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mObjective: Although a modest body of literature exists on accreditation, little research has been conducted on the impact of accreditation on primary healthcare organizations in the Middle East. This study aimed to assess the impact of accreditation on primary healthcare centres in Kuwait, from the perspective of healthcare professionals. The study also aimed to develop an understanding of the impact of implementing an international programme of accreditation in the country’s developing primary care system and to identify the facilitators and barriers resulting from the introduction of such a programme in the primary healthcare setting. Context: A range of methods were used in order to evaluate the impact of accreditation on primary healthcare centres in Kuwait following an accreditation programme implementation in selected public PHC centres. This included a systematic review, followed by fieldwork in Kuwait. Fieldwork comprised a quantitative survey based on Primary Healthcare (PHC) centres and qualitative interviews conducted with key healthcare professionals. The PHC centres were divided into early adopters and late adopters in order to explore possible differences in the perceptions of the health professionals in each setting. Subjects and Methods: The work employed a mixed methods approach, with three inter-linked studies in order to answer the research questions. The first study was a systematic review of the international literature published between 2003 and 2013. The results were analysed and guided using Normalization Process Theory which is often used to understand the implementation of complex interventions such as accreditation. The second study was a self-administered anonymous questionnaire distributed to 520 employees in three PHC centres defined as early adopters conducted in summer 2015. The return was 375 questionnaires achieving a 72 % response rate. Analysis included Pearson’s Chi-squared tests to test for significance, Kruskal-Wallis tests and multiple regression models. The third study was qualitative semi-structured interviews with 18 key stakeholders in the Kuwaiti Ministry of Health, including the Quality and Accreditation department, local surveyors and heads of PHC centres. The interviews were conducted between October 2015 and June 2016. Finally the key results from each study were compared and synthesised using Normalization Process Theory to fully understand the ‘work’ underpinning the implementation of accreditation. Results: Results from all the research methods were analysed and synthesised using Normalization Process Theory. While policies and those involved in the strategic planning of accreditation may have a clear idea of what accreditation was trying to achieve, this was not always clear to those on the ground. Becoming involved in the accreditation process and doing the work required by accreditation enabled individuals to develop a clearer view, and understanding of what accreditation was about. Taking part also helped individuals see the value and benefits of being an accredited organisation. Employee engagement and participation in the accreditation programme helped break down professional barriers, created a sense of teamwork, and increased confidence in the process and what accreditation was aiming to achieve. The systematic review identified several strategies that promoted staff engagement in the accreditation process, including selecting key facilitators or ‘champions’, assigning credible leaders that champion continuous quality improvement, and explaining the ethos behind the accreditation process. The qualitative interviews suggested that staff awareness and involvement had increased, and that this may have empowered employees within the workplace and allowed them to voice their opinions more freely. The data across the three studies suggest that the more staff participated in the tasks associated with accreditation work, the more confident they tend to be about the positive impact that accreditation plays on quality improvement and the role they have to play in the process. Financial support for accreditation came up in all three studies, but particularly in the review and the interviews. Financial support was a major barrier which has affected several different aspects of the accreditation programme, including staffing issues, information dissemination, and training. Staff shortages and turnover were another issue that impacted the sustainability of the programme. An important facilitator during the accreditation process was the provision of training and documentation, including guidelines and clear standards. Finally accreditation was seen to improve the quality of services delivered, in particular through standardising delivery of services, improving the local healthcare culture and improving teamwork and collaboration across the PHCCs. Conclusion: The suggested findings show that while professionals project a positive attitude towards accreditation, their views are not built on substantial information and not supported by evidence based research or monitoring plans that could determine and quantify the exact benefits to accreditation when it comes to quality. While evaluating such quality improvement programmes can be difficult, it is not impossible. While this study contributed to the knowledge of how professionals perceive the outcomes of accreditation, there was no opportunity to assess patient views. Patient views of accreditation remains an under researched area and, again, a programme of research would beneficial to the long-term implementation of accreditation programmes.

