Background: Although there is a growing body of literature surrounding new psychoactive substances (NPS), and reasons for general use have been described, there is little understanding as to why certain NPS spread through user populations and become popular. This research used Rogers’ 1962 diffusion of innovations theory (DOI) to help better understand the NPS market and how it is shaped and characterised. Objective The aim of this research was to explore the diffusion of NPS in the UK and why different NPS diffuse and others fail to do so, to identify appropriate public health interventions to reduce harm. Methodology: A mixed methods approach was undertaken, which comprised four studies. The first study involved a critical analysis of the appropriateness of Rogers’ DOI to explain the diffusion of NPS. This study was followed by two sets of interviews. The first interview study was conducted with NPS online retailers based in the UK. The second interview study involved interviews with NPS professionals including law enforcement professionals, drug policy organisations and NPS early warning system representatives from the UK, wider Europe, America and Australasia. These findings were analysed using thematic analysis. The final study was an online questionnaire and choice-based conjoint analysis with UK pre-existing recreational drug users aged between 18 and 35. These findings were analysed using Latent Class Analysis. Results: The DOI was found to be applicable for the diffusion of an NPS product. However, the theory should be used in application to different individual NPS; NPS should not be classed as a homogenous group of substances and NPS users should not be classed as a homogenous group either. It was found that the theory should be updated in relation to NPS to include the influence of the internet. The key reason for the diffusion of an NPS was found to be the psychopharmacological effects of a product. However, there should also be an acknowledgment of the importance of friendship networks, and increasingly online forums. Even if a product had the desired psychopharmacological effects, if these are not communicated then it is unlikely to diffuse at a fast rate. Conversely, unless a product had the psychopharmacological effects desired by an individual, despite positive feedback from friends and online forums, it would be unlikely to diffuse. The emergence of NPS did not have a transformative effect for all drug-using groups; instead, it affected different user groups in different contexts. Similarly, it is likely that the introduction of the UK Psychoactive Substances Act will not have a transformative effect on the use of NPS by all drug-using groups. Nevertheless, the changes in health and social harms associated with individuals accessing NPS through the underground market or choosing to use traditional illegal drugs should be recognised. Finally, the need to conduct research with a range of stakeholders, to gain a greater understanding of motivations for drug use to assist with future public health interventions, was an important finding of the thesis.

