Recent government reports indicate that there is a high incidence of enduring mental health problems in the African and African Caribbean communities living in the UK. Although research has explored the experience of service users from both of these communities, little is known about how family carers experience caring for a relative with an enduring mental health problem from the same communities. The aim of this investigation was to explore the lived caring experience of seven carers from the African and African Caribbean communities who cared for family members with an enduring mental health problem. A hermeneutical phenomenological approach, as described by Van Manen was used, which encompassed descriptions of carers’ experience of caring and subsequent interpretation of their lived experience. Analysis of the findings revealed the caring experience to encompass: (i) being there and staying there; (ii) losing oneself and re-discovering self; (iii) keeping an on-going dialogue with others, (iv) a conscious awareness of cultural stereotypes and (v) sustaining hope during the caring experience. The study concluded that carers from both communities maintain a strong familial obligation in their caring experience. Carers also make use of local community care groups to assert their carer role with mental health and social care services. Recommendations for future research are discussed in relation to improvements in mental health and social care provision.

A number of large scale Salmonella outbreaks have been associated with low aw food products where the significant causal factor was most likely cross-contamination. These studies sought to both: assess Salmonella survival and survival mechanisms when dried onto stainless steel under simulated food factory conditions, and to develop enhanced factory control approaches for this pathogen. Fifteen isolates of Salmonella survived 30 days under desiccation and one strain survived for one year and potentially could survive longer. Differences in the survival between different Salmonella serotypes, and isolates of the same serotype (S. Typhimurium), were noted. A 2-population Weibull model was used to model survival, since following an initial reduction in viability (72 h), no further reduction was seen. There was enhanced survival of Salmonella at lower temperatures and relative humidity, with the presence of food debris and when water was added. At a physiological level, attributes associated with osmoresistance (RDAR phenotype, motility, filamentation, EPS production) were not observed in all desiccation resistant strains, additionally survival was greater on surfaces rather than in hyperosmotic solutions. Desiccated cells did not show increased sodium hypochlorite and propanol resistance. To assess molecular survival mechanisms, three RNA extraction methods were compared and real-time RT-PCR was performed for 13 genes. All selected housekeeping genes showed change in expression therefore were not used. Genes in desiccation sensitive strain had higher fold change during desiccation than in resistant strain (aceA, nifU and otsB). The principles of HACCP were reviewed and a prerequisite management programme, based on a risk assessment of sources and vectors, was designed and applied in a low aw food factory, to help control Salmonella cross-contamination. These results suggest the potential for extended survival of Salmonella in food factories, describe the most suitable model to predict survival kinetics, give some insight into Salmonella survival mechanisms and stress responses under desiccation conditions and identify strains and methods for further research studies. The results also confirm the need to keep low aw factories free of food debris and to eliminate water to reduce Salmonella survival. Given the potential for Salmonella survival, the results also highlight the need for the control of cross contamination to the food product via an improved prerequisite management plan.