Background: Population health interventions by their nature affect an entire population and are typically delivered outwith of health services and within the community, such as in schools. An example of such interventions are those that aim to improve children’s social and emotional wellbeing, which have demonstrated effectiveness in the short-term and potentially the long-term. However, challenges arise when conducting economic evaluations of population health interventions, most notably the difficulties of identifying, measuring, and valuing broader intersectoral costs, health, and non-health outcomes. Economic evaluation in an education context is relatively novel, but could provide decision-makers with information to help them make transparent and consistent decisions about how to allocate limited funds. This thesis examined the role for economic evaluation in school-based interventions and sought to determine appropriate methods for its implementation in addition to examining appropriate child-focused outcome measures. Thus, the overarching research question asked, ‘How should the cost-effectiveness of school-based, population health interventions aimed at children be determined?’ Methods: A mixed methods approach to this thesis was used: (i) a systematic literature review and narrative synthesis to determine which evaluation methods (economic and non-economic) are currently being used in school-based population health interventions; (ii) a case study to illustrate an economic evaluation (including cost-utility and cost-effectiveness analysis) of a school-based intervention to reflect on the advantages and disadvantages for decision making in this context; and (iii) an exploration of outcome measures (through mapping validation) for valuing child health and social and emotional wellbeing in school-based programmes to support future evaluation work in this context. Data for the economic evaluation and mapping validation study were available from a cluster randomised controlled trial of the Roots of Empathy programme in Northern Ireland (Ref: 10/3006/02). Results: The systematic review found that the methods currently being utilised to evaluate school programmes are varied (including economic evaluation, cost only, and effectiveness only studies), with poor quality reporting for the economic evaluations. Of the few cost-utility analyses in school-based settings identified, none had directly measured health-related quality of life using child measures or values. The case study cost-utility analysis using Child Health Utility 9D of a school-based intervention was found to be cost-effective from the National Health Service perspective with an incremental cost-effectiveness ratio of £11,000 per quality-adjusted life year (confidence interval: -£95,500 to £147,000), however the wide confidence interval demonstrates considerable uncertainty. This uncertainty is likely due to a lack of statistically significant effect that remained at the 36-month follow-up. Cost-effectiveness analysis using child behavioural descriptive measure, the Strengths and Difficulties Questionnaire, resulted in an incremental cost-effectiveness ratio of £197 per unit decrease in total difficulties score (confidence interval: £77 to £471). The Strengths and Difficulties Questionnaire is suitable for measuring social and emotional wellbeing, but is less advantageous for cost-effectiveness decision-making as no consensus has been reached as to what a clinically meaningful change in score represents, nor has a cost-effectiveness threshold been defined. It remains uncertain how these cost-effectiveness results will be interpreted in an education decision-making context where cost-effectiveness thresholds have not been set up. The mapping validation study validated a mapping algorithm to convert the Strengths and Difficulties Questionnaire into child health utility. Using this algorithm provides an option for valuing incremental changes in health-related quality of life against a generally accepted cost-effectiveness threshold from a health service perspective. Conclusions: Given the findings from the various aspects of work undertaken for this thesis to address population health issues, this thesis identified cost-benefit analysis as currently the most comprehensive method for determining the value for money of school-based public health interventions. Cost-benefit analysis incorporates monetary valuation of multisector outcomes in a final net benefit/loss result allowing clear, consistent, decision-making criteria to be set. Other methods such as cost-consequence analysis, cost-utility analysis, and multi-criteria decision analysis may also be suitable depending on the decision-making context and problem. This thesis demonstrates a lack of clear decision-making criteria in place for funding allocation decisions in education (e.g. education specific cost-effectiveness thresholds). Furthermore, there is no equitable method currently in place for apportioning the cost of funding public health interventions that generate benefits for multiple sectors. From a health service perspective, directly measuring child health utility using the Child Health Utility 9D is preferred as it is the only preference-based measure developed specifically for children and valued by young people. Mean child health utility can be predicted by mapping from the Strengths and Difficulties Questionnaire. This affords the opportunity to estimate longer-term utility by utilising long-term cohort data that routinely collects the Strengths and Difficulties Questionnaire, as long-term cost-effectiveness of school-based preventive programmes is an area in need of further research. The school setting plays an important role in shaping our young people’s futures. Economic evaluation of school-based population health interventions is justified, as schools need to maximise their existing resources in order to give children the best start in life.

