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Background: The fundamental rights of people with benign essential blepharospasm (BEB) to access timely care and treatment is significantly challenged in the United Kingdom and across the world. The condition causes intermittent and sustained spasms, temporary blindness, facial contortion and social stigma which debilitates the lives of those affected. Patient feedback and personal observation as a specialist practitioner within an outpatient clinic suggest the care provided fails to meet individuals' needs at a time of acute relapse. In the absence of qualitative evidence, a systematic quality of life review was undertaken in relation to BEB care and treatment. Although people with BEB were shown to have poorer quality of life than healthy individuals, quantitative evidence with numerical scales fails to represent the lived experience of BEB. Retrospective to the findings of the current research, a metasynthesis of BEB care and treatment experience was examined through text and opinions from the UK, the United States of America (USA), Australia and Canada dystonia websites. This offered health professionals a model guide on how to improve services. Aim: The aim of this study is to explore the impact of BEB outpatient treatment and care on patients' lives. Method: The study data emerged from 10 individual interviews and one focus group discussion. It provided a deeper understanding of BEB lived experience. A lack of knowledge, visual, functional and psychological decline, namely the anxiety experienced from untimely care and treatment in an acute relapse. Qualitative assessment of the patient experience provided the means to give patients a voice to improve the service. This study offers a novel contribution - it bridges the gap between policy, theory and practice. Outcome: The service has been configured through electronic treatment records, NHS Attend Anywhere video severity assessment to improve access, greater community through focus group discussion, uniform practitioners' training, the introduction of more injectors and clinics to improve geographical disparity. The service is set to address delayed referral, communicating a list of BEB red flags to primary care.

Myocardial ischemia tops the list of causes of death around the globe, but its diagnosis and early detection thrives on clinical echocardiography. Although echocardiography presents a huge advantage of a non-intrusive, low-cost point of care diagnosis, its image quality is inherently subjective with strong dependence on operators' experience level and acquisition skill. In some countries, echo specialists are mandated to supplementary years of training to achieve 'gold standard' free-hand acquisition skill without which exacerbates the reliability of echocardiogram and increases possibility for misdiagnosis. These drawbacks pose significant challenges to adopting echocardiography as authoritative modalities for cardiac diagnosis. However, the prevailing and currently adopted solution is to manually carry out quality evaluation where an echocardiography specialist visually inspects several acquired images to make clinical decisions of its perceived quality and prognosis. This is a lengthening process and laced with variability of opinion consequently affection diagnostic responses. The goal of the research is to provide a multi-discipline, state-of-the-art solution that allows objective quality assessment of echocardiogram and to guarantee the reliability of clinical quantification processes. Computer graphic processing unit simulations, medical imaging analysis and deep convolutional neural network models were employed to achieve this goal. From a finite pool of echocardiographic patient datasets, 1650 random samples of echocardiogram cine-loops from different patients with age ranges from 17 and 85 years, who had undergone echocardiography between 2010 and 2020 were evaluated. We defined a set of pathological and anatomical criteria of image quality by which apical-four and parasternal long axis frames can be evaluated with feasibility for real-time optimization. The selected samples were annotated for multivariate model developments and validation of predicted quality score per frame. The outcome presents a robust artificial intelligence algorithm that indicate frames' quality rating, real-time visualisation of element of quality and updates quality optimization in real-time. A prediction errors of 0.052, 0.062, 0.069, 0.056 for visibility, clarity, depth-gain, and foreshortening attributes were achieved, respectively. The model achieved a combined error rate of 3.6% with average prediction speed of 4.24 ms per frame. The novel method established a superior approach to two-dimensional image quality estimation, assessment, and clinical adequacy on acquisition of echocardiogram prior to quantification and diagnosis of myocardial infarction.

This thesis presents the results from a mixed methods study examining the health and wellbeing of older women in the UK. In the context of an ageing population, understanding the determinants and nature of health and wellbeing in later life is important in improving health service provision. Women are more likely to live alone in later life in addition to experiencing different life course trajectories to men. Gender variations in the outcomes and experience of later life are well recognised. Living alone poses particular challenges in later life in terms of social and practical support and the existing evidence does not explore the implications for this for older women in the UK. The original research carried out for this thesis consists of two main phases in addition to a scoping review of existing literature. Quantitative analysis of data from the Understanding Society dataset was followed by qualitative analysis of transcripts gathered in 1:1 interviews with seven women between the ages of 65 and 80 who live alone in the UK. These interviews were undertaken during the summer of 2020, during the Covid-19 pandemic. One of the main findings is that women who live alone in the UK are older and in poorer health on average than their co-habiting counterparts. This highlights an important potential vulnerability in this population. Logistic and linear regression analyses indicate that household composition is not a predictor of poorer health and wellbeing once socioeconomic factors are included in the models. Another key finding from the regressions is the comparison of determinants of health between those who live alone and those who cohabit. The determinants of health and wellbeing differ between those two groups, suggesting different needs for support. Of particular interest is that although volunteering rates were comparable for the two groups, volunteering was a significant predictor of better health and wellbeing for those who live alone but not for those who live with others. This indicates that social factors influence the health and wellbeing of older women differently depending on their household composition: it also points to the importance of supporting older women who live alone to be able to engage in such civic activities if desired. The results of the qualitative analysis provide complementarity to the statistical analyses by providing a richer picture of the experience and life course trajectories of older women who live alone in the UK. The examination of the qualitative data was undertaken in two separate analyses. The first analysis used an Interpretative Phenomenological Analysis to examine the lived experience of living alone in later life. This was particularly important given the timing, during the Covid-19 pandemic. Three overarching themes were Productivity, Ownership, and Interconnectedness. The second round of analysis of the qualitative data used Critical Narrative Analysis. This enabled the use of a life course approach and a critical theoretical lens - in this case, critical feminist gerontology - to examine the data further. The three key themes from this analysis were Rootedness, Busyness and New Paths. Finally, the findings from each of the analyses were synthesised with the existing empirical and critical literature. This study contributes to the existing knowledge regarding the health and wellbeing of older women living alone in the UK in several ways. Firstly, it confirms that older women who live alone are a more vulnerable group, reporting poorer health and wellbeing overall. However, it also confirmed the importance of socioeconomic factors in mediating the effect of household composition in terms of health and wellbeing outcomes. The role of volunteering as a promoter of health and wellbeing in this population is demonstrated and this is added to by the results of the qualitative analysis which underscored the value of volunteering for older women living alone. Valuable insights are also gained regarding the experience of living alone as an older woman during the Covid-19 pandemic in the UK which posed additional challenges to issues around social connectivity and independence. Indications for future research and implications for policy and practice are given. For example, further research is needed on the effect of volunteering on health and wellbeing in addition to exploring ways in which to maximise health benefits in older women, especially those who live alone. Policy and public health practice should consider how volunteering and other time-use variables are related to health and wellbeing whilst also being mindful of the effect such a drive might have on those unable to participate.

