in preventing cognitive decline and dementia. However the duration of follow-up in these trials was short and there may be benefit in the long-term. My aim was therefore to establish if long-term follow-up of the Prospective Study of Pravastatin in the Elderly at Risk (PROSPER) study was feasible. I found that it was feasible to follow-up 300 elderly survivors from the Scottish arm of the PROSPER study and the methods could be extended to the whole group. As expected nearly half of the PROSPER participants were dead. Additionally a large proportion of traceable participants had significant cognitive impairment. Smoking cessation, control of blood pressure and management of other vascular risk factors should be made a priority in areas of low SES. Additionally further research is needed to fully clarify the association between SES and stroke incidence. Avenues for exploration might include the possibilities of poorer access to effective stroke care, reduced uptake of care and poorer oral health in lower SES groups. In addition public health campaigns regarding smoking cessation should be directed at lower SES groups. I have shown that a large scale follow-up of the PROSPER participants is feasible and may determine new and novel risk factors for dementia and assess the long-term effect of a period of treatment with pravastatin.

Inflammation is widely considered to be an important contributing factor in atherogenesis and the risk of atherothrombotic complications. Baseline measurements of some inflammatory markers are known to be predictive risk factors for future cardiovascular disease (CVD) events in prospective epidemiological studies. Inflammatory markers dominant in the literature are acute phase response (APR)-associated and include fibrinogen, C-reactive protein (CRP) and, more recently, interleukin- (IL-) 6. This thesis reviews the literature and suggests the need for further research into novel inflammatory markers of CVD risk. The broad aim was to expand on limited existing data and ascertain if circulating levels of four novel inflammatory markers (tumour necrosis factor alpha [TNF alpha], IL-18, soluble CD40 ligand [sCD40L], and matrix metalloproteinase-9 [MMP-9]) are associated with classical cardiovascular risk factors, and with future CVD events in several epidemiological studies. In studies of pre-analytical variables, all four markers had commercially available assays acceptable for epidemiological use, but only IL-18 and TNF alpha displayed assay stability and the ability to be measured in plasma or serum. Due to limited serum samples, MMP-9 and sCD40L were less extensively measured. Results suggest a moderate positive association of MMP-9 with coronary heart disease (CHD) risk (although confounded by smoking and markers of general inflammation), while serum sCD40L may be moderately inversely related to CHD risk. More data is required for these markers. IL-18 and TNF alpha displayed similar degrees of short-term biological variability and regression dilution as CRP. Population distributions of both cytokines were consistent with limited previous reports. Both displayed associations with conventional vascular risk factors (such as age, gender, HDL cholesterol, and smoking), although interestingly, associations with epidemiological measures of obesity were poor. Both cytokines demonstrated moderate associations with vascular disease in a retrospective CHD study. In 3 prospective CHD or CVD studies, IL-18 demonstrated consistent but moderate associations with risk of vascular events in age- and sex-adjusted models (Odds ratio [OR]~1.6 in the top versus bottom third of the population). The association became borderline significant after adjustment for conventional risk markers. Associations of TNF alpha with risk of CHD in these studies were inconsistent, and more data are needed. In 3 prospective stroke studies, TNF alpha demonstrated some moderate associations with acute stroke outcome and recurrent stroke risk, but not with incident stroke in the elderly with vascular disease. IL-18 demonstrated no association with risk or outcome in any stroke study. Meta-analysis in 4 suitable prospective studies showed (in full adjustment models) that IL-18 (OR 1.18 [95% CI 0.95-1.48] comparing extreme thirds) and TNF alpha OR 1.05 [0.67-1.64]) have at best weak independent associations with CVD risk. Therefore these markers are unlikely to add significantly to clinical vascular risk prediction models, although these cytokines may still be of biological significance and potential therapeutic targets. More data is required for these markers. In conclusion IL-18, TNF alpha, MMP-9 and sCD40L may show weak associations with CVD. However, despite animal and tissue models indicating that they may play pivotal roles in atherogenesis, circulating concentrations of these inflammatory markers have limited independent vascular risk associations. Elevated circulating levels of APR-associated markers may sensitively reflect exposure to a wide range of adverse pro-inflammatory stimuli including lifestyle exposures, whereas some other inflammatory markers may not.

