Background: Patient safety in healthcare organisations received global attention following the Institute of Medicine’s release of its hallmark report “To Err Is Human: Building a Safer Health System”, where it was estimated that 44,000–98,000 patients die annually in US hospitals as a result of errors in care. Similar rates of error and avoidable harm have been reported in different research studies in many modern health systems across the world. “Safety Culture” has been identified as a key element of healthcare organisations’ ability to learn from errors and reduce preventable harm to patients resulting from health care. The perceived importance of safety culture in improving patient safety and its impact on patient outcomes has led to a growing interest in the assessment of safety culture in healthcare organisations. The use of safety climate questionnaires is one of the most popular methods for assessing safety culture. These questionnaires are thought to help in measuring healthcare workers' perceptions of the prevailing safety culture or “safety climate” in their organisations. Since no surveys of safety climate have been conducted at public hospitals in the state of Kuwait, nor are valid or reliable survey instruments available, this thesis aimed to investigate patient safety climate in public hospitals in Kuwait. The main objectives of the study were: 1. To identify an existing safety climate tools to be employed in my PhD thesis. 2. To test the psychometric properties of the identified tool in a sample of Kuwaiti public hospitals. 3. To provide a measure of the prevailing safety climate in Kuwaiti public hospitals. 4. To explore with key stakeholders the main findings of the safety climate survey and identify the potential barriers and facilitators to safety improvement initiatives in Kuwaiti public hospitals. Based on the overall findings, a series of recommendations are made for clinical leaders, policy makers and others to consider and a conceptual model informing a systems’ based approach to safety culture theory and practice is proposed for future research. Methods: A multi-method, triangulated approach including both quantitative and qualitative methods was adopted for the study. There were four phases of the research: A systematic review of published literature on safety climate tools used in acute hospital settings was carried out using seven electronic databases, with manual searches of bibliographies of included papers and key journals. A suitable tool was identified. A cross-sectional survey of 1,511 healthcare staff in three public hospitals was conducted for two purposes: Firstly, to assess the psychometric properties of the identified tool and develop an optimum model for assessing safety climate in Kuwaiti hospitals. Secondly, to provide an assessment of the current state of safety climate in Kuwaiti hospitals. Finally, interviews with key personnel were conducted to extend the examination of the survey findings and provide a rounded picture of the current state of safety climate in Kuwaiti public hospitals. Results: The search strategy identified 3,576 potential papers. Of these, eighty-eight papers were reviewed, with five studies meeting the inclusion criteria. Three out of five studies, covering three tools, were rated as ‘good’ quality papers and reported more robust psychometric properties. The Hospital Survey on Patient Safety Culture (HSOPSC) was selected as the most appropriate for my PhD thesis (in terms of usability, applicability and psychometric properties), and was pilot tested with minor modifications. A modified version of the HSOPSC was used to conduct the survey using a sample of healthcare staff with an 87% (n=1,310) response rate. Results of psychometric evaluation, including exploratory factor analysis, confirmatory factor analysis, reliability and correlation analysis, showed an optimal model of eight factors and 22 safety climate items. General evaluation of the prevailing safety climate amongst the workforce in acute hospital settings was conducted. The dimensions “Teamwork within units” (84%), “organisational learning-continuous improvement” (82%), “supervisor/manager expectations and actions promoting safety” (77%) and “management support for patient safety” (74%) were identified as strongly positive areas for the three hospitals. The dimensions “Non-punitive response to error” (34%), “communication openness” (47%) and “frequency of event reporting” (50%) were identified as areas in need of improvement. Building on the survey findings, interviews with key stakeholders added rich insight into hospital employees' perceptions on safety and allowed exploration of emerging issues in more detail. The research findings of my PhD thesis, and of the literature informed the design of a preliminary framework that aims to extend the examination of the construct of safety climate beyond the domains and items that typically inform safety climate theory to include system wide factors which potentially influence the prevailing safety culture/climate. Conclusions: This is the first validation study of a Standardised safety climate measure in a Kuwaiti healthcare setting. The study assessed the psychometric properties of the HSOPSC questionnaire and constructed an optimal model for assessing patient safety climate in Kuwaiti hospitals. It highlighted important patient safety and staff wellbeing concerns to inform organisational and national learning, and provided a baseline for measuring patient safety climate in Kuwaiti hospitals. As such, my PhD thesis raises and emphasizes the critical importance of appropriate validation of safety climate questionnaires before extending their usage in different countries or healthcare contexts. It provided new knowledge about areas of strength and weakness in safety climate with the potential to drive local improvements in Kuwaiti public hospitals. It is recommended that future investigations of patient safety culture and climate combine both quantitative and qualitative approaches and adopt a system wide approach to inform safety climate theory and questionnaire development, leading to stronger frameworks guiding safety culture research and practice.