Background: Older people are at risk of dehydration due to a wide range of agerelated physiological changes. Additional conditions such as dementia or physical frailty may contribute to low fluid intakes and further predispose to dehydration. Care home residents are more likely to be admitted to hospital with dehydration, but there few recent studies that evaluated the amount of fluids that residents consume or the barriers to hydration that they experience. Objectives: To assess current hydration care in nursing homes, identify barriers to drinking adequate amounts and develop strategies to optimise fluid intakes in the older care home residents. Method: This study was conducted in one care home in London, which provides care to a multi-ethnic population of the residents. Focus groups conducted in preparatory phase investigated factors necessary to provide adequate hydration care. Exploratory phase used observations, focus groups and interviews to determine how drinks are currently provided and to explore attitudes of staff and residents towards hydration care. The intervention phase used Model for Improvement framework to identify and test strategies to improve hydration for the residents. Results: Observations revealed that most residents consumed less than the recommended minimum of 1500ml of fluids. Hydration not seen as a priority resulted in several barriers that hindered staff ability to serve adequate amounts of fluids, and residents' enjoyment and ability to consume them. Interventions were designed to overcome these issues and included: training, increasing the number of drink opportunities, improving preference compliance and introduction of a new drinking equipment. During the testing, most interventions resulted in the residents consuming more fluids, but sustaining these interventions was difficult. Barriers to sustainability included poor leadership and task-oriented work culture. Conclusions: This study demonstrated that fluid intakes in care home residents are suboptimal. This is mostly due to insufficient number of opportunities for the residents to obtain drinks as well as not receiving adequate assistance and preferred drinks. Implementation of the interventions which address these barriers increases fluid intakes. Care homes need to implement appropriate strategies, but this requires organisational commitment with support from senior managers and strong leadership at operational level.

Background: South Asian communities are increasing in the UK and there is a significant growth of this population from the 2001 and 2011 Censuses. In Brent and Leicester more than 30% of the population are from a South Asian background. South Asian men make a significant proportion of this population (Office for National Statistics (2012)). In general men’s health is under-researched and there is little research that focuses on the health of men from ethnic minorities in the UK. The sexual health of men is well researched particularly in the field of Human Immunodeficiency Virus (HIV) but this largely focuses on men who have sex with men and there is little UK research that examines the issues surrounding the sexual health of men in the South Asian community. This thesis focuses on producing a better understanding of South Asian men’s perspectives on sexual health through participatory research and dialogue. Methods: A South Asian men’s participatory action research group (PAR) was established to collectively explore South Asian men’s sexual health in Brent; followed by ten semi-structured and five in-depth one-to-one interviews with South Asian men in Leicester. The data from the three phases was thematically analysed using a qualitative descriptive method and key themes identified in relation to the perspectives of South Asian men towards sexual health. . Findings: This study uncovered deep seated cultural and religious issues that are important for those working in the field of men’s sexual health to understand. The themes emerging from the data highlighted that talking about sexual health carries connotations of stigma and shame that are largely associated with non-acceptance 4 of homosexuality and what South Asian communities consider to be western or ‘white’ liberal culture. Generational differences and the strong influence of first generation immigrants and religious leaders emphasised the theme of shame and stigma. Misconceptions about what is meant by sexual health were evident, with participants focusing on infection and promiscuity rather than health and suggesting that culturally sensitive information was lacking. Themes focused on how services could be more accessible and culturally acceptable also focused on the need to ‘be private and discreet’ and to some degree ‘hidden’ to prevent stigma and shame. Conclusion: South Asian men’s sexual health cannot be understood without understanding the wider local South Asian community which encompasses religious and cultural influences which impact South Asian men’s perspectives on sexual health. These perspectives have been shaped by cultural and geographic origins, patterns of migration, religious and family expectations, generational and marital status. These issues result in a lack of engagement amongst South Asian men and sexual health services. The findings of this study suggest that services should target South Asian men at an individual, cultural community and service level to build trust and provide services that are accessible and culturally acceptable. There is also a need to create greater understanding about the nature of sexual health and align it with men’s health issues more generally. Establishing forums and creating information sources that facilitate open discussion among men in South Asian communities to de-stigmatise sexual health would also assist in reducing stigma.