Antibody production in the lungs is an essential defence mechanism against respiratory pathogens. However, little is known about the local activation of B cells in the lung. The production of BAFF and APRIL by airway epithelial cells could contribute to local recruitment, activation, class switch recombination and antibody production by B cells in the lung. In vitro, BEAS-2B cells were used to characterize BAFF and APRIL production simulated either by RSV infection or addition of cytokines. RSV and IFN-β significantly induced expression of BAFF mRNA and protein but not APRIL. BAFF mRNA reached significantly high levels at 12h and declined at 48h after either RSV infection or IFN-β stimulation. Western blot analysis of resting epithelial cells showed that membrane BAFF was expressed by resting cells. On RSV infection or IFN-β stimulation, expression of membrane BAFF increased at 12 and 24hours and disappeared at 48h, which suggests soluble BAFF was cleaved from the membrane and released into the culture supernatant by 48h, where it was measured by ELISA. When BEAS-2B cells were infected with RSV after pre-incubation with anti-IFN β, expression of BAFF was blocked, which indicates that airway epithelial cells can produce BAFF in an interferon dependent manner. BEAS-2B cells did not express CXCL12, CXL13, CCL19 or CCL21, which indicates there are other potential sources that express these chemokines during RSV infection rather than the airway epithelium. A murine model of RSV infection was used to examine expression of BAFF, APRIL and of the chemokines CXCL12, CXCL13, CCL19 and CCL21. Cytokine mRNA and RSV N gene expression were measured by Taqman PCR in lung tissue from control mice at day 0 and mice challenged with RSV (A2 strain) or control UV-treated RSV at days 1, 2, 4, 7, 8, 10, 14 and 21 days after RSV infection by ELISA. RSV N RNA was significantly detected at day 1, 2 and 4 after RSV infection compared to UV RSV control. BAFF mRNA expression was increased significantly after RSV infection on day 1 ,7 and 8 in comparison to UV treated RSV control at the same time points. Equally, BAFF protein was also elevated significantly after RSV infection at days 1, 2, 4, 7 and 8 in comparison to UV- RSV control at the same time points. CXCL13 mRNA expression was increased significantly after RSV infection on day 1 and 7 in comparison to UV-RSV control at the same time points. Moreover, CXCL13 protein was increased significantly after RSV infection at day 1, 2 and 7 in comparison to UV RSV control at the same time points. CXCL12, CCL19 and CCL21 mRNA and protein levels were not increased significantly after RSV infection, which may indicate they are not active during RSV infection. Examination of mouse lung sections showed strong positive staining of B cells (CD20) following RSV infection at day 1, 2, 4, 7 and 8 and FACS analysis B cells numbers were increased significantly at day 6 and 8 following RSV infection relative to UV-RSV control. RSV infection results in up-regulated BAFF and CXCL13 expression, consistent with a role for CXCL13 in recruiting B cells and BAFF in promoting airway B cell survival or differentiation. Collectively, these results suggest that the airway epithelial could help recruit and support B cell growth and development and Ab production in the lung.

The recent identification of two novel influenza-like viruses in bats, H17N10 and H18N11 virus, and the discovery of serologically positive Eidolon helvum bats in Ghana for avian H9 virus prompted my hypothesis that, in addition to the large repertoire of zoonotic viruses hosted, bats may serve as asymptomatic reservoir species to conventional influenza A viruses found in birds and mammals. To begin to test this hypothesis, the susceptibility of three bat cell lines, derived from lung epithelial cells of Eidolon helvum, Carollia perspicillata and Tadarida brasiliensis (TB1-Lu), to low pathogenicity avian viruses (H2N3 [A/mallard duck/England/7277/06] virus and H6N1 virus [A/turkey/England/198/09] virus), and human viruses (USSR H1N1 virus [A/USSR/77] and pandemic H1N1 2009 virus [A/California/07/2009]) was determined. All three species of bat epithelial cells were found to be more robust and resistant to influenza virus infections than permissive MDCK cells. Infected bat cells produced lower levels of viral RNA and viral progeny, and were more viable than correspondingly treated MDCK cells. Interestingly, bat cells were more susceptible and replication permissive to avian than human influenza viruses. Among the bat cells, TB1-Lu cells were the least susceptible to influenza virus infection and that appears to be related to a lack of sialic acid α2,6-Gal receptors, mammalian virus-preferred host receptors, which were present in the other two bat species. The innate mechanisms underlying resistance to influenza virus infection in bats remains to be determined, however, inhibition of the JAK/STAT pathway was found not to affect virus production from infected bat cells suggesting that JAK/STAT signalling may not have a major role in influenza virus resistance in bat cells. Modulation of NF-κB signalling was found to affect virus production suggesting that tight regulation of NF-κB may be key in controlling the pro-inflammatory response to influenza infection in bat cells and warrants further investigation.