Background and aim: Accreditation is a process of evaluating an organisation. It comprises a self-assessment against a set of standards and an external evaluation followed by a report. The trend towards implementing healthcare accreditation has reached the Middle East, since the World Health Organisation reported, in 2003, a lack of accreditation programmes in this region. Many countries in the Middle East, including Kuwait, have been developing and implementing accreditation programmes since then. The aim of this research was to explore implementation of the accreditation programme in Kuwait general hospitals from the multiple perspectives of the healthcare professionals involved. Methods: The research employed a multiple methods approach with three inter-linked studies. The first study was a systematic review of the international literature that explored the implementation of accreditation programmes. Data analysis was guided by Normalisation Process Theory (NPT). The second study was a documentary analysis of the accreditation reports of six general Governmental hospitals. The third study involved interviews with twenty-five participants, from two general hospitals, who represented different professional backgrounds and were all self-assessment team members. The accreditation implementation process was explored in depth, focusing on the impact of the programme and the factors that influenced the process. Both the documentary analysis and the interviews were analysed by thematic analysis. The findings of the three studies were then synthesised, using Normalisation Process Theory. Results: The findings from the three studies identified four broad areas representing the process of accreditation implementation: understanding the accreditation process; engagement with the accreditation process; the work of accreditation; and monitoring the impact of accreditation. Within these themes, key factors were found to influence the successful implementation of the programme. These were: understanding the process; individuals’ engagement; communication and teamwork; leadership support; resources; infrastructure; adaptation of Standards; and education and training. The evidence for the impact of accreditation programmes on healthcare services in the systematic review was inconclusive. However, accreditation was perceived, in the interviews, to have a positive organisational impact. On the individual level, the findings identified the process of implementing accreditation to impact positively on the personal development; improve working relationships; and the morale of the teams. Conclusion: This thesis has contributed to the evidence for the implementation of accreditation in the hospital setting and its impact, from the perspective of accreditation self-assessment team members. Furthermore, it provides valuable insights for policy makers within the Kuwaiti healthcare context in future planning and monitoring of the National Accreditation Programme.