Mental health problems in individuals and in the Scottish population are less well defined by routine data and diagnostic criteria than are physical health problems, but they have similar relationships with social gradients. Primary care in Scotland in recent years has been given an emphasis on health inequalities and on prevention and is also expected to provide frontline services and ongoing support to patients with mental health problems. Addressing health inequalities and inequalities in mental health are thought to require action on social circumstances as well as on biological conditions. However, the health service works within an established biomedical culture influenced by the strong medical workforce system and the broader political emphasis on accelerated economic growth. Policies express a general expectation that all public sector services have addressing health inequalities built in to their functions, but there is evidence to suggest that primary care has not yet found its place in meeting this expectation. To date there have been few concrete proposals for action and no guidelines for primary care to address health inequalities. The study set out to identify the contribution that primary care can make to reducing and preventing inequalities in mental health. Interpretive policy analysis was used as the framework for the study. In contrast to traditional policy analyses, which take an objective approach to comparing policy interventions, interpretive policy analysis can help to synthesise perspectives or reframe debates. It regards stakeholders’ interpretations of policy as drivers for change on the ground rather than the policies themselves. Stakeholders are described as being within three “communities of meaning” of policymakers, implementing agencies and service users, and each grouping can have several internal communities making different interpretations of the same policy. There were four communities of meaning relevant to this study: policymakers; primary care strategic staff; primary care and mental health frontline professionals; and services a patient might encounter. The policymakers’ perspectives on health inequalities and inequalities in mental health were drawn from an appraisal of nine health and social policies current at the time of the main study period (2002 – 2006). The other three communities were identified within one Community Health Partnership in the West of Scotland. Data were collected using document analyses, observation of a primary care mental health needs assessment and interviews with 21 frontline primary care and mental health professional staff from 14 disciplines. Identification of the services a patient might expect in relation to inequalities in mental health was elicited through frontline professionals’ responses to a vignette. All nine policy documents in the appraisal included aims to tackle some aspects of health inequalities, but inequalities in mental health were barely mentioned. The documents presented a disjointed picture of definitions for inequalities that lacked a clear overall interpretation of inequalities in health. They also proposed actions which often did not flow from the definitions and clouded the identification of expectations on primary care for addressing inequalities in mental health. For example, documents suggested that poverty, area deprivation and other social circumstances were linked with health inequalities, but the emphasis for action was skewed towards individual lifestyles and organisational change. The confused policy picture was mirrored by similar disjunctions between definitions and actions among strategic and frontline professional staff. In addition, there were clear differences between definitions identified in policy documents and those given by professionals, suggesting that frontline professional staff appeared to draw information about mental health and inequalities from public media and practice experience rather than from research and policy. Observation of a mental health needs assessment included an appraisal of the local strategic context and additional interviews with key senior staff. The observation found that inequalities were not considered for action in the mental health needs assessment nor in most of the other local strategic processes. This was despite some key strategic staff’s individual perspectives that social inequalities can impact on mental health, and despite information about local social and mental health inequalities being made available. The observation concluded that the culture of the organisation was not conducive to tackling inequalities in mental health. Frontline and strategic staff were generally unclear about identifying a patient’s social circumstances which might put them at most at risk of developing mental health problems. Although some frontline professionals linked mental health and social inequalities in defining health inequalities, most were unlikely to intervene on addressing a patient’s social circumstances. While frontline professionals and strategic staff almost universally defined health inequalities as differential access to services, few indicated that they would take action to ensure access, for example, following a patient’s non-attendance. The culture of the observed primary care organisation was not conducive to driving change on inequalities in mental health, and its contribution to reducing and preventing inequalities in mental health is at an early stage. Interpretive policy analysis identified disjunction and gaps in understanding and leadership to address inequalities in mental health at policy, planning and practice levels, but also identified potential areas for development. The study concluded that some of the building blocks are already in place for the primary care organisation to respond to policy leadership on inequalities in mental health should that time come.