manifestation of PE in mothers who later develop the complication; histamine receptors H1 and H2, and DAO messages are expressed in juxtapositions at the foeto-maternal interface, Histidine Decarboxylase (HDC) HDC activity is elevated in PE placentae; and while elevated histamine upregulates the proteins for Th1-like cytokines, it also down-regulates DAO message expression after prolonged exposure in the placenta. The findings further show that lipopolysaccharides and pro-inflammatory cytokines including IL-10 and INF-g increase histamine production in the placenta; and the histamine has a positive feedback loop regulatory relation with the proinflammatory cytokines. Furthermore, the validation of Elevated Histamine Model (EHM), an in vitro model designed for studying histamine effect in placenta showed that placental micro explants (∼50 mg) in long-term culture (explants that have undergone syncytiotrophoblast regeneration) at the liquid-gas interface in 8% oxygen is an optimum culture condition to study effects of histamine in the placenta. EHM produced RNA with quality akin to time zero pre-culture explants. The works also led to the identifications of a core set of significant genes that are consistently expressed in both normal (NP) in PE placentae but at varying levels, and a further subset of significant genes expressed consistently only in PE placentae (PE specific genes). Comparison of EHM significant genes with the PE specific genes confirmed the presence of 270 consistently expressed genes that appear to underpin the effects of elevated histamine in the placenta with implications for PE pathogenesis. Further analyses of these EHM genes in PE placentae showed that the natural process by which pre-eclampsia develops is affected by the amount of histamine in the maternal blood and placenta, and the natural process by which pre-eclampsia develops is indirectly affected by histamine via covariate functional groups regulated by specific histamine regulated PE placental genes. 5 Conclusion: Histamine receptor genes are expressed at the foeto-maternal interface; DAO genes are expressed in the placenta; HDC activity levels are increased in PE placentae; there is cross-talk between histamine, DAO and cytokines in the placenta; elevated histamine regulated the expression of specific genes in the placenta and these genes are abnormally expressed in PE placentae; the functions of the histamine regulated genes also identified in PE placentae are involved in tissue morphology and possibly poor placentation, metabolic defects, endothelial dysfunction, inflammation, immunologic response, angiogenic and anti-angiogenic response in PE placentae. Therefore it is reasonable to conclude that the elevated histamine observed in PE would have pathophysiological roles in PE and early detection leading to effective control of maternal blood histamine levels has survival values and it’s thus recommended.

The National Health Service (NHS) in England is changing, not only in terms of the technical aspects of care (such as that afforded by new technology), but also in the way in which care is delivered to patients. For example, due to the increasing pressures being placed upon health services, hospitals need to develop innovative ways to reduce the length of time patients actually spend in hospital. Whilst this improves capacity planning, bed management and patient flow, it also seeks to ensure improved patient safety by delivering care and ongoing treatment in the most appropriate setting. However, discharging patients from hospital can be challenging and fraught with complexities. Therefore, the efficient and effective management of this process can have a considerable impact on subsequent clinical outcomes and readmission rates. As such, effective discharge planning and practice has become an integral part of health service policy and, in recent years, there has been an increased emphasis placed on the contribution nurses make to this process (Department of Health, 2002; 2005a; 2005b). New recommendations from the Kings Fund (Seale, 2016) suggest that a collaborative relationship between patients, carers, third sector parties and communities is central to the future of the NHS. This is because these perspectives are fundamental; indeed, patients are the reason the NHS exists. Since 2010, this has been the aim of my doctoral research ― to explore a shared leadership approach in determining the principles of care. The purpose of this study is to gain an insight into (and a greater understanding of) patient experiences during the discharge process following percutaneous coronary intervention (PCI) after myocardial infarction (MI) ― commonly known as a heart attack. PCI is a relatively new procedure; since its implementation it has resulted in patients staying in hospital for less than three days. Previous management would regularly result in patients remaining in hospital for longer than seven days. However, reducing the length of stay has potentially impacted how information and communication are both provided and understood by patients on discharge from acute hospital care. Previous research such as Hainsworth (2006), Department of Health (DoH) (2004) and Picker (2010) suggests that whilst there has been a great deal of emphasis placed on policy, there still remains scope for improvement in practice. As qualitative research is a form of social enquiry that focuses on the way people make sense of their experiences and the world in which they live, this research focuses on individuals who have had a heart attack and have then undergone the same treatment. The aim is to understand, describe and interpret their experiences, behaviour and feelings by looking at social processes and interactions. This was based on undertaking three separate focus groups involving patients, clinicians and members of the management team from a local NHS acute hospital in West London. Furthermore, in-depth, semi-structured interviews with eight patients were conducted. The idea behind surveying patients', clinical staff and managers narratives/opinions, was to establish a holistic view of discharge planning and practice. Recommendations for change could then be made dependant on these findings, in order to improve the effectiveness and efficiency of this process, in addition to patients’ experiences. Following the completion of the focus groups and semi-structured interviews, analysis was undertaken to identify whether any common themes emerged across the three different groups. Although the narratives identified varying views, the most significant of the emerging themes was that of communication and the attitude of staff. Indeed, further analysis confirmed that communication was a prevalent issue in all three focus groups. The findings suggest patients have specific individual needs; this would not be surprising given the treatment and care received. Communication was also noted to be a major theme for patients; whilst clearly the majority of patients were relatively happy with the care received, they remained keen to make suggestions for improvement. The attitude of staff also featured strongly; patients were keen to suggest the changes they required and their rationale for these suggestions. The clinicians' themes mirrored the patients' themes, whilst also incorporating resource and innovation. The managers' themes commonly focused on service and proposed new ways of working, which included 'joined-up' working across acute and community services. Furthermore, the clinicians' and managers’ themes recognised that the attitudes of all groups of staff remained a challenge. In conclusion, this study has demonstrated the requirement for and the importance of effective communication throughout the entire discharge process. The aims are as follows: to ensure that post-procedure patients are discharged home or into a community setting safely; that they receive the right care, treatment and information in the most appropriate setting; and that they find and use ways to facilitate their recovery. Furthermore, this study has validated the importance of empowering patients to live with their diagnosed condition/disease by enabling the provision of support post-discharge. To this end, there is a need to ensure that positive values (such as empathy and compassion) remain a core part of the discharge planning process. This can be achieved by recognising each patient as an individual who is trying to make sense of a daunting life-changing experience whilst maintaining their own core belief and value systems. As a result, recommendations for improvements and change within this study have been based upon these findings. Further research needs to be defined to ensure that discharging patients from an acute hospital to their home or community setting remains both safe and effective, whilst also being informative and empowering.