Parkinson’s is a common neurodegenerative disorder that can have a significant impact on an individual’s health, quality of life (QoL), and wellbeing, causing a substantial economic burden on patients, their caregivers, the health service, and broader social and community services. Whilst Parkinson’s wide range of QoL and financial impacts have been well documented relatively little research has explored to what extent such impacts have been appropriately incorporated into economic evaluations. Economic evaluation is used by the National Institute for Health and Care Excellence (NICE) in the UK to guide health-care resource allocation in the NHS. It uses preference-based outcome measures to measure and value the health outcomes of different interventions. These health utilities are combined with durations to estimate quality-adjusted life-years. The important role of the preference-based outcomes requires them to be accurately capturing the benefit of interventions, otherwise the estimation of cost-effectiveness of interventions will be not be reflecting true preference/choice between interventions. This may lead to mistakes in funding decisions and insufficient allocation of resources. Despite the importance of accurately capturing the benefit of interventions, the existing generic preference-based measures (e.g., the EQ-5D measure as recommended by NICE) are sometimes criticised for their ‘health-related’ nature as insufficient to capture all the QoL aspects that are affected by the disease or the intervention. This raises a question of “is the generic ‘prescribed’ measure appropriate for all disease areas and all interventions?” For diseases that have broad impact on people’s health and wellbeing such as Parkinson’s, a broadly scoped preference-based wellbeing instrument which could measure the impact of intervention beyond health may potentially fill the gap of the limited scope of the ‘health-related’ preference-based measures (if any). Meanwhile, there are concerns relating to their relevance and sensitivity to specific health aspects and their validity in general to be used in the healthcare context. Given this, the aim of this thesis is to examine the performance of the existing preference-based outcomes in people with Parkinson’s, and evaluate the potential of using a generic preference-based capability-wellbeing measure, ICECAP-O, in this population. This thesis conducted a systematic review of the existing preference-based measures to assess their construct validity and responsiveness in people with Parkinson’s. Two empirical studies explored these properties of the ICECAP-O measure in people with Parkinson’s. Construct validity and responsiveness are the two key psychometric properties relevant to preference-based measures for their use in economic evaluations. Data for both empirical analyses were obtained from the PD MED large-scale randomised controlled trial. This thesis has identified evidence of limited responsiveness of the existing preference-based measures in people with Parkinson’s and suggested that the current commonly used preference-based health-related QoL measures may underestimate the value placed on the mental and social wellbeing aspects that Parkinson’s populations are affected by. This limited ability of the utility values to differentiate health states may have an impact on resource allocation decisions. Especially as this relates to the cost-effectiveness of interventions that have the capacity to influence the mental and social wellbeing aspects of people’s lives. This highlights the need for consideration of a broadly scoped measure such as the ICECAP-O to incorporate such aspects in economic evaluations of diseases such as Parkinson’s. This thesis established the construct validity and responsiveness of the ICECAP-O instrument and demonstrated that there are valued capability wellbeing attributes in Parkinson’s beyond those quality of life attributes reflected by the EQ-5D instrument. It contributes to understanding the use of broadly scoped outcome measures for economic evaluations in Parkinson’s by showing that the ICECAP-O capability wellbeing instrument was able to provide a preference-based assessment of these under-represented aspects in the Parkinson’s population, without compromising its sensitivity to the clinical and specific physical QoL dimensions in this patient group. While further exploration of the role of ICECAP-O in economic evaluation and decision making through the work of assessing ‘sufficient capability’ is required, this thesis establishes initial foundations for the use of the ICECAP-O as a preference-based instrument to measure the impact of interventions in Parkinson’s populations.

The growing use of decision analytic modelling (DAM) to aid decision making in healthcare has triggered the need for increased scrutiny of the methods used and the assessment of compliance with these methods. The assessment of structural uncertainty surrounding the choice of model structure and model external validity represent some of most frequent challenges faced by researchers. This thesis used systematic reviews and two case studies focused on the self-management of hypertension in patients at high risk and thrombolysis in acute stroke to critically examine all available guidelines and statements of good practice and the adherence of current research to good practice guidelines. Two case studies were developed to assess structural uncertainty surrounding the choice of model structure and the impact of the exclusion of secondary events. The results here indicate that DAM guidelines lack practicality due to the extensive amount of information available and their complexity; furthermore, researchers are failing to identifY and correctly assess model structural uncertainty. This thesis makes an important contribution to current knowledge by developing and proposing the use of a practical five-dimension framework to improve the current standards of reporting results of DAM and by illustrating, through case studies, the assessment of structural uncertainty arising from the choice of model structure via scenario analysis and the use of extensive sensitivity analysis.