Aim and Objectives: The overall aim of this work was to explore the current organisation of general medical services in Scotland, and by doing so, to create evidence which would identify a more effective and acceptable organisational model for the future delivery of primary care (general medical services) within the Scottish context. There were three research objectives: to improve understanding of the views of the public in relation to the organisation of general practice (general medical services) within the wider context of primary care within Scotland; to improve understanding of the views of professionals working within primary care in relation to the organisation of primary care; and to identify and refine models of primary care, and then to test these models of primary care against the status quo with primary care staff and with representatives of the public. Methods: Mixed methods were used to answer the research questions. These included group-work with members of the public in order to identify their priorities for the future of primary care; and semi-structured interviews with a purposive sample of primary care staff which combined members of the core practice team with Community Health Partnership and Health Board managers. Two alternative models for the provision of primary care general medical services were identified by combining the findings from the public and primary care staff with the literature. The two alternative models were then explored by public representatives and primary care staff using mixed methods which combined scoring of the models with deliberative discussion. Results: Work with the public identified a number of specific priorities. The most important priorities included: quality of care; access to care; and holism. A number of other issues such as a desire for involvement in their own care and the importance of access were also identified. Equity was also acknowledged as being important. There was general agreement between the public and primary care staff in terms of priorities, although staff were resistant to an increased role for the public in overseeing the organisation of practices. Staff and the public agreed on the high levels of variability in general medical practice and the public were concerned about low levels of holism. Staff and managers described an emerging sense of confusion about the roles of general practice. Practice staff had very negative views of Community Health Partnerships and Health Boards in terms of governance, and there was a lack of leadership and direction across primary care. There was evidence of low levels of trust between practice staff and CHP/Board managers. Skillmix was seen as desirable, though some saw it as a means to cost reduction. The independence of practices within the NHS was overwhelmingly supported by staff, who felt that this was preferable to the difficulties encountered in the directly employed and managed system. Practice ownership and the issue of profit was contested with a number of staff being uncomfortable with the idea, but there was a recognition that removing this driver might have negative consequences. There was ambivalence about the move to a wider model of health and the impact of integration with other sectors which was seen negatively by practice staff. Two alternative models were identified: a local contract model and a social enterprise model. These were tested by public representatives and primary care staff against the status quo. The public scored the local contract more highly on the domains of patient influence on service organisation, and on patient and carer involvement in their care. The public representatives scored the social enterprise model significantly more highly than the local contract model and the status quo. The primary care group did not score the novel models significantly higher than the status quo. The staff group were concerned about proposals to increase the involvement of the public in the organisation of services. Conclusions: The work builds on that of others who have identified the public’s priorities for primary care. It suggests that holism, patient influence in service organisation and equity are important priorities. The work with primary care staff confirms work by others relating to difficulties with the governance of primary care. Alternative independent models of provision were advanced which might address some of the current difficulties in general medical services. The author proposes that user involvement should form an important part of primary care governance, bringing together conflicting perspectives of CHP/Board managers and practice staff. The public’s main role in governance is to mediate between the positions taken by health professionals and managers, creating a shared perspective which is acceptable to the public. Furthermore, the concept of conditional trust and the emergence of new forms of professionalism which foster interdisciplinary working are proposed as potential solutions to the current impasse.