Cancer is a major illness in the United Kingdom with differences in prevalence, morbidity and mortality, across the population. The focus of this study is two-fold: firstly, to explore African and African-Caribbean Londoners' experience of cancer services and secondly to use a narrative approach, focused on cancer, specifically related to African and African-Caribbean Londoners, an approach that has not been undertaken previously. Therefore, I also aim to explore whether such a research approach has value as a reseearch tool for these communities. Five research questions frame the focus of the study, namely: What factors affected their experiences of cancer services? How did culture, ethnicity and societal factors influence their experiences? How do those factors influence the stories they tell and the way they tell them? What were good and bad practices which affected their experiences? What is the value of the narrative approach in research related to cancer focused on African and African-Caribbeans? It is intended that this thesis will have a wider methodological relevance for BME health research, as well as relevance for BME cancer service research and provide suggestions on practical application of actions to address some challenges. The African and African-Caribbean communities together form the second largest minority ethnic group in the UK, but health research foucusing specifically on cancer related to these two communities is limited. The incidence of cancer is expected to increase amongst minority ethnic communities for a number of reasons: an aging minority ethnic population and changes in lifestyle and environment. It is therefore essential to gain a greater understanding of issues for African and African-Caribbean communities which either hinders or aids in providing an enhanced positive experience of cancer services in London. London was chosen because it is the most diverse, multicultural, multiracial city in the UK and hence the assumption that it has well-developed health structures and systems in relation to cancer, which meet the diversity of its population. Narrative research using dialogic analysis is the methodology used. In-depth interviews were conducted with twelve participants who were recruited through convenience and snowballing. The nine women and three men in the study originated from Nigeria, Ghana, Kenya, Trinidad and Jamaica. The findings demonstrate that ethnicity, religion and community play a significant part in impacting on their experience with cancer services. The narratives identify factors which reflect positive and negative experiences of the engagement of Africans and African-Caribbeans with cance services. Positive experiences of cancer services were articulated from the narratives, which included clinicians apologising for mistakes and clinicians creating an environment which encouraged a positive relationship between themselves and the patient. Some of the challenges patients articulated have been addressed in previous research. These include: cultural sensitivity, lack of access to information on cancer services, lack of respect, feelings of powerlessness and vulnerability. However, areas this research unearthed from the narratives that are not addressed elsewhere are: the power of church leaders, breast self-examination (BSE) and cultural issues associated with self-examination, acknowledgement of the heterogeneity of African and African-Caribbean communities and how that is played out in health seeking behaviour and beliefs surrounding cancer. Courage and resilience are concepts which are rarely explicitly mentioned or recognised in earlier UK research, including the role black men play as carers, a subject virtually non-existent in health research. As a qualitative research method, narrative research proved valuable in enablinig an understanding of issues that affect African and African-Caribbean communities in relation to cancer and receiving cancer services. Dialogic analysis provides a basis to reveal the depth of the participants lived experience and how those experiences shape their behaviour in relation to cancer care. This thesis illustrates that like all patients with cancer, the cancer experience is an individual phenomenon. However, narratives demonstrate that those experiences are bound up in historical, cultural, social, religious and spiritual perspectives.