Culex quinquefasciatus mosquitoes play an important role in the transmission of vector-borne diseases of public health importance including lymphatic filariasis (LF) as well as many arboviruses. Insecticide-based approaches are one of the most important interventions to mitigate disease burden; nevertheless increased resistance of vectors to insecticides imposes a challenge for the sustainability and effectiveness of both current and future vector control interventions. Hence, understanding the dynamics and likely mechanisms underlying the evolution of resistance will be critical to effective decision-making in insecticide resistance management strategies. The present study was set out to investigate the genetic basis of insecticide resistance in C. quinquefasciatus from Uganda. Two objectives were developed, 1) to investigate patterns of insecticide resistance across the south of the country and how this might reflect local selection and genetic structure and 2) to investigate the basis of the molecular mechanisms underlying resistance to all four classes of insecticides recommended for vector control. The population genetic study compared and contrasted microsatellite markers and two resistance-associated loci (Vgsc-1014F and Ace1-119S). While no significant difference in genetic diversity across populations were detected by microsatellites, higher frequency of Vgsc-1014F compared to the Ace1-119S mutations was observed in all populations suggesting that the Ugandan Eastern – Southwest populations are under a heterogeneous selection pressure, which created a pattern of local adaptation in these populations. Additionally, the copy number (CN) assay developed in this study indicated the presence of CN variation in the voltage gated sodium channel (Vgsc) gene in about 10% of the individuals assayed from these populations. Genotypic/phenotypic association tests conducted on bendiocarb resistant-individuals suggested that this resistant phenotype was not underlying solely by the 119S target-site mutation in the Ace-1 gene. Indeed, synergist bioassays show an increase of mortality of around 25% in mosquitoes pre-exposed to either TTP or PBO, indicating a possible resistance mediated by detoxification enzymes. Using a novel whole-transcriptome microarray we profiled the bendiocarb-resistant phenotype and implicated two P450s (Cyp-Cx1 and Cyp6n23) with the highest up-regulation expression compared to a susceptible strain. Remarkably, the predicted Cyp-Cx1 is closely related to two P450s from the family Cyp6, which were already validated in vitro as insecticide metabolizers in A. gambiae and A. aegypti, which corroborates a likely association of metabolic resistance in the investigated bendiocarb-resistant phenotype. Taken together the results yielded by genomic and transcriptomic experiments provide evidence that Ugandan C. quinquefasciatus mosquitoes are under heterogeneous selection pressure imposed by insecticides from distinct classes, and that the evolution of insecticide resistance is mediated by at least two main genetic mechanisms; target-site mutations (Vgsc-1014F and Ace1-119S) as well as over-expression of detoxification enzymes.

Title: A Comparison of the Equity-supportiveness of Organizational Cultures of (Public) NHS Organizations and (Private) Social Enterprise (SE) Providers Theory: New Public Management (NPM) has been the most influential paradigm in public administration in the last three decades. NPM-driven ideas such as provider competition, privatisation and patient choice have resulted in increased interest from recent UK governments in Social Enterprises (SEs) for delivering public health services. NPM-based changes have been criticized for creating inequitable provision of healthcare and increasing unjust health inequalities. It is worth asking whether equity for patients is promoted equally effectively by public (NHS) organizations and SE providers. Research Aims and Methodology: A mixed methods approach was employed. The quantitative strand used a survey to compare the equity-supportiveness of NHS and SE organizational cultures [124 respondents (68 NHS and 56 SE staff) from 21 organizations (12 NHS and 9 SEs)]. The qualitative strand used semi-structured interviews with 27 SE staff members to examine organizational changes in SEs and the impact of these changes on equity in service provision. Findings: By achieving better alignment with organizational values, reducing bureaucracy, speeding up decision-making, giving staff more autonomy and responsibility, encouraging initiative, risk-taking and innovation, involving staff more actively in strategic decision-making, and making better use of technology, Social Enterprises are promoting equity to an equal or greater degree than public (NHS) organizations. Implications: However, the SE model (currently limited to community healthcare services) remains unclear and problematic, suggesting caution in its use by larger NHS acute Trusts. More research is needed before a policy to support the adoption of the SE model in public service delivery is mainstreamed.