This thesis explores the ways in which the Gujarati communities come to understand, experience and conceptualise ‘mental health’. These were explored under the following categories: social, cultural, economic and institutional. Ethnic inequalities and ‘mental health’ have been widely researched but explanations can provide a distorted picture for particular communities (Raleigh, 1995). Published information on measuring rates of inequalities focus use of services and wide categories such as ‘South Asians’ can be misleading in health research (Nazroo et al., 2002). Not only are current epidemiological studies problematic with the categories they utilise to group people together, but also using the medical model to define ‘mental health’ as an universally applied term indeed has its’ pitfalls. The major one that is inherent to this thesis is the complex relationship culture and social factors has in contributing to understandings of ‘mental health’ and how they are managed. Therefore, the crux of this thesis explores practices and beliefs the Gujarati communities have that help ‘mental health’ management but also their limitations that constrain and restrict help-seeking from western health services. This research is informed by two key phenomena and the complex relationship between the two – ‘mental health’ and culture. There is an exploration of social processes such as culture and the range of identity and historical factors such as migration, family, social capital and religion to name a few. A Bourdieusian analytical framework is used, in particular his forms of capital; social, cultural and economic to illustrate how culture influences conceptualisations, experiences and management of ‘mental health’ and how culture contributes to the complexity that cuts across the universality/specificity binary of addressing ‘mental health’. Qualitative interviews with the Gujarati communities in Leicester were used to explore these issues. 35 interviews were conducted with first-generation Gujarati migrants and 15 were conducted with second generation Gujarati migrants. These were all recorded, analysed using various thematic analytical techniques, analytic induction and cognitive mapping. It is argued that, strong forms of social and cultural capital contribute to and strengthen cultural opinions of mental illness as ‘mad’, ‘crazy’ and ‘slow’. Thus, these attitudes and understandings are lived realities for the Gujarati communities. However, it is also strong forms of social capital that contribute to potential ‘mental health’ problems due to the pressure of ‘social obligations’. This entails, behaving in a certain manner that abides to and maintains acceptable norms in the Gujarati communities. Consequently, social and cultural capital are underlying factors that explain the stigmatized nature of ‘mental health’ and their help-seeking trajectories. Additionally, the empirical data from my interviews has begun to demonstrate that attitudes towards ‘mental health’ are not as simple as being educated about it but rooted deeply in social and cultural practices, beliefs and traditions. Rightly so, Dogra et al. (2005) argues conceptualisations and expressions of ‘mental health’ can vary across cultures and thus these need to be considered when looking at ethnic groups. Additionally, due to the changing nature of cultures, continuous research is required to uphold suitable treatment and support for ‘mental health’. Therefore, I argue that research that informs policy in this area, such as cultural components of ‘mental health’ needs to be inductive rather than deductive in nature.

Since the introduction of effective antiretroviral therapy (ART), persons living with human immunodeficiency virus (PLWHA) are living longer. Life longetivity among PLWHA makes quality of life (QoL) critically important for patients and providers of medical and social services. However, this issue has not been assessed systematically in North-eastern Nigeria. The purpose of the study was to assess health-related QoL of PLWHA receiving ART in North-eastern Nigeria using a mixed method approach. The study was based on the revised Wilson and Cleary conceptual model (RWCM) which integrates both biological and psychosocial aspects of QoL. The model has been widely applied to different population in high income countries but it has never been tested in PLWHA in resource limited countries such as Nigeria. A survey relating to various domains of QoL was completed by 443 PLWHA and path analysis was used to assess the associations between QoL domains. Structural equation modelling was used to assess the fit of the RWCM to PLWHA in North-eastern Nigeria. Furthermore, 14 in-depth interviews were conducted to explore the lived experience of PLWHA and throw light upon the associations identified in the quantitative analysis. Participants with better physical and cognitive functioning and better general health had significantly better overall QoL. General health perception and characteristics of the individual and the environment explained 87.1% of the variance in overall QoL. The results showed that the data adequately fit the the RWCM (CFI = 0.934; RMSEA = 0.055, 90% CI: 0.049 – 0.062, p = 0.089). The analysis of the qualitative data identified five themes which in part helped to explain the associations identified in the quantitative data. These include: QoL is more than being free of disease; impact of HIV on well-being; stigmatisation; coping with HIV; playing with ART. Additionally, the data examined the impact of insecurity on healthcare and QoL as during the course of the study there was presence of political insecurity in the area. The RWCM is applicable to PLWHA in North-eastern Nigeria and provides a useful framework to understand QoL in this context. Both the quantitative and qualitative data suggest that certain aspects, eg. spirituality, stigma and treatment impact have a pronounced impact on QoL of PLWHA in this area. Recommendations are made to improve psychosocial support services for HIV-infected people.