This thesis is my autoethnographic account as I pursue a career as a Service User Representative with the Dorset Mental Health Forum over several years leading up to 2010. This is a period of change in both the social care and health worlds as they impact on to people suffering from mental distress. In this period are introduced Personal Budgets and a three-year pilot scheme to look at the viability of rolling out Personal Health Budgets, in which Dorset is selected as one of 20 sites nationally. There is also a change of government from a Labour administration to a coalition of the Conservative and Liberal Democrat parties, but this does not seem to have changed the planned modernisation of both social care provision and healthcare provision started by the outgoing Labour government. Also in this period we see the wide-ranging revision of the Mental Health Act 1983. My original contribution to knowledge is in describing the development of a service user representative model that works well in Dorset, UK. This thesis is not about the history and development of the mental health service user involvement but I do offer a précis of the history of service user representation for those unfamiliar with it. This thesis is laid out in roughly chronological order. I try to show how I changed my views with the help of other people over the period. I also try to explain what it is that ails me. The reason I do this is to paint a picture of a person who is in general "normal" but suffers from mental disorders that sometimes alter the way he sees the world. It is with this backdrop that I ply my trade of being representative of and to other mental health service users. I lead the reader from a consideration of method and methodology and ethics, through the precursors of my mental illness, to how that illness has been treated by the National Health Service, and how it impacts on my role. The main way that I do this is by offering a vignette of my life and then immediately afterwards analysing that vignette in the light of emergent themes. In this way, I ensure that the emergent themes are themselves based in a reality that can be accessed to some degree by the reader. There were challenges along the way including personal ones, such as having to take time out from my studies to attend courses of psychological treatment and having several heart attacks leading to hospitalisation, as well as the usual ones of finding people to contribute to my research. I end this thesis by offering a model that service users may find illuminating when setting up their own service user representation services.

Research has suggested that a bi-directional relationship exists between sleep disruption and depression. Not only is poor sleep a commonly reported symptom in those with depression, some aspects of sleep have also been shown to predict the onset of depression. Despite sleep problems being a commonly reported occurrence throughout the perinatal period, the field of perinatal sleep research remains in its relative infancy. However, recent studies suggest that sleep disturbances during this time may increase the risk of developing postpartum depression. Currently, research in this area is limited by studies that have failed to control for depressive symptoms at baseline, relied upon subjective, often retrospective, measures of sleep, and have only measured symptoms of postpartum depression in the early postpartum period. Few studies have used polysomnography, considered the ‘gold standard’ of sleep, and no studies to date have specifically compared the relationship between subjective and objective sleep. Therefore, the major aim of this thesis was to gain a better understanding of the specific aspects of sleep that were most relevant to postpartum depression. In order to address this aim, studies were carried out to: explore the aspects of sleep most relevant to major depressive disorder; examine differences in sleep between pregnant and non-pregnant women; investigate the relationships between subjective and objective measures of sleep; explore longitudinal changes in sleep, fatigue and depression throughout the perinatal period, and finally; examine which aspects of sleep at which time-point were most relevant to the development of postpartum depression. Overall this thesis found that women experience significant changes to their sleep throughout the perinatal period. While the sleep of third trimester women is considerably poorer than that of non-pregnant women (both objectively and subjectively), the most significant changes occur in the transition between late pregnancy and the early postpartum period. Furthermore, increased amounts of sleep and reports of difficulty falling asleep during late pregnancy predicted the development of postpartum depressive symptoms. This suggests that certain aspects of sleep during late pregnancy may serve as markers for women at risk of developing postpartum depression.

Anthropologists are increasingly called upon to assess trauma to the skeleton and contextualising the nature of this trauma. Blast injury is a type of trauma which is increasingly seen in a variety of contexts, such as terrorism, human rights violations, combat and accidents. The purpose of this study was to examine blast injury in the human skeleton and apply robust multivariate statistical methods, alongside morphological methods, to identify blast trauma based on the distribution of injury in the skeleton. The objectives of the study were to identify patterns in a sample of cases from mass graves in Bosnia and to determine differences between the blast injury cases and gunshot wound cases which can identify indicators of blast injury for future use. This was done using Pearson‘s χ2, cluster analysis and multiple correspondence analysis. Secondly, the identified indicators were applied to two methods of binary logistic regression model to test prediction of the presence or absence of blast injury in the sample, as well as assessing the results of the two methods. Lastly, the results of these analyses were subsequently compared with clinical literature to identify similarities and differences which can aid anthropologists in determining presence of blast injury in large assemblages. This also served to address the specific argument that the injuries seen in the Bosnia sample are combat related, as claimed in court proceedings in ongoing cases at the International Criminal Tribunal for the Former Yugoslavia. It was found that cluster analysis was not useful for the sample examined in the research, however multiple correspondence analysis permitted graphical differentiation between the blast injury and gunshot cases, identifying variables which contributed to the variance and could be used as indicators of blast injury. Binary logistic regression was employed to test the significant contribution of these variables to a model predicting the presence of blast injury in a sample. It was found that presence of trauma to the right shoulder girdle, left forearm, vertebrae, right pelvis and left femur could indicate the presence of blast injury in an assemblage, with correct average classification in 74.86% of cases. The prevalence of trauma in the Bosnia sample was compared with examples from terrorist incidents and combat situations to identify similarities and differences between these and found that there significant differences in the prevalence of trauma in the Bosnia sample. This highlights that this sample does not resemble any combat patterns of injury, answering the question posed in ICTY court proceedings. This work contributes new knowledge to anthropology on the identification and differentiation of blast injury in assemblages as well as demonstrating the use of multivariate statistical methods for trauma analysis. These results can be applied to anthropological investigation of historical contexts as well the modern investigations which will require knowledge of blast injury currently and in the future.