The introduction of multi-drug therapy (MDT) in 1982 has transformed the treatment of leprosy. By the end of 2001 more than 12 million people had been treated and cured. Since 1991 attention has turned to the task of eliminating leprosy as a public health problem. Progress towards this goal was initially dramatic, with substantial falls in registered prevalence. However, in part this trend reflects the shortened duration of treatment. While prevalence has fallen, the number of new cases has continued at an unexpectedly high level. While reported rates of disability among new patients have also fallen, published statistics draw attention to countries and locations where they remain unacceptably high. The sustained numbers of new cases and the numbers presenting with advanced signs of disease give rise to questions about underlying processes. Central to the elimination campaign are the principles of early detection and treatment with MDT. Progress towards early detection promises a reduction in the rate of Grade 2 disability and a reduced transmission of infection. One interpretation of observed trends is that factors delaying presentation threaten progress towards early detection and to achievement of the elimination goal. Research Objectives: The present research is a response to this situation. The primary objective has been to develop an understanding of delay in presentation as the cumulative effect of help-seeking actions reflecting the local context of knowledge, attitude and practice towards leprosy. The focus has been on the experience of individual patients and their narrative of help-seeking actions. Results: Lack of awareness of the early symptoms was the primary contributor to delay in each location. In Malawi other contributors to delay included use of traditional medicines, interactions with the health services and delayed lay referral. Cost, gender and the AIDS epidemic were also relevant. In Nilphamari, northern Bangladesh, use of health services and traditional medicines was minimal. Expression of fear of the impact of leprosy on the family was a risk factor for delay. In Purulia, India, reported delays were shortest. Few people relied on traditional medicines and health services were effective in making referrals. Previous contact with an affected person and expression of fear for the impact of leprosy on the family were risk factors for early presentation. In Hubli, India, health services were effective in recognising the possibility of leprosy but patients did not comply with the referrals. In Paraguay delay was linked to traditional health beliefs, reliance on natural healers, interactions with the health services, delayed lay referral, cost and gender. Discussion and Conclusions: Our assessment of the chosen methodology was that it provided information adequate for the problem-solving task. Research findings draw attention to three aspects of delay. First, we found delay to be a risk factor for impairment. Since the disability rate used as an indicator in leprosy control sanctions delays where there is no disability, we discuss the use of an alternative indicator based directly on delay. Second, awareness of factors contributing to delay provides an agenda for problem-solving activities. The present research draws attention to lack of awareness as the primary contributor. It identifies mixed experiences resulting from contacts with health services. It notes non-compliance with referrals. Third, the reported impact of the leprosy diagnosis and examples of enacted stigma draw attention to the persistence of stigmatising attitudes in each of the five fieldwork centres. These attitudes encourage concealment and denial. Findings suggest that delay might be considered a form of coping behaviour, allowing the affected person to come to terms with their disease before formal diagnosis and start of treatment. In this sense delay may be considered an indicator for the strength and persistence of traditional stigmatising attitudes.

Interpersonal violence is a public health concern in England and Wales. Nationally, over half of all victims of interpersonal violence sustain physical injuries, whilst approximately one-fifth suffer injuries serious enough to require medical treatment. Interpersonal violence therefore places a considerable burden on criminal justice and health service resources. Accurate and reliable data on the extent and correlates of violence at both national and local level are required in order to inform prevention strategies. Despite this, police and crime survey measures of violence have reported contradictory national trends, whilst few studies in England and Wales have examined either correlates of violence-related injury or the mechanisms explaining how such correlates increase risk of sustaining violence-related injury. This thesis presents findings from three studies which aimed to remedy these deficiencies. Firstly, Emergency Department (ED) attendance data were collected from 100 EDs across England and Wales and time series statistical methods employed to detect both national and local trends. Secondly, regional price indices for alcohol were calculated and associations with regional rates of violence-related injury and socioeconomic measures examined. Thirdly, potential mechanisms linking deprivation with increased risk of violence-related injury among adolescents and how these differed according to gender were examined qualitatively. Findings revealed violence-related injury decreased nationally by 6.4% between January 2005 and December 2012. Rates of violence-related injury were shown to be highest among men, 18-30 year olds and those living in the North West of England. Modelling revealed a significant negative association between violence-related injury and the real price of on-trade and off-trade alcohol; in so that a 10% increase in real alcohol price would reduce violence-related ED attendances in England and Wales by over 60,000 per year. Modelling also revealed that poverty and income inequality had the largest impact on rates of violence-related injury. At micro level, adolescent females were shown to be particularly sensitive to the effects of deprivation; poor alcohol regulation by parents and a lack of structured and appealing leisure activities may potentially increase risk of violence-related injury among this cohort. This thesis has shown ED data to be an invaluable tool for investigating trends and determinants of violence-related injury in England and Wales by clarifying national and local trends and identifying risk factors at both macro and micro level. Implications for violence prevention policies that can be drawn from these findings include targeting regions where violence is higher, raising the price of alcohol above inflation, and improving alcohol regulation and leisure opportunities among deprived adolescent females.