The aim of this thesis is to document the early natural history of HIV infection. A medical clinic for the care of HIV infected patients was established in Edinburgh in October 1985. By November 1989, 409 patients had attended this clinic and most were under regular follow up. Most patients were injection drug users (IDUs) accounting for 78% attenders, 12% were homosexual men, 7% were infected heterosexually, 1% from blood products and in 2% there were no documented risk factors. Most of the IDUs acquired HIV infection between September 1983 and June 1984 and are a unique cohort for prospective natural history studies. The other clinic attenders provide a valuable comparison group. The first four years of the clinic were chosen as the cut off point for early natural history, being six years after the introduction of HIV into the IDU population of Edinburgh. Morbidity was assessed by hospital admissions. All hospital admissions by HIV positive patients in Edinburgh were analysed. These included admissions to the designated HIV unit and to all other general and psychiatric hospitals in Edinburgh. All deaths before November 1989 were analysed, whether they occurred in hospital or at home and all post mortem results were obtained. By November 1989, 910 admissions were recorded. Although 612 of these were to the designated HIV unit, 298 were to other hospitals in Edinburgh. IDUs accounted for 702 (77%) admissions, homosexual men for 136 (15%), patients with heterosexually acquired HIV infection for 62 (7%) and recipients of blood products for 10 (1%). The most frequent admissions were for conditions directly related to drug use. These comprised overdose, trauma, injection injuries and detoxification and accounted for 220 admissions. From comparisons with published data this number is in excess of what would be expected in a historical cohort of HIV negative IDUs. Most days in hospital were used by patients with respiratory conditions (187 admissions). These were the single commonest reason for admission to the designated HIV unit. The majority (97) were for bacterial chest infections (BCIs) and only 48 were with Pneumocystis carinii pneumonia (PCP). Of these 48 admissions, seven had a concomitant BCI. Differentiating BCIs and PCP clinically was difficult, as was the diagnosis of PCP in IDUs. A clinical algorithm was therefore drawn up for the management and investigation of IDUs presenting with respiratory symptoms and a separate study of the use of induced sputum techniques was conducted. This latter study confirmed the value of these techniques, obviating the need for bronchoscopy, the usual "gold standard". Thirty four deaths were recorded before November 1989, of which 19 were due to AIDS, two to liver disease and 13 were ascribed to drug use. Post mortem examination revealed that one of the deaths in the latter category was due to a florid meningoencephalitis. Despite the prevalence of bacterial infections, no deaths were attributable to this. Multiple pathology was detected in all patients dying of AIDS, with unexpected findings in eight of the nine patients who had post mortem examinations. These findings demonstrate a high level of morbidity and mortality even in the early years of HIV infection. Most previously published studies have focused on homosexual men and patients with advanced HIV disease and AIDS. This thesis has the advantage of documenting disease in patients hitherto not the focus of research, namely women, IDUs and patients with early stage HIV infection. It also provides a complete picture of an epidemic in one city, having studied all hospital admissions and deaths. The preponderance of bacterial infections as a cause of morbidity is important for prevention and prophylaxis. The documentation of health care utilisation is vital for planning of future resources.