Background: There is strong evidence linking obesity to health issues and long term conditions such as high blood pressure, type II diabetes, heart disease and some cancers (NICE, 2006). Despite this growing evidence base, the prevalence of obesity continues to rise and rates have more than doubled in England in the last 25 years (Public Health England, 2014). Currently 26% of adults are obese (Health Survey for England, 2014), and the proportion of women that are classified as overweight and obese has risen to 57% (Health Survey for England, 2014). Weight loss can reduce the risk of an individual developing these conditions and can increase their healthy life expectancy. It is estimated that approximately one in every two adults in England are actively trying to lose weight, the majority of which are over-weight or obese women (Piernas, Aveyard and Jebb, 2016). This indicates that over-weight and obese women are motivated to lose weight but are struggling to achieve or maintain a healthy weight. To-date potentially effective weight management interventions have been identified as long term multi-component interventions including diet and exercise components along with behavioural strategies. However, weight changes have been small and weight regain has been found to be very common (Loveman, Frampton, Shepherd, Picot, Cooper et al, 2011; Dombrowski, Knittle, Avenell, Araújo-Soare & Sniehotta, 2014). Despite the primary focus on weight loss being to improve health, research suggest that people’s prime motivation to lose weight is unrelated to health (Piernas, Aveyard and Jebb, 2016). Aim: This study aims to improve the understanding of the challenge of achieving and maintaining a healthy weight in overweight and obese young women. In particular, it aims to i) better understand the barriers and facilitators to achieving and maintaining a healthy weight as experienced by these young women, ii) further understand the relationships and influences of these factors, to iii) inform and develop a new theoretical framework in which to capture this social phenomena and societal challenge. Recruitment: This study recruited 14 female participants aged 18- 35 years, with a BMI over 30 (or 28 with co-morbidity), actively seeking support to lose weight. Participants were recruited through purposive sampling in two primary care practices in East London as part of the ‘Peer Support Weight Action Programme’ (SWAP). This was a Randomised Controlled Trial run by Barts Health NHS Trust and Queen Mary’s School of Medicine and Dentistry, funded by the National Institute for Health Research, Health Technology Assessment fund. Design: The research is qualitative in design utilising in-depth semi-structured interviews. Interviews took place with women recruited to take part in a weight loss programme before commencing the intervention, and follow up interviews took place approximately six months after completion of the weight management programme. Grounded Theory Analysis was used to analyse the data. Results and Findings: An overarching theoretical framework is presented from the findings of the data analysis of the pre and post weight loss attempt interviews. A new ‘Emotion and Mindset’ model is presented to explain the challenge of achieving and maintaining a healthier weight in young women. It includes the core categories of sense of self, emotion and mindset, self-efficacy, and stress and conflicting priorities and has been theoretically framed around the concept of Finding the Health Enhancing Equilibrium - maintaining a positive sense of self whilst generating action to achieve and maintain a healthy weight. It describes the balancing act required between these key contributing elements to engage in positive health behaviour which contributes to achieving and maintaining a healthy weight. Recommendations: Based on the findings from this study, and supported by previous findings (Cochrane, 2008), weight management interventions targeting young women need to build in coping strategies to support individuals cognitively, behaviourally and emotionally. These should include building self-efficacy (NOO, 2011; Ashford, Edmunds, French, 2010), sense of self and re-aligning identity (West & Brown, 2013). Individuals need to be taught how to identify, address and re-orient dysfunctional thoughts, to identify potential stressors such as triggers and environmental cues to prevent relapse. Consideration needs to be given to weight loss maintenance and ongoing tailored support. Further research is needed to identify what type and method of support is most effective and for whom.

Perinatal mental illness is a global health issue with detrimental outcomes for women and their families if left untreated. Unfortunately, many women do not get the treatment they need for many reasons, one often acknowledged reason is that the stigma some women experience inhibits disclosure of their needs to healthcare providers. This thesis looked at Internet resources for women with perinatal mental illness, in particular online forums. It examined how forums might affect stigma and thus disclosure behaviour. This thesis is by prospective publication. Article 1 aimed to describe and interpret qualitative studies regarding forum use and perinatal mental illness stigma. A metasynthesis of five studies identified four key themes: a safe place to talk; virtual support; stigma and identity; and repair of the mother identity (Moore, Ayers & Drey, under review). Article 2 aimed to identify what websites about postnatal mental illness were available and assess them for content and quality. A systematic review of 114 websites evaluated accuracy of information, resources and website quality. Results showed information was largely incomplete and difficult to read; resources were limited and website quality was variable (Moore & Ayers, 2011). Article 3 aimed to determine how women with perinatal mental illness use web based resources. A qualitative interview study (n= 15) found that the anonymity and non-judgemental social support on forums may have made it an acceptable way to challenge internal stigma and that most women described forums as providing a space to discuss stigma and test out disclosing about their illness to others (Moore & Ayers, 2016). Article 4 therefore aimed to identify whether forums for perinatal mental illness reduce stigma and facilitate disclosure. Thematic analysis of 1546 posts over six months on a forum for postnatal mental illness suggested that forum discourse reconstructed ideology of motherhood as compatible with perinatal mental illness. Many women overcame stigma and posted that they had taken advice and disclosed to a healthcare provider (Moore, Ayers, & Drey, 2016). The final article developed and tested a hypothesised model of the relationship between stigma and disclosure about perinatal mental illness. Study 5 developed a questionnaire measure of stigma for perinatal mental illness in order to test the model. Questionnaire items were completed online by women with perinatal mental illness (n=279). Psychometric testing suggested it was a valid scale with three subscales: external, internal and disclosure stigma (Moore, Ayers, & Drey, 2017). Study 6 tested a hypothesised model that stigma would mediate the relationship between forum use and disclosure to healthcare providers. An online survey of women with perinatal mental illness (n=200) who had used forums provided partial support for this hypothesis, with internal stigma mediating the relationship between length of forum use and disclosure (Moore, Drey, & Ayers, 2017). This research highlights the importance of considering the stigma associated with perinatal mental illness and its role in online forum use and disclosure. Overall, findings suggest that forums may facilitate recognition of stigma, which may in turn lead to greater disclosure of symptoms to healthcare providers. However, the relationship between forum use, stigma and disclosure may be more complex than our initial model proposed. Similarly, most participants in these studies were white, well-educated and actively participated in the forums. Future studies would benefit from testing these relationships using longitudinal designs with more representative samples.