This doctoral study investigates the different forms, levels, and pathways of youth engagement with climate change and the implications for the well-being of youth in different contexts of vulnerability and adaptability. It aims to understand such engagement through the accounts and interactions of youth themselves and within their own environmental, socio-cultural, and political context, thereby contributing a holistic understanding of youth engagement in specific countries, an area under-researched in current literature. cultural stereotypes, and socio-political worldviews and structures; b) the need for enhancing young people's skills and prospects for future employment and welfare within an increasingly interconnected, technologically-driven, and sustainability-oriented workplace, through incorporating more critical, futures-oriented, and inter-disciplinary pedagogies of education and learning for sustainability within the higher education curriculum; c) the importance of academic and socio-political spaces and opportunities that foster critical reflection, interpersonal interaction, and collective action in strengthening young people's influence for change and their subjective and social well-being; and d) the need for more critical and empowering platforms and pathways that promote meaningful youth engagement and conscious power-sharing amongst youth and other stakeholders in society. Key recommendations emphasize multi-stakeholder partnerships with youth across political, academic, medical, civic and corporate spectrums to empower young people, especially higher education youth, to meaningfully contribute to future educational, developmental, and health agendas and strategies. The study aligns its conceptual and methodological rationale through applying a critical interpretivist research approach which ensures an analytical, contextual, and in-depth understanding of such engagement in different countries. It is conducted in the Netherlands and South Africa, which historically have had distinct vulnerabilities and approaches to climate change and diverse pathways for youth engagement. Particular emphasis is placed on higher education youth who constitute the future leaders, informed decision makers, and active and innovative agents of society. Fieldwork was undertaken throughout 2011, coinciding with the International Year of Youth and the COP17 international climate change conference. In each country, focus groups were conducted with university and college students from diverse socio-demographic and academic backgrounds. These focus groups sought depth and meaning through critical reflection, futures thinking, and a profound and interactive dialogic process. Qualitative interviews investigated more in-depth the emerging themes; whereas participant-observation, meetings with key informants, and document review promoted a comprehensive and valid understanding of the context in which such engagement is taking place. Key findings reveal: a) the contextual power differentials that strongly shape youth efficacy and agency, especially personal demographic and academic backgrounds, cultural stereotypes, and socio-political worldviews and structures; b) the need for enhancing young people's skills and prospects for future employment and welfare within an increasingly interconnected, technologically-driven, and sustainability-oriented workplace, through incorporating more critical, futures-oriented, and inter-disciplinary pedagogies of education and learning for sustainability within the higher education curriculum; c) the importance of academic and socio-political spaces and opportunities that foster critical reflection, interpersonal interaction, and collective action in strengthening young people's influence for change and their subjective and social well-being; and d) the need for more critical and empowering platforms and pathways that promote meaningful youth engagement and conscious power-sharing amongst youth and other stakeholders in society. Key recommendations emphasize multi-stakeholder partnerships with youth across political, academic, medical, civic and corporate spectrums to empower young people, especially higher education youth, to meaningfully contribute to future educational, developmental, and health agendas and strategies.