The thesis maps out my experiences of, and thinking about, health promotion over my fifteen-year career as a health promotion specialist and lecturer. It adopts an exploratory, reflective approach starting with an account and analysis of health promotion as I experienced it in practice from the mid 1980's onwards, and ending with an exploration of the way reflexivity works in a medium-sized health promotion department in England. This exploration took place in 2000 at a time when the department like many others were facing an uncertain future and a possible merger with a department of public health. The thesis begins with my reflections on health promotion and its theory, and my personal experience of being managed in a health promotion department. This account forms the first step of a research process, and the role of reflexivity in this process is highlighted. Using qualitative techniques of data analysis, themes emerge relating to the way the accounts were written, the social and psychological processes being acted out; and the emotional tapestry involved. A co-operative research encounter based on the story-dialogue method with a medium-sized health promotion department generated six streams of qualitative data. The separate analyses are combined to produce overall meta-themes which tell a collective story of the hidden scripts and conventions operating in the health promotion department at the time. These include limits to what can be said, associated avoidance and cynicism, and an acknowledged lack of reflexivity. There was an embedded rhetoric about democracy, valuing and consultation that was vulnerable to being over-ridden or diminished. Similarly, there was a lack of specificity about what health promotion as an entity and team working actually means to the department. Within this scenario, staff became individual tacticians and placed high regard on their autonomy. Reflexivity facilitated and legitimised through story-dialogue enabled emotional expression, criticism, and agreement and appreciation. Reflexivity in the encounter translated hope and uncertainty into future-facing and future action. It helped re-establish and specify a collective identity and it provided some detail about nature of health promotion and team working. These meta themes are discussed in relation to changes and movements in contemporary health promotion in England including the life and meaning of 'health promotion' discourse and the creation, reification and impact of 'tribal' discourses in health promotion and public health. These discourses based on difference are shown to be questionable and point to a demise of reflexivity in more recent health promotion discourse. Adherence to this discourse is argued to leave health promotion open to charges of elitism and has hindered searches for common values, language and standards. Moreover, it has meant a failure to articulate a new health promotion.

Community pharmacists are increasingly providing public health services in response to government policies. Published literature regarding the views of the general public related to pharmacy public health services, although important in ensuring uptake of these services, was limited. This study series aim to explore the general public's perspective on how to maximise the appropriate utilisation of community pharmacy services for improving public health. A large study comprising four sequential phases was designed and conducted in Sefton borough. Initially, to gather background information, focus group discussions (FGDs) and semi-structured interviews were undertaken with the general public and key stakeholders. The second phase involved the development and testing of a questionnaire extracted from the qualitative findings and a literature review. The questionnaire focused upon seven pharmacy public health services related to cardiovascular risks as well as views on factors influencing pharmacy use and advertising/promotion techniques. Geodemographic concepts, widely recognised in public health, were also included to identify potential benefits to pharmacy practice research. Next, a large scale survey was administered among the general public using eight survey modes, to additionally evaluate the range of methods available/for gathering public views. Finally, survey findings were evaluated by representatives of survey respondents using a FGD. Results indicated that, although stakeholders considered that community pharmacy can make an extensive contribution in supporting public health, pharmacy public health services are used at a relatively low level by the general public and awareness of services is also low. Survey respondents indicated a willingness to use services in the future. Important factors influencing pharmacy use include loyalty, location and convenient accessibility. Appropriate promotional campaigns are a key facilitator to help raise the public's awareness. The findings will help the profession to increase uptake of pharmacy public health services. The variety of survey modes used proved beneficial in obtaining diverse population demographics, with street survey being the optimal technique, however, the potential for social desirability bias must be considered with this and other interviewer-assisted approaches. MOSAIC™ as a geodemographic tool is potentially useful in helping to target services for specific groups and is recommended for use in further research.