Exposure to toxic elements is a significant threat to public and individual health worldwide. Toxic elements such as heavy metals are associated with increased mortality and morbidity in both men and women and are a substantial contributor to neurological deficits and developmental delay in children. Analysis of skeletal material yields important information regarding exposure to toxic elements in a given population. This project has investigated toxic element exposure in 215 adults living in urban South Africa who died between 1960 and 1999. Exposure to toxic elements, particularly exposure to lead, has significant impacts on human health, even at very low levels. To date, little research has been conducted on human exposure to toxic elements in adult urban South Africans and a clear gap exists regarding toxic element exposure rates during the latter half of the 20th century. Among the primary aims of this research is to address this gap in knowledge and to quantify human exposure to these elements during the apartheid era. Bone element concentration was analysed by ICP-MS to determine the concentration of six elements that are toxic to humans: lead, cadmium, manganese, arsenic, antimony and vanadium. The results of this research demonstrate clear racial divisions in toxic element exposure in all but one element investigated. In the case of lead and cadmium, white males in the sampled population show significantly higher bone element concentrations than either black males or black females. It is surmised that apartheid-era separation of racial groups in regards to residence, occupation and movement within the urban landscape are partly, if not significantly, responsible for these differences in toxic element exposure. Lead exposure is strongly associated with exposure to traffic in urban Pretoria and Johannesburg, which is evident in both the limited environmental data available and the present study. Designated residential areas for white individuals were situated in and adjacent to the central business districts of both cities and are the areas associated with high traffic. Black residential areas were located on the urban periphery, often near industrial areas and mine dumps. The result is a lead exposure pattern by which white individuals in the sampled population yield double the bone lead concentration of black individuals. The wide divide in socioeconomic strata between the black and white population also factors significantly and is an additional result of apartheid policy. For arsenic and antimony, black individuals, particularly females, show significantly higher bone element concentration than white individuals. These elements are strongly associated with acid mine drainage, a form of pollution which results from mining activity. The close proximity of black residential areas to mining activities and the heavy reliance on ii contaminated surface water is likely responsible for higher exposure rates to these elements in the black population. This research has established that rates of exposure to toxic elements in urban Transvaal were moderate considering the level of industrial and mining activity in the region and the notably lax environmental regulations in place during the latter half of the 20th century. Despite this, bone element levels, particularly that of lead, cadmium and manganese are within ranges documented to cause negative impacts on human health. It is highly likely, given the bone element concentrations reported here, that these elements caused significant and negative health effects in the sampled population and were a clear threat to overall public health in urban South Africans.

Violent behaviour can be seen all over the world and across time; it is also intrinsically linked to culture. As such, the analysis of skeletal material presents excellent physical evidence of violent occurrences within communities. The current thesis looks to understand the possible presence of fracture patterns and interpersonal violence in London during the 18th and 19th centuries by analysing the fracture patterns observed on six skeletal collections from the geographical area and characterised by various social and economic contexts. The contextualisation of each burial ground proved to be imperative to the research. The statistical results revealed that grouping collections together based on their socioeconomic status does not describe nor explain the fracture patterns seen in the collections considering that some did not emulate the characterisation implemented upon them by the media or City officials at the time. It also was found that the patrilineal society and the subsequent sexual division of labour had a profound effect on the results especially when comparing the prevalence of fractures between men and women. Therefore, this thesis provides a comprehensive overview of fracture patterns and the presence of interpersonal violence in regards to the different lifestyles and socioeconomic contexts found in London during the 18th and 19th centuries and how such behaviour affected the individuals’ daily lives.

Mycobacterium Ulcerans (also known as Buruli Ulcer) is a rare skin disease which is prevalent in rural communities in the developing world mostly in Africa. Even though the mortality rate is low morbidity and consequent disabilities which affect the quality of life of sufferers is very high. If the disease is reported early treatment is available but many people receive help late in the disease process. Many reasons have been given in the literature why people receive treatment late. The aim of this study was to explore the experiences of people living with Buruli ulcer in a rural district in central Ghana in order to understand their diagnosis and support needs. The study was qualitative in design and used Glaser‟s version of grounded theory. It consisted of semi-structured and unstructured interviews, participant observation, conversation with opinion leaders, traditional healers, people living with Buruli ulcer (who were not part of the study) and a focus group interview with six health care professionals. The Dermatology Life Quality Index (DLQI) tool was also used to determine the quality of life of people living with Buruli ulcer in the study area. Three principal categories of Delayed treatment, Quality of life as a mirage and Seeking to be myself and a Basic Social Psychological Problem (BSPP) of Reliving the trauma of my ulcer were derived. These led to an encompassing core category of My needs matter. The theory explains the needs of people living with Buruli ulcer and that this followed a three stage process whereby Delayed diagnosis was the cause of the BSPP, Quality of life as a mirage the consequences and Seeking to be myself as the strategies required to deal with the BSPP of Reliving the trauma of my ulcer. How to deal with the consequences of this disease and the approaches to dealing with the needs of this vulnerable group have also been explored. The outcome of this thesis and its contribution to knowledge is a theory which explains the needs of people in the early stages of and living with Buruli ulcer and why their needs matter.

The thesis in part describes a research journey of a psychotherapy practitioner engaging in research development. It details, narrates and values the synchronistic events that enabled the ‘story’ to emerge. The central enquiry draws on embodied phenomenological research methods and poetic experiencing to explore the experiences of psychotherapists who have an understanding of nonduality and the perceived impact of this on their psychotherapeutic work. Nondual experiencing is also studied following a synchronistic research visit to Pakistan. Here, embodied spirituality is explored, using video and the concept of ‘Therao’ is studied and utilised as an aspect of skilful practice. These are drawn together and compiled as a summary of skilful means in psychotherapeutic practice. Additionally, as a Doctorate in Professional Practice two studies are presented as part of the practice development component. Both used creative video and performance as part of research presentation. The first, a project based on the Mandala with people living with HIV. The second ‘Beyond Statistics’ is an enquiry into the lifeworld experiences of gay men living with the co-infection of HIV and HCV. The thesis strongly articulates the significance of practice based research as a basis for humanising practice and the development of tacit and pathic knowledge. It identifies 10 key qualities present in practitioners who have a spiritual understanding of nonduality and the positive impact of these on depth connection with client work. The thesis also acknowledges, in line with current developments, the importance of including the cultivation of these depth relational qualities within a psychotherapy training curriculum.