Background: Public health researchers and practitioners have repeatedly called for policy to be informed by academic evidence. The rise of the evidence-based medicine movement has demonstrated the potential benefits of using evidence for clinical decision-making. Recently, politicians and policy documents have echoed these calls for increased use of evidence in policymaking by drawing upon the discourse of evidence-based policy. However, efforts to understand the relationship between evidence and public health policy are underdeveloped and often make limited use of knowledge from other fields, including political science and sociology. This thesis aims to explore the relationship between evidence and public health policy in the UK using two contemporary case studies: the English public health White Paper, ‘Healthy Lives, Healthy People’; and the development of minimum unit pricing of alcohol in Scotland. Methods: The first case study: ‘Healthy Lives, Healthy People’ case study investigates the extent that three prominent discourses that draw upon academic work are reflected by the policy statements contained within the White Paper. The three areas examined include evidence on ‘what works’, the Nuffield framework on public health ethics and insights from behavioural science (‘nudge’). These discourses were chosen as they are not only rhetorically prominent in the White Paper, but also because they reflect the range of direct use of specific research findings and more conceptual use of research-derived ideas. To examine the extent that evidence on ‘what works’ has been incorporated into ‘Healthy Lives, Healthy People’, the research evidence for each of 51 specific policy actions described in the White Paper was reviewed. A critical analysis of ‘nudge’ and the Nuffield framework was conducted by contrasting their application with the authors’ original articulation. The second case study explores the development of the high-profile public health policy of minimum unit pricing of alcohol by drawing upon three different sources of data. First, a review of policy documents was conducted. Second, a systematic document analysis of evidence submissions that were received by the Scottish Parliament’s Health and Sport Committee in response to its consultation on minimum unit pricing was performed. This analysis drew specifically on a framework for analysing political argumentation. Third, 36 semi-structured interviews were carried out with a broad range of policy stakeholders. Interviewees were purposively chosen to obtain diversity in supportiveness for minimum unit pricing, as well as by professional position (academic, advocate, civil servant, politician, industry representative). The evidence submissions and interview data were thematically coded and organised using NVivo 9. Results: By systematically assessing the evidence underpinning the English public health White Paper, the study empirically established that public health policy does not meet conventional public health standards for being evidence-based. Similarly, the prominence of ‘nudge’ and the Nuffield framework in the text of ‘Healthy Lives, Healthy People’ do not appear to be matched by the actions suggested. However, this first case study finds that while evidence does have an influence, it does not determine policy. This relationship appears complex, partial and contingent rather than direct and instrumental, therefore necessitating a more detailed and focused case study. The second case study begins by providing a detailed description of the process by which minimum unit pricing developed in Scotland. It then draws on the analysis of evidence submission documents combined with interview data to identify a crucial role of public health advocates, who reframed the alcohol policy debate to bring about policy change. Epidemiological concepts were important in helping to achieve this shift in policy framing. Having investigated more conceptual influences of evidence, econometric modelling carried out by a team at the University of Sheffield is focused on as an example of a specific piece of research evidence that was perceived by interviewees to be influential in the policy debate. The different types of influence that the modelling study had on the policy process are determined and reasons for its influence investigated. The study also finds that interviewees believed econometric modelling could be more widely used to inform future public health policymaking. Lastly, a ‘multiple lenses’ approach builds upon these findings and political science theory to produce a comprehensive explanation of the policy process and describe the roles of evidence on the minimum unit pricing policy process. Discussion: Analysis of the ‘Healthy Lives, Healthy People’ White Paper shows that despite the prominent rhetoric for evidence-based policy, this is not reflected by the reality of current public health policy in the UK. The investigation of the development of minimum unit pricing of alcohol in Scotland demonstrates that evidence influences the policy process in a number of ways but these influences are heavily context-dependent. The role of evidence in changing the framing of the policy debate has been identified as of particular importance for this case study. The devolution process and evolving nature of political institutions also raises particular opportunities, but also challenges, for public health professionals. The strengths of the thesis include its use of two case studies to investigate the relationship between evidence and public health policy, the analysis of multiple sources of data in relation to minimum unit pricing policy and the application of political science theories that are typically underused in public health research. Limitations include the caution required when making generalisations from these data, particularly since these case studies have been purposively chosen. Drawing upon the two case studies, a conceptual model for the relationship between evidence and public health policy is articulated. The model suggests that evidence is likely to be used in different ways depending on the extent that the political values underpinning an issue are contested, with the importance of evidence for rhetorical purposes being a legitimate and helpful means of highlighting the health aspects of public policy issues. Lessons for public health researchers and practitioners, as well as directions for future research and theoretical implications, are considered and discussed.