This dissertation explores the experiences of migration and sex work amongst migrant males operating in London. Twenty-five non-UK born males, who were working as independent internet-based escorts, contributed to this study. This investigation used convenience sampling selection to recruit participants from two sexual health programmes specialising in male sex workers in London. The data was compiled through in-depth interviews and analysed using thematic analysis. This study provides connections between the trajectories that participants reported towards the UK and the routes of entry in to sex work. It also delivers insights about their experiences operating as independent internet-based escorts in London. Finally, it contributes information about their risk perception and unprotected sex experiences in the context of commercial sex, which allows the contemplation of risky sexual behaviour from the perspective of an occupational risk.

Background and aims: Very little is known about khat use in the UK. The aim of this study was to explore the barriers and enablers to quitting khat from the perspective of those using it and the barriers and enablers to supporting users to quit from the healthcare professional (HCP) perspective. Methods: A qualitative study using semi structured interviews with users and HCPs in London. The Theoretical Domains Framework (TDF) was used to collect and analyse the data. The important domains were mapped onto the Behaviour Change Techniques Taxonomy (BCTT_v1) and two interventions targeting khat users and healthcare professionals were designed. Results: A total of 10 khat users and 3 HCPs were interviewed. The beliefs held by khat users regarding the consequences of continued use facilitated their decision to quit. The social influences from those around them were a barrier and enabler. For healthcare professionals, the social influence of other colleagues and working together was key in enabling them to support clients. Social/professional role and identity was also an important enabler, as the healthcare professionals saw supporting users to quit as an integral part of their role. A range of BCTs were identified as potential ways in which quit attempts could be more successful, from the user and HCP perspective. Conclusions: The study has highlighted key factors in enabling khat users to quit and HCPs to support them to do so. It has clear implications for current quit khat services and demonstrates how to target interventions by focusing on key barriers and enablers to quitting khat and supporting HCPs to deliver services. Recommendations for practice in the field of substance misuse and areas for future research have been identified.

In India, alongside Information Technology, health care has become a leading sector in the country‘s development as a 'knowledge economy' (World Bank 2005). One of the major achievements and beacons of economic reform is the growth of some of the most technologically advanced hospitals in the world. This thesis examines the social processes shaping the expansion of the private health care system in the state of Kerala, South India, where large corporate hospitals and 'super-speciality' medicine have spread throughout urban and many rural areas. It explores the intersections between the local and the global, as the health system becomes the major driver of industrial development, unevenly linking the local health care system to the global marketplace for technologies, health care professionals and patients. It examines the three faces of the health care system in Kerala - as a knowledge industry and route to social mobility for the middle classes, in particular doctors and nurses; secondly, as a consumer economy, as people prioritise spending on health care and shop for treatment in the urban marketplace; and finally as a moral economy, as people develop high levels of dependency on doctors, hospitals and technologies in the hope of receiving good health care. The ethnography is set in Malabar, Northern Kerala, where the expansion of private health care has been financed by remittances from migration to the Arabian Gulf countries. The thesis examines the influence of migration and economic reforms on local ecologies of health and health care; the impact of the globalisation of trade in health services in the developing world; the relationship between the private health care system and the middle classes in South Asia; and the role of markets in the delivery of health services. Based on 18 months of participant observation across the urban and rural health care market with local communities of doctors and patients, it examines how doctors and patients adjust to a changing ecology and economy of health care.