Background: Back pain is a common disorder, affecting up to 2 in 3 of the adult population, with the general practitioners (GPs) being the first point of contact for help. Bio-psychosocial management of back pain has been shown to be problematic. Meeting patients‟ expectations is alleged to play a vital role in concordance, adherence and satisfaction with the given treatment; a more potent aspect, however, could be a state of matched patient-GP expectations, which could have an influential effect on the process and outcome of the medical consultation. This aspect, however, has not been fully investigated in the literature and further research is needed to discern the potential importance of this matching on different aspects of the consultation. Methods: The main aim of the study was to investigate the matching of patient-GP expectations related to the back pain consultation in primary care by means of (1) developing a structured questionnaire that can measure this matching; (2) using the tool to measure the matching of patient-GP expectations; and (3) exploring the perceived importance of such matched expectations on different aspects of the consultation. Using a mixed methods sequential nested design, 11 GPs and 57 back pain patients (from 11 general practices in the South of England) completed the Expectations Questionnaire (EQ) that measured the matching of their expectations. Telephone interviews were then used for exploring the perceived importance of this matching. The study tested the hypothesis that the matching of patients‟ and GPs‟ expectations was perceived as an important attribute for a successful back pain consultation in primary care, from the patients‟ and GPs‟ perspectives. Results: The study showed that the EQ can be used as a valid and reliable tool for measuring the matching of patient-GP expectations. The results showed that patients and GPs had mismatched expectations regarding one third of the EQ items. These were mainly related to the psychosocial aspect of the management. The data suggested a trend within the back pain consultations, where patients were less likely to express their expectations and the GPs were less likely to enquire about any unmet expectations at the end of the visit, which could render many expectations unaddressed and unmet. Thematic data analysis revealed several emerging themes with regard to the importance of matched expectations, namely, enhanced communication, trust, empathy, satisfaction and adherence, and have identified different or lack of agendas, time, caseload, cultural and language variations and continuity of care as possible barriers to this matching. Conclusion: The study revealed several convergences, but also identified a significant mismatch between patients‟ and GPs‟ expectations. Matched expectations were perceived as a significant indicator of the quality of the back pain consultation. Considering the many challenges and difficulties in managing back pain in general practice, a state of matched patient-GP expectations has the potential for improving the overall consultation experience, in terms of both the process and the outcome.

Post-mortem blood drug concentrations vary greatly and as a consequence of post-mortem change and redistribution may not reflect the concentration at the time of death. Tissues that are located away from central drug reservoirs and that lack esterase activity, e.g. muscle and vitreous humour (VH), have the potential to provide more reliable post-mortem toxicological specimens. In the absence of a blood sample the toxicologist may have to rely on such tissues yet few studies have been undertaken to examine the relationship between drugs in blood and less conventional tissues at the time of death. The purpose of this study was to investigate the distribution of opiates (heroin specific compounds) and cocaine and their respective metabolites in VH and muscle with a view to elucidating the interpretive value of these tissues. Analytical methods were developed and validated to measure drug concentrations in blood, VH and muscle, including throughout the rectus femoris thigh muscle, in cases of drug related death. To assist with interpretation of drug concentrations measured in post-mortem tissues the in vitro stability of cocaine and 6-acetylmorphine (6AM) was examined during the putrefactive process and under different storage conditions. Relationships between blood and tissue drug concentrations were assessed in relation to case circumstances with particular focus on the approximation of survival time. In contrast to a report previously published in the literature, this study found the concentration of cocaine, and its metabolites, benzoylecgonine (BZE) and cocaethylene (COET), to be uniformly distributed throughout the thigh muscle (n = 7). Concentrations of cocaine in muscle were markedly higher than in blood and correlated well with the blood. The stability of cocaine in muscle tissue was found to greatly exceed that in blood and VH. These preliminary results also indicated that the cocaine to BZE ratio measured in both muscle and VH may be of value in the assessment of survival time. These findings promote the use of muscle as a toxicological specimen for cocaine determinations. Further work is required to validate these findings and to examine the distribution of opiates in muscle, which could not be assessed in this study. The relationship between femoral blood and vitreous humour morphine concentration (n = 70) was found to be dependent on survival time and possibly influenced by accumulation of morphine in the VH. These findings demonstrate that the concentration of morphine in blood cannot be inferred from that measured in the VH. The VH provided a useful adjunct to interpretation owing to the prolonged detection of 6AM in this matrix. The addition of 1.5% sodium fluoride to VH was found to be essential for 6AM stability during storage. The utility of rapidly metabolised heroin specific compounds in blood as indicators of survival period following heroin intake and the role of concomitant drug consumption in heroin fatalities was also discussed in this thesis.