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Methyl methacrylate (MMA) and its derivatives are currently produced using methods which rely on crude oil resources and natural gas as feedstocks. A novel and sustainable route to the precursor methacrylic acid (MAA), has recently been developed. This method involves the production of MAA from renewable feedstocks via microbial fermentation. Unfortunately, the toxicity of MAA is a significant issue, inhibiting the growth of potential host biocatalysts at concentrations as low as 10mM. This ultimately limits production titres and reduces the economic viability of the process. Therefore, in situ product removal (ISPR) via liquid-liquid extraction has been investigated in order to reduce the concentration of MAA in the aqueous phase, preventing inhibition of the biocatalyst during its production. Twenty-two water-immiscible organic solvents were tested for biocompatibility with Escherichia coli MG1655 and Saccharomyces cerevisiae DSM70449, the majority of which were toxic towards both organisms. Surprisingly, E. coli demonstrated a significantly higher tolerance towards the solvents, particularly when grown in minimal medium. Unfortunately, the biocompatible solvents demonstrated extremely poor extraction efficiencies of between 9 – 50 % MAA, from aqueous systems. Ionic liquids (ILs) were therefore investigated as potential replacement solvents for the ISPR of MAA. Twenty-two ILs were synthesised and tested for biocompatibility with E. coli and S. cerevisiae. Seventeen biocompatible ILs were identified and their physicochemical properties and extraction capabilities were evaluated. The ILs demonstrated extraction efficiencies superior to those of traditional organic solvents, extracting up to 93 % MAA from aqueous systems. Alternatively, the direct bioproduction of alkyl methacrylate esters offers the added benefit of phase separation above a critical concentration, removing the need for an extraction solvent, and therefore their toxicity was assessed. However, the esters were found to have a higher toxicity than MAA towards E. coli and S. cerevisiae. Unexpectedly, an n-butyl methacrylate (BMA) tolerant E. coli mutant was discovered during toxicity measurements. Five BMA resistant strains were isolated and upon whole genome sequence analysis, mutations were found in three genes, soxR, acrR and ybcO. An improved BMA tolerance was found in the mutants containing both the soxR and acrR mutations. These findings offer the potential for the development of these strains to create a sustainable route to BMA.

This thesis explores inter-organisational relationships and behaviours when complex healthcare pathways are planned, designed, procured and implemented in the English National Health Service (NHS) in a process known as commissioning. Commissioning and healthcare provision in the NHS is organised separately and operates as a quasi-market system. Clinical Commissioning Groups (CCGs) commission the majority of local healthcare for their populations and purchase services accordingly from many different types of healthcare provider organisations. Poor integration between different provider organisations has been suggested a contributing factor to the unsustainable demands the NHS is currently facing. New models of provision have been recommended in policy as a commissioning strategy to improve integration and these require collaboration and effective inter-organisational working between organisations. Healthcare is a highly complex institutional field and the institutional logics perspective offers a theoretical framework to explore how institutions embedded within a field guide behaviour. Bureaucratic, market, corporate and professional logics are known to exist in healthcare and can be used to break down institutional complexity into abstract constructs to understand the demands organisations face but enquiry has tended to focus on sole organisations rather than inter-organisational behaviour. However the institutional logics perspective offers the opportunity to explore the influence of institutional demands on inter-organisational relationships in complex institutional fields. This study sought to explain how logics influence inter-organisational behaviours as organisations work together to develop integrated care pathways. Using stroke service commissioning as a contextual example, the study explored three comparative case studies of the commissioning processes used to reorganise and develop stroke services into integrated care pathways across acute and community providers. Using methods associated with the ethnographic tradition, fifty-four semi-structured interviews with commissioners, providers, patient representatives and advisory bodies were completed, ten commissioning meetings were observed and strategic documentation for each organisation were collected. Thematic analysis was used to identify key themes which were then viewed through the institutional logics framework lens to explore how logics were present and influencing the commissioning processes as they progressed. The empirical findings suggest that an organisation’s interpretation of the institutional environment influences how an organisation and their individuals behave. In turn those behaviours influence how the organisations they are attempting to work with respond. Establishing a shared goal between the organisations was crucial but an organisations response to institutional demands may make this difficult to achieve. Collaboration was considered key to successful integration but this was only successful when commissioners were able to negotiate complex logics to facilitate shared goals and means of achieving them. This was most successful when organisations co-opted an alternative logic to compliment the organisations they were attempting to work with for different phases of the commissioning process. When complimentary logics were op-opted, organisations were better equipped to work collaboratively but if contradictory logics were in play, there was increased risk of inter-organisational relationships breaking down. Some commissioners used this strategy effectively to develop inter-organisational relationships while hiding the logic which informed their underlying goal which allowed them to maintain control of the commissioning process. This suggested that an organisations interpretation of the institutional environment and skills at using logics to manipulate the means of achieving goals was important. In conclusion, when logics are used by organisations to compliment the beliefs and behaviours of other organisations when they attempt to work together, they are able to establish effective inter-organisational relationships that allow collaborative work towards shared goals. This may be an important characteristic of commissioning organisations as they attempt to commission new models of integrated care.