There are more mobile phones in the world than there are people, and numbers are increasing. Immediate access to technology has completely permeated everyday life, and for many people their mobile devices are an indispensable accessory that accompanies them everywhere, including the bathroom. Mobile devices can harbour pathogenic microorganisms on their surfaces, that can survive for days, before potentially being transferred onto hands or other objects that they come into contact with. These devices are also rarely decontaminated. Whilst these microorganisms are generally not of concern to the healthy adult, they may be to the very young, the elderly, and those with reduced immunity. This study determined if mobile devices can be used in the healthcare setting and not be an infection risk. A six-stage mixed methodology approach was employed, with laboratory investigations into the contamination on mobile devices, the efficiency of transfer from them, and the effectiveness of decontamination methods. Analysis of existing NHS mobile device policy and application of the Hazard Analysis Critical Control Point process to perioperative practice provided real-world perspective. The findings from this study identified that current literature is under-reporting the contamination on mobile devices, and determined that the bacterial presence is transient, not constant. Transfer efficiency of up to 79% was recorded for Staphylococcus aureus from a device onto a wet gloved hand, and observation of perioperative practice identified five hazards specific to the presence of a device, that could become a risk to patient safety, but could be managed through application of Critical Control Points. This study also found that over 40% of NHS organisations in mainland UK do not have a mobile device policy, and only 11% make any reference to their infection prevention and control. Testing of decontamination methods determined that a two-stage process of wiping with a dry lint-free cloth, followed by exposure to UV-C, was the only approach that effectively reduced contamination levels without contradicting manufacturers’ guidance and thus voiding the device warranty. Optimum criteria for mobile device policy, and suggestions for in-context application, are proposed.

The pervasive demand and desire for an ideal body evident in today's society has led to the normalisation of beautification and enhancement treatments. Unlicensed weight loss (UWL) drugs which comprise of 2,4 dinitrophenol (DNP), sibutramine and rimonabant are just one method used in enhancing and improving the body in line with social expectations. However, previous research exploring the use of these drugs has been confined to male dominated bodybuilding communities, despite women experiencing increasing pressures to look a certain way. This doctoral research explores the use of UWL drugs by women, focusing specifically on attitudes and perceptions of UWL drug use, motivations for use, experiences of use and self-reported adverse effects. This qualitative research involved an online forum analysis. Online discussion forms (n=10) were selected based on their levels of popularity, the proportion of female users accessing them and because they contained relevant UWL drug discussion. All threads (470) relating to UWL drug discussion were downloaded and analysed using thematic analysis conducted through the software package NVivo version 10. Four forum moderators and three female UWL drug users were also recruited, with their interviews presented as case studies. Online communities can provide a raft of knowledge concerning hidden or hard to reach populations. This research however advocates for greater consideration to be given to the methodological and ethical implications of online research and reflects on what is public information, the protection of anonymity and protecting online users from harm. This research also identified that removal of a license from a drug does not prevent use, but once outside regulatory control or medical supervision, UWL drugs are often purchased online with risks to the user of potential drug interactions, adulteration and contamination. UWL drug user engagement needs to be reclaimed as part of a wider health agenda, something that has been lacking due to the unlicensed status of the drugs. However, the findings highlighted the diverse motivations for why women use UWL drugs as well as differences in experiences, drugs used, willingness to take risks and adverse effects and argues against there being a typical female UWL drug user. Given this heterogeneity, a one size fit all model for harm reduction may be ineffective. Additionally the rapid changes in online communities as well as the diffusion of these drugs into different populations creates another challenge for public health in identifying and targeting specific groups. Online discussion of these drugs focuses on user experience and anecdotal evidence. Education on the different types of drugs as well as the risks and harms of using them is therefore warranted for all online communities as well as a focus on specific harm reduction strategies including harm minimisation, engagement with health care practitioners and peer to peer education. However, further consideration is needed concerning how this information should be disseminated, identifying those who have authority within the community, but also have the appropriate credentials, knowledge, skills and desire to offer advice.