The provision of adequate nutritional care to hospital patients continues to be an international problem, despite numerous initiatives and attempts by interested parties over several decades to make improvements. The focus of this research was to critically evaluate the effects a hospital ward eating environment can have on patients’ foodservice experience and to establish if providing an enhanced dining environment could improve outcomes. A case study approach was employed on two Orthopaedic wards in an Acute Care Hospital which considered the variables that concurred in the contextual environment of the foodservice provision, to provide an in depth appreciation of Orthopaedic patients’ dining experience. The study used a mixed methods, sequential, exploratory, research process, consisting of four phases incorporating; semi structured interviews with patients, patient questionnaires, exploratory interviews with stakeholders and measurement of patients’ food intake and mood. Following the empirical processes this study has engaged in, theoretical contributions have been made which include; (1) A conceptual model for factors affecting patients’ foodservice experience developed from a synthesis of literature and theories with regard to the provision of hospitality, mealtime experiences and nutritional care provision for patients; (2) A questionnaire to measure hospital patients’ overall food experiences has been developed; (3) An explanatory model for factors influencing hospital patients’ foodservice experience has been developed; (4) A comparison of the patients’ mean, daily, nutritional intakes with the recommended levels, provided updated evidence of poor nutrition in the research setting, whilst factors influencing reduced food intakes were established; (5) The provision of an enhanced group dining experience for the patients, established positive outcomes for patients and stakeholders; (6) A theoretical model was developed that establishes a hierarchy of factors influencing Orthopaedic patients’ foodservice experience and food intake. This research study makes a contribution to our understanding of how sociological and environmental factors can enhance patients’ dining experience which may ultimately lead to improved nutritional intake.

A novel approach which has potential to improve quality of patient care on general hospital wards is proposed. Patient care is a labour-intensive task that requires high input of human resources. A Remote Patient Monitoring (RPM) system is proposed which can go some way towards improving patient monitoring on general hospital wards. In this system vital signs are gathered from patients and sent to a control unit for centralized monitoring. The RPM system can complement the role of nurses in monitoring patients’ vital signs. They will be able to focus on holistic needs of patients thereby providing better personal care. Wireless network technologies, ZigBee and Wi-Fi, are utilized for transmission of vital signs in the proposed RPM system. They provide flexibility and mobility to patients. A prototype system for RPM is designed and simulated. The results illustrated the capability, suitability and limitation of the chosen technology.

Methadone is increasingly involved in drug overdose cases and the molecular actions of the drug in vivo are largely unknown requiring elucidation. This study set out to examine the relationship between methadone toxicity and CYP2B6 and mu (μ) opioid receptor (OPRM1) single nucleotide polymorphisms (SNPs). Using SNP genotyping, the association between OPRM1 A118G and CYP2B6 T750C, G516T, and A785G variations and post-mortem methadone concentrations were investigated. The allele frequencies of OPRM1 and CYP2B6 variants were then studied in a control population of live non-methadone using subjects, to determine the prevalence and distribution of specific variations in post-mortem and living subjects. Further in vitro study was conducted to assist in interpreting the association between OPRM1 and CYP2B6 variations and individual susceptibility to methadone. Cloning strategies were designed for the studies of promoter activities affected by the T750C promoter SNP on CYP2B6 expression, and the role of the OPRM1 A118G variation for receptor internalisation following methadone treatment was investigated. A significant association was identified between high post-mortem methadone concentrations and G561T and A785G (CYP2B6*6) variations reflecting poor methadone metabolism. Furthermore, the OPRM1 A118G SNP significantly correlated with higher post-mortem methadone concentrations and the in vitro analysis of A118G indicated that this could be due to a reduction in receptor internalisation in 118 AG subjects. The findings from the research contribute to pre-determining, in part, individual susceptibility to methadone accumulation and toxicity. Specific screening to identify CYP2B6*6 and OPRM1 A118G carriers prior to addiction treatment could therefore be valuable as part of a cost-effective risk management strategy. Furthermore, CYP2B6*6 and A118G could be used to interpret toxicology results identifying subjects with poor metabolism.

Collectively, these writings significantly contribute to our academic and clinical knowledge of assessing dementia. We have learned a great deal from studying and helping people with Down's syndrome; however, perhaps more importantly, this work should contribute significantly to our rather limited knowledge of assessing dementia in people with Down's syndrome and thus may step towards improving and widening access to service provision for these valued people.

Background: There is increasing evidence that psychological factors such as stress and depression might have an influence in the onset of many physical illnesses, but less is known about their effect from early life. This study is an epidemiological life-course analysis to test: (1) the hypotheses that early-life psychological factors are linked to later development of chronic disease (cancer, diabetes, and asthma) in mid-life, (2) whether such associations can be explained by pre-existing confounding factors, and (3) whether such links are mediated by other biological, behavioural, social, and cognitive factors. Methods: The data were from two ongoing prospective longitudinal studies following the lives of about 17,000 people born in Great Britain in one particular week in 1958 and 1970. Outcomes included diagnosis of cancer, asthma, and diabetes up to the year 2000. Psychological measures taken from ages 5 to 16 years were the main predictors. Associations were examined using discrete-time survival analysis and structural equation models, adjusting for potential confounders and mediators. Results: In the 1958 cohort, a standard deviation increase in the scores of conduct problems at ages 11 and 16 years, indicating severe behavioural problems, was associated with 2 to 34% increase in the odds of being diagnosed with cervical or all cancers after adjusting for childhood confounders. These effects were completely mediated by adulthood psychological distress and health behaviours. Only the teacher-reported behavioural problems significantly predicted the risk of diabetes after adjusting for family history of diabetes and sex (odds ratios of 1.05 to 1.08, p