This Thesis is part of a wider programme of work being pursued by the Glasgow Centre for Population Health (GCPH) which is examining health outcomes in West Central Scotland and other post-industrial regions throughout Europe. Scotland‘s health has been improving since the industrial revolution but its position relative to improving trends within Europe has been deteriorating. This is recent, dating from the period since the Second World War and becoming more problematical over the past three decades. While deprivation is a fundamental determinant of health, in the case of Scotland (and particularly West Central Scotland (WCS)) it does not explain the entire extent of the higher levels of mortality. There is, of course, a well established link between deindustrialisation, deprivation and poor health. However, the unexplained additional mortality in Scotland and WCS (the Scottish Effect) compared to other similar post-industrial regions and the time scale of Scotland‘s worsening relative health status, require further investigation. Other research has examined this question using a range of well established public health principles and methods. This thesis adds to this understanding by providing a comparative analysis of the political and socioeconomic contexts for the observed mortality trends. Post-industrial change is discussed at three levels. These are (i) International regions – Eastern Europe and Western Europe (ii) Countries – Scotland within the UK is compared with two Eastern European (Poland and the Czech Republic) and two Western European (France and Germany) countries. (iii) Regions within countries that have been subject to deindustrialisation. Five post-industrial regions are investigated (West Central Scotland, The Ruhr, Germany, Nord Pas-de-Calais, France, Katowice, Poland and Northern Moravia, Czech Republic). These regions were selected because they are analogous in their experience of deindustrialisation but diverse in their political and socioeconomic histories. The main aim of the thesis is to determine what aspects of the political and socioeconomic context in WCS have diverged from comparable post-industrial regions of Europe and whether these might form the basis of potential explanations for the region‘s poor health record. Two methods were employed. First, a detailed narrative literature review was undertaken to examine political and socioeconomic change in the post-war period at the national level with a particular focus on policy responses to deindustrialisation. Second, case studies were conducted on the five regions listed above. These examined political and socioeconomic changes in each of the five regions in some detail using published data and a variety of literatures as source materials. In this way a rich but diverse picture of economic restructuring as a response to deindustrialisation emerged. Insights from the literature review and case studies were then brought together to formulate some conclusions about why health in WCS has suffered more adverse effects than in the other four regions. This thesis has shown that there was a broad correspondence between life expectancy and the socioeconomic/political success of states in Central East Europe and Western Europe during the 20th Century. When states prosper and their governments enjoy the confidence of the population, health improves. In all the countries covered in this analysis, deindustrialisation damaged health and slowed improvements in life expectancy (in some cases putting it into reverse). The institutional path dependencies and country-specific factors outlined in this thesis help to explain the divergence in policy responses and subsequent economic development that can be observed in each of the five regions and their parent countries. The five countries and regions have each taken a different approach to deindustrialisation, have varied in the levels of social protection provided and each manifests a very different context. In response to economic restructuring (and associated social costs), policy in WCS (and the UK) has focused primarily on narrow economic growth policies, emphasising employment and physical regeneration, but not social outcomes such as community cohesion and sustainability.