Introduction: World Health Organisation (WHO) policy presents parental HIV disclosure to children as beneficial and encourages parents to disclose. Most research on disclosure has been conducted in high income countries and tends to represent women’s choices in terms of a disclosure/non-disclosure binary which, I argue, is premised on rationalist theory models of decision making and disclosure which fail to contextualise women’s experiences, particularly those women who live in the Global South. This research study aimed to address gaps in existing research by exploring the maternal disclosure experiences of HIV positive Jamaican mothers to their seronegative children and offers a critique of existing WHO policy. Methods: I carried out in-depth interviews with 15 HIV positive Jamaican women with at least one seronegative child aged over 10 years, associated with one clinic and one NGO in Kingston, Jamaica. I adopted a feminist approach to Interpretative Phenomenological Analysis (IPA) and applied Hochschild’s concept of emotion work to make sense of women’s experiences. In attending to the structural factors shaping health actions, a feminist approach highlights the relationship between Jamaican contextual factors of poverty, violence and complex familial formations and women’s disclosure decisions. Conceptual resources drew on feminist critiques of dominant discourses of motherhood, including governmentality and responsibilisation, which, I argue, underpin policy imperatives on disclosure to children. Results: Mothers’ experiences of maternal disclosure to children occurred on a spectrum, rather than a disclosure/nondisclosure binary, and included: full disclosure, partial disclosure, nondisclosure, denial of HIV, differential disclosure (telling only some of their children) and disclosure by others. Experiences of disclosure were affected by financial risks and practical issues as well as consideration of children’s long-term physical and mental health, education prospects and the impact on other family relationships. Mothering at a distance (mothers living apart from their child/ren) and the fear or reality of ‘downfallment’ (a child being HIV positive) further complicated disclosure experiences. The women described strategies which challenged negative characterisations of HIV positive women in order to present themselves as capable mothers and manage their own and their children’s emotions. Conclusion: Disclosure of maternal HIV to children is a complex issue, carrying risks as well as benefits, which are particularly heightened in low income contexts. When women disclose this could be seen as a form of governmentality and when they don’t disclose their mothering is called into question within policy discourses predicated on evidence from the Anglo North. The over simplistic disclosure /non-disclosure binary fails to consider the emotion work women engage in to manage their illness and their mothering identity in the context of their relationships with their children. This research adds to the HIV disclosure literature from low and middle income countries and extends maternal HIV disclosure research through the use of a novel approach, feminist IPA, to understand women’s experiences. The research findings point to the need for a more nuanced policy on disclosure in low and middle income countries.

Musculoskeletal conditions are believed to cost UK society approximately £7.4 billion per year, with 30 million working days lost each year due to musculoskeletal conditions. Currently, within the UK, sickness certification can be self-certified for a period of seven days after which time a General Practitioner is required to authorise any further period of absence from work for patients. In April 2010 the Sickness Certificate was replaced with the Fit Note. The existing literature has offered little ‘in-vivo’ insight into the primary care consultation in relation to the management of patient musculoskeletal work-related concerns since the introduction of the Fit Note, and there is a paucity of research exploring the patient experience of these consultations. The research questions in this thesis broadly ask: How are musculoskeletal work-related concerns discussed and managed within the primary care consultation? How do patients experience these consultations? Mixed qualitative methodology is used within this study. Interpretative methods are used to thematically analyse 100 video-recorded consultations and 19 semi-structured interviews to answer these research questions and provide insight into this area. Findings reveal that the management of musculoskeletal work-related concerns within the primary care consultation is sub-optimal. Accessing work-related support for these people is complicated and contingent upon how they come to identify themselves as candidates for work-related support. The theoretical framework of candidacy is offered as a useful device for understanding and conceptualising the patient experience of these consultations. Interactions with healthcare, in combination with sociocultural factors, mediate how people come to understand their candidacy to seek musculoskeletal work-related support. Directions for further research in this area are provided.