Green hospitals with improved hospital waste recycling practices can be a key solution to the potential problems associated with hospital waste disposal and management. Recycling of household hospital waste could significantly impact on the overall waste disposal management systems and how hospital waste is segregated and eventually disposed. The involvement of hospital staff is of key importance in improving recycling performance, however, the perceptions of hospital workers towards recycling of hospital waste is still not clear and there is a lack of research in this area. The factors that determine the recycling behaviour are not adequately described in the medical literature, and differences between hospital workers perceptions of recycling in developing versus developed countries have not previously been extensively studied. This thesis was designed to examine the factors influencing the knowledge and attitudes of hospital workers towards toward recycling of hospital waste, using a novel questionnaire. A pilot study was first performed to test the efficiency of the questionnaire, conducted via sending the self-administered questionnaires to 12 experts. Their views were considered in the development of the final version of the questionnaires. These were distributed randomly in 2 pre-selected hospitals in the UK and 3 similar hospitals in Libya. A total of 453 questionnaires were returned. The response rates were generally low in both counties (less than 20%). Females and nurses responded significantly more frequently than men and physicians. In general there were relatively low levels of knowledge about waste management and recycling practice. In this study, none of the Libyan hospitals practiced any recycling and the hospital workers in Libya were significantly less enthusiastic towards recycling than their UK counterparts. Training in hospital waste management and education were found to be weak predictors of positive attitudes. Results showed that it is difficult to predict the recycling behaviours among hospital workers, however, waste management staff were more positive towards recycling than those without training in waste management. The study has shown similar results to previous studies, in that hospitals in developed countries generated much less waste compared to hospitals in developed countries. Unexpectedly, knowledge was weakly linked to attitudes in both UK and Libyan hospitals. This may be due to the fact that the attitudes of clinicians and hospital workers are not necessarily related to their knowledge but rather affected mostly by the hard working hours and busy atmosphere which makes recycling more challenging. The study opens doors for further studies to investigate factors influencing recycling attitudes, and encouraging hospitals in developing countries to commence recycling practice and provide whatever infrastructure is needed to make this possible. More education and training on hospital waste management should be encouraged in developing countries. Introducing new technologies in hospital waste management, particularly recycling of hospital house hold waste may change the future prospective of hospital waste disposal in developed and developing countries. More studies intervening with educating the hospital workers in waste management, particularly in recycling of hospital waste and it's relatively safety should be encouraged. Key words: Healthcare waste, hospital household recycling, knowledge, attitudes, hospitals, healthcare workers, waste management.

This thesis focuses on quality improvement in local NHS services in response to national legislation. The preparatory literature search of healthcare, change and quality theories identified the common theme of participation for success as well as a distinct gap in quality management models suitable for healthcare. Action research was used to develop, implement and evaluate such a model, combining qualitative and quantitative methods, enabling ownership of the model by participating stakeholders, and facilitating change by reflection and action. The thesis is organised into three main parts from which key themes emerge. The first section establishes health and its care as the most basic of human needs. Healthcare delivered through public provision has a medically dominated hierarchy of stakeholders with different expectations: users pursue a social model of care, managers a business model, and providers a scientific model. The lack of evidence on which to base provision has resulted in autonomous clinical practice which, without reference to guidelines, is difficult to assure. In a culture of professional awareness, autonomy can provide an opportunity for service improvement The second section describes the development of the Quality Synthesis Model through participant involvement. Recent experiences of change in the NHS provided direction through: the need for clarity and agreement over quality issues, vision and values; a strategic approach; and capacity and empowerment to respond. In addition, these followed generic best practice of a conducive culture, communication, commitment and measures of progress. Finally, in the third section, the empirical chapters describe implementation and analyses of the model in the sample semi-profession service of chiropody with older people. Quantitative and qualitative data was collected through records, repeat surveys and sub sample telephone interview. Evaluation of the model was against: • operational criteria requirements • compatibility with commissioning • sound methodology • changes in stakeholder culture. The results suggest that the Quality Synthesis Model is a cost-effective answer to local quality management in a culture of professional awareness, respecting the influence of the ultimate power of medicine. Together with the principles of change management, and particularly the lessons learned from the implementation of previous initiatives, local NHS units could successfully move towards a sustained responsive culture through the use of the model.