In this study, the biocatalytic production of methacrylic acid (MAA), a commodity chemical with a large global market, was investigated. The target was to develop MAA formation via enzymatic decarboxylation of itaconic, mesaconic, citraconic and citramalic acid. Several candidate enzymes were tested, but none catalysed the target reactions. Therefore, a novel high throughput screening method for decarboxylases was developed to enable protein engineering. The screening assay detected gaseous CO2 with a pH-dependent colorimetric reaction, in a 96-well format. Focused mutagenesis was then performed on the mevalonate diphosphate decarboxylases (MVD) from Saccharomyces cerevisiae and from Picrophilus torridus. However, MAA formation was not observed, even after screening over 3800 variants. Further investigation was then performed on some of the candidates to understand why MAA was not formed and to develop alternative strategies for enzyme selection. P. torridus MVD was discovered to belong to a new class of enzymes, mevalonate-3-kinase, and to be part of a novel archaeal mevalonate pathway. The enzyme also catalysed the formation of isobutene from 3-hydroxyisovalerate with unprecedented production rates. S. cerevisiae and Aspergillus niger phenylacrylic acid decarboxylases, previously believed to be cofactor-free enzymes, were proposed to require divalent metals and a novel organic cofactor. The enzymatic mechanism of Pseudomonas fluorescens α-amino-β-carboxymuconate-ε-semialdehyde (ACMS) decarboxylase was investigated. Through inhibition studies, it was demonstrated that the aldehyde and amino moieties of ACMS could be directly involved in catalysis, in contrast to the previously reported mechanism. This information partially explains why some of these candidates could not catalyse the target reaction, and provides insights into their potential future use for the bioproduction of MAA. Although this route does not seem feasible at present, this study gives foundation and guidance for future investigations.

Background/aim: In the Western world, the emergence of historical research on the effects of the social determinants of health has provided the discipline of public health with new insight into this aspect of population health complementing the more traditional focus on the history of medicine. The Islamic Caliphate was a dominant power in its time and little is known about its public health history. This thesis aims to provide a chronologically historical account of the policies taken in this period and analyse them in the light of modern theories of public health. Materials and Methods: This thesis employed a qualitative research technique. Known primary and secondary historical sources were examined and data translated and presented in a chronological order. Modern historical sources analysing the historical accounts of that era were also used. Policies affecting health were retrieved and analysed using modern day research into the same policies. Results: The analysis has resulted in a revisionist argument that policies affecting public health in a positive way did exist in a sophisticated manner in the Islamic Caliphate albeit in an inconsistent manner. The study complements the works of medical historians who identified a “Golden Age” in the later era of the Caliphate with advancements in medical science with a potential “Golden Age” in the early era related to the social determinants of health. Conclusion: This thesis provides for the first time a chronological study of policies affecting public health in an era of public health history that has not been studied before. In addition it provides for the first time a modern analysis of these policies.

The aim of this thesis is to conduct an empirically informed and philosophically robust ethical analysis of health-related human research undertaken during armed conflicts using the case study of Darfur, west Sudan (2004-2012). It adopts an empirical bioethics approach that combines the collection and analysis of empirical data with traditional philosophical analysis. The empirical data were collected using a systematic review of the studies that were conducted in Darfur during the chosen study period, followed by a qualitative project in Sudan. The qualitative findings were used to inform the philosophical discussion where the lines of arguments suggested by the project participants1 and the literature were scrutinized. This empirically-informed approach was chosen to overcome some of the shortcomings of the use of an abstract philosophical theorization when applied alone to an applied ethics field like humanitarian (research) ethics. Four main themes emerged and are discussed in the light of the relevant literature. The overall thesis is that the mainstream research ethical governance models are inadequate to ethically guide humanitarian activities as they lack the needed moral representativeness and operational feasibility. To overcome these problems, I argue that ethical oversight should shift from individualistic autonomy-based bioethics to relational autonomy and trust-based bioethics and from committee-based to community- situated governance models.

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.