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.

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.

In modern society, blood donor motivation and recruitment is a fundamental part of health care delivery. Well defined and documented programmes exist throughout the world but new ideas are always welcome. The situation in the Sudan is different and much remains to be done by way of comparison with elsewhere. This thesis outlines the objectives of a study, how it was supported, sponsored and achieved. It describes briefly the geography of the Sudan, the source of Sudanese economy, climate, culture and historical backgrounds. The problems of existing services in the Sudan are reviewed and a brief account of the demographic characteristics of the Sudanese population is given. Two surveys done in West of Scotland and in the Sudan are described in detail. This work discloses and compares the positive motives that enhances giving of blood and the negative motives that hinders its donation. The comparison is between an Eastern Society with a voluntary motivation not fully activated because of lack of understanding and awareness of the need to give blood voluntarily for strangers and Western Society with a well established voluntary system of donation. An addition to this research was the investigation into the immunity to tetanus and hepatitis in the Sudanese population. An estimate of the percentage of individuals with detectable levels of hepatitis A and B antibodies and tetanus antibodies is included since there is a need to establish a plasmapheresis programme as part of a good Blood Transfusion Service for the procurement of specific immunoglobulin's. This work has revealed major differences between the West of Scotland and the Sudan and suggestions are made for their resolution. The main conclusion and comparison are summarised in Chapter 7. It is hoped that many of the suggestions in this thesis can be introduced in the Sudan at an early date.

The purpose of this thesis is to examine the impact of financial incentives to promote health behaviour change. Financial incentives include tangible rewards as cash, vouchers and lotteries that are offered to individuals conditional to the fulfilment of health guidelines. Despite the growing use of such patient incentives in practice, some fundamental questions are yet to be answered: (1) Are financial incentives effective? (2) What type and size of incentive is more effective? (3) Do patient income and past health behaviour moderate the impact of incentives? These questions are analysed in the context of (a) blood donation and (b) compliance with health care including adherence to treatment, disease screening, immunisation and appointment keeping. Behavioural economics, in particular prospect theory, provide the theoretical foundations for this work and substantiate my hypotheses about the effect of financial incentives. I perform the first meta-analyses in the literature to quantify the impact of patient financial incentives to promote blood donation (chapter 3) and compliance (chapter 4). These results show that financial incentives do not promote blood donation but increase compliance with health care, particularly for low income patients. Two large field studies were developed to further examine the effect of incentives in compliance - testing pioneer incentive schemes. I test the impact of a certain (£5 voucher) versus uncertain (£200 lottery) incentive framed either as a gain or loss to promote Chlamydia screening (chapter 5). I also develop the first study ever testing preferences for sequences of events in the field – using the naturalistic setting of colorectal cancer. This study compared the effect of a €10 incentive offered at the end of screening versus two €5 incentives offered at the beginning and end of screening (chapter 6). The former showed the voucher framed as a gain was the most effective incentive and the latter showed that smaller two €5 incentives increase screening more than a single €10 incentive (which had a detrimental effect compared to no incentive). I fundamentally contribute to the literature by showing that (i) patient financial incentives do not increase the quantity of blood donations and may have an adverse effect on quality, providing empirical evidence to a long-standing policy debate. Furthermore (ii) small certain rewards around £5 are likely to be the optimal incentive for compliance with health care, (iii) higher incentives may be more effective if offered as smaller segregated incentives of the same amount and (iv) incentives have over twice the impact on low income patients than on more affluent patients.

This thesis focuses on the care of older people, both those with and without dementia, by family caregivers and one group of health professionals (trainee clinical psychologists). This thesis considers and explores a number of factors which are important to those providing care. These factors have been defined specifically as Religion / Spirituality in the literature review, which focuses on family caregivers of people with dementia. However, in the empirical paper those factors important to providing care were not pre-defined by the research team but emerged from the data. It is hoped that, in conjunction, these papers will contribute to understanding the perspectives of those caring for older people. Chapter 1 is a systematic literature review investigating the association between religion/spirituality and the psychological wellbeing/role adjustment among Black and Minority Ethnic (BME) family (informal) dementia caregivers. It focuses on one specific factor ‘religion/spirituality’ in order to understand one aspect of the dementia caregiving experience. Chapter 2 is an empirical study exploring trainee clinical psychologists’ experiences of working with older people, including people with and without dementia. Interpretative phenomenological analysis (IPA) was used to analyse the transcript data from eight interviews with participants. Three superordinate themes and nine subordinate themes emerged following the data analysis. The themes are explored, including implications for research, clinical practice and clinical psychology doctoral training. Chapter 3 is a reflective account, which includes the experience of carrying out the research and the insights it provided. Adopting the theme of ‘story’ allowed a connection to be made between hearing the stories of older people, and hearing the stories of participants in IPA research. The theme of ‘story’ then also allowed further exploration of this topic in books, research and media articles.

This thesis explores the experiences of informal carers of people with dementia. Undertaking a caregiving role can have a wide range of implications for the carer from negative outcomes such as increased physical and psychological stress to positive experiences such as a sense of pride or mastery in the role. Through further exploration of these differing experiences, this thesis informs understanding of the caregiving role and suggests new directions for carer support and research. The first paper is a critical review of the qualitative research exploring the positive aspects of caregiving in dementia. After database and manual searches were conducted, fourteen studies met the inclusion criteria and were reviewed. Carers across the studies consistently described a variety of positive aspects of caregiving. They also highlighted a number of factors that were important in supporting their positive caregiving experiences. Clinical implications relating to the inclusion of positive aspects in the holistic assessment and support of caregivers are discussed. The second paper reports on a quantitative study that explored the relationship between self-compassion, dysfunctional and emotion-focused coping strategies and carer burden. Survey data was collected from 73 informal caregivers of people with dementia. Carers with higher levels of self-compassion reported lower levels of carer burden. The use of less dysfunctional coping strategies was found to mediate this relationship. Emotion-focused coping strategies were not found to be a mediator. Clinically, compassion-based interventions represent a potentially useful intervention for carers. The final paper reflects on the differing contributions of qualitative and quantitative methodologies to research in psychology. The impact of the different methods on participants is considered along with the challenges to conducting diverse research in clinical settings. The scientist-practitioner nature of clinical psychologist role is noted as key in both respectfully representing participants and valuing the use of varied, clinically relevant research.

This dissertation examines the evolution of British diabetes management over the over the course of the twentieth century. It argues that through a series of technological, political, institutional and epistemological changes, British diabetes management came to centre on the bureaucratic discipline of professional medical labour by the early 1990s. That is to say that, by the end of the period discussed here, medical professionals and state bodies united in heralding care protocol, guidelines and audit systems as the best means to improve the quality of medical care, and, through improved risk management, to improve national health outcomes by extension. In undertaking such a study, however, this thesis looks to do more than simply add a new perspective to the growing literature on the history of diabetes. Instead, it both expands current understandings of the history of twentieth-century chronic disease control strategies in Britain, and historicises and reformulates existing literature on the emergence of clinical governance-style mechanisms for managing British medicine. In bringing these literatures and perspectives together, therefore, it is able to gain new insight onto the multiplicity of approaches taken to public health in the twentieth century, and to see structured and reviewed medical care as a framework that gradually emerged out of changing professional and political activities during the previous century. As a condition seen from the mid-century onwards as a model chronic disease, diabetes mellitus provides an excellent lens through which to read these histories. The history of its management and prevention, moreover, will only grow in importance over the coming decades as prevalence rates for the condition itself continue to rise into the twenty-first century.