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Abstract General Practitioners (GPs) have been identified as 'gatekeepers' to existing psychological support services by Psychologists working in the field of appearance (Rumsey and Harcourt 2005, pg 146). Currently no research exists which investigates primary care decision making regarding referral of patients with disfigurements to psychological services. Therefore, this study utilised a mixed methods design and sought to investigate the factors which GPs, GP trainees and medical students use as cues in decision making regarding referral of patients with disfigurements to psychological services. Seventeen UK based GPs, eight GP Trainees and 25 medical students responded to 12 vignettes about hypothetical patients with disfigurements where variables regarding the severity and visibility of the patients' condition and their levels of psychosocial distress were systematically varied. Participants were asked to identify the patients' prevailing problems and rate their likelihood of referral to a range of services on a rating scale and provide qualitative responses on working with patients with disfigurements. Medics were most likely to refer patients experiencing high levels of distress to primary and secondary psychology services. GPs, trainees and medical students were also able to identify psychological distress and offered biopsychosocial explanations and consequences for the prevailing issues of the patients' detailed in the vignettes. Thematic analysis of qualitative data suggested an acknowledgement of patient need for psychosocial support but also barriers to provision within the National Health Service. However, participants' responses also revealed a reliance on cues to referral shown to be unrelated to psychological distress in previous studies. Medics accounted for the severity and visibility of a patients' condition in their decision making, particularly in the absence of high levels of distress, where severe and visible conditions were more likely to prompt referral than less visible or less severe conditions. This may be accounted for the lack of knowledge, experience and training reported by participants. Further research in this area is needed, not only to ensure that patients receive appropriate access to psychosocial support, but that health care professionals are adequately trained and supported in their medical decision making with patients with disfiguring conditions.

Numerous theoretical frameworks have been applied to further our understanding of the correlates, causes and consequences of disability, and each is accompanied by a particular conceptualisation of disability. In this thesis, disability was conceptualised as behaviour. The concept of disability as behaviour is accompanied by psychological theories of behaviour and behaviour change within which behaviour is viewed as a product of motivational factors. A repertory grid study indicated that people with mobility disability use motivational concepts to distinguish between physical activities typically used to index their disability. These data lent support to the suitability of the disability as behaviour concept in this population. Consequently, psychological theory, in the form of the theory of planned behaviour (TPB) and social cognitive theory (SCT), was used to account for walking disability in an orthopaedic sample. The empirical application of psychological theories requires the operationalisation of the constructs within those theories. An investigation of the content validity of existing measures of the perceived control constructs from the TPB and SCT indicated current measurement items do not show discriminant content validity. These data were used to select perceived control items into the study of disability in an orthopaedic sample. The content validity of the perceived control items was investigated using confirmatory factor analyses applied to the responses of the orthopaedic sample. Structural equation modelling indicated that both the TPB and SCT could account for walking disability in the orthopaedic sample. Finally, the ability of the TPB and SCT to mediate between the central constructs of the main medical model of disability, namely the International Classification of Functioning Disability and Health (ICF), was assessed using structural modelling. This integrated model accounted for a greater proportion of the variance in walking disability than did the ICF alone, suggesting psychological theory can be used to improve the ICF model.

This PhD studies the relationships between impairments, activity limitations (AL), emotions and perceptions of control in people with (chronic) disabling conditions within the context of a rehabilitation setting. The International Classification of Functioning, Disability and Health (ICF) has become widely adopted within rehabilitation and can be used to describe the process of functioning and disability. Johnston proposed an integrated model of disability which integrates a psychological theory (the Theory of Planned Behaviour (TPB) within the WHO-ICF model. Using this integrated model of disability the following research questions were investigated in a cross sectional, longitudinal and N-of-1 study.

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This thesis examines perceptions of risk for bowel cancer. Nationwide bowel screening will be introduced in the UK in April 2006. To achieve maximal uptake of screening it is essential that the population is sufficiently motivated to attend, and perceived risk is recognised as being the 'motivational engine' behind preventative behaviour. Studies 1-3 used data from the UK Flexible Sigmoidoscopy (FS) Trial to examine perceptions of bowel cancer risk. In Study 1 an optimistic bias was found. Being male and older were associated with lower perceived risk, while having a family history of bowel cancer, poorer subjective health, more symptoms and higher levels of anxiety were associated with increased perceived risk. Study 2 explored how perceived bowel cancer risk compared with risk status defined by findings at the FS test. A modest relationship was found between subjective and objective risk. Study 3 investigated how well the five factors identified by Weinstein (1984) explained the variance in perceived risk for bowel cancer, but found that only 8% of the variance was explained. The qualitative interviews in Study 4 found support for Weinstein's framework and provided information on how better to operationalise the framework. These measures were used in Study 5 and the variance explained increased to 18%. Study 6 was a randomised controlled trial assessing whether giving people simple, accurate information of bowel cancer and its risk factors i) increased knowledge of bowel cancer ii) reduced the optimistic bias associated with symptomatic status, family history, age and gender, and iii) increased interest in attending bowel screening. The intervention successfully increased knowledge, but failed to reduce optimistic beliefs or to increase interest above the high levels found in the control group. Future research should consider influences on perceived risk not accessible to self-report and how people draw conclusions from generic risk information.

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This thesis works towards a social psychology of health inequalities in order to further understanding of the relations between structure and agency (re )producing these inequities. It does so by exploring the ideological construction of health and identities associated with the axes of inequality. Employing a material-discursive methodological standpoint to link work on inequality with that of 'lay health beliefs', it is argued that discourse is the semiotic moment of practices (re )producing health inequalities. Critical discourse analysis thereby provides a means to examine the ideological construction of health and identities associated with health inequalities. The interview and focus group methods used to generate text in interaction with a small, diverse sample of participants living in Bristol are described, paying particular attention to the reflexive issues embedded within the research process. F our competing ideologies within which health and illness were constructed as discursive objects are described: minimalism, associated with health as the absence of illness and medical ideology; psychological constructions of health as wellness or happiness relating to psychological ideology; lifestyle constructions of life ethics pertaining to health promotional ideology; and holism, the interdependency of mind, body and spirit, tied to alternative health ideology. The four interwoven health identities arising from these ideologies of health and respecting the key axes of inequalities in health, namely social class, gender, ethnicity and place, are considered. Resistance to class as prejudice is explored, alongside an examination the politics of class identity and a reading of working class and middle class health identities. Hegemonic gender identities of women as carers and men as uncaring, active agents are then examined. Ethnicity as health identity emerges as a site of solidarity and fragmentation closely linked to place via the concept of community. Finally, constructions of pollution, space and community provide a structural and spacial grounding to health identities associated with place. In conclusion, the usefulness of this social psychological analysis is evaluated in consideration of individualisation in ideologies of health, interpreted as 'internalised oppression', 'methodological product' and 'an assertion of agency' in the context of recent debate about identity in late modem society. In sum, the thesis both examines the social structuring of subjects and foregrounds the ethical and political dimensions of the ideologies of health within which inequalities research must recognise its' reflexive engagement

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L'objectif de cette thèse est de décrire et comprendre les processus interactionnels qui gouvernent les consultations d'annonce de diagnostic de glioblastome par une équipe pluridisciplinaire à une personne adulte. Le glioblastome est une tumeur cérébrale grave qui engage le pronostic vital à court et moyen terme. L’annonce de son diagnostic constitue un acte interlocutoire fondateur dans le processus de soin qui va sceller une relation entre deux individus, un qui sait mais qui a du mal à dire, et l’autre qui veut savoir tout en redoutant de découvrir et comprendre une réalité sombre qui le concerne. Cette révélation faite au patient et à son entourage est un acte engageant pour celui qui annonce la mauvaise nouvelle, ce dernier ne pouvant se détacher ni des émotions qu’il va provoquer en l’autre ni des siennes propres. Pour ce travail de recherche, un dispositif original a été mis en place pour l’annonce du diagnostic faite à quatre patients entourés de leur famille et personne de confiance. Deux équipes de professionnels étaient composées de médecins, psychologue et infirmiers. Les analyses de quatre consultations d’annonce constituées chacune de cinq entretiens polylogiques ont mis en évidence les attentes parfois surprenantes des patients vis-à-vis des médecins quant à la manière d’annoncer, ainsi que les effets psychiques de cette annonce. Les stratégies discursives utilisées par les interlocuteurs en présence, dans une visée inconsciente probablement protectrice pour la plupart, sont également dévoilées et permettent de donner des repères précis, notamment en ce qui concerne la formation des médecins mais également des autres acteurs impliqués dans l’annonce de diagnostic. / This thesis aims at describing and understanding the processes of interaction that are at stake during the announcement of the diagnosis of glioblastoma to an adult by a team encompassing various fields of action. Glioblastoma is a serious brain tumor that can be life-threatening in a short or mid- term. The announcement of the diagnosis is of paramount importance in the healing process that is going to seal a relationship between two persons, one who knows but who has some troubles telling it and another one who wants to know while fearing to discover and understand a dark reality about himself. This revelation that is said to the patient and his/her relatives is an engaging act for the person announcing the bad news, the latter being unable not to feel concerned with the impact of his words or to deny his own emotions. For this research, an original scheme was put into practice to announce this diagnosis to four patients who were surrounded by their families and friends. Two teams of professionals were composed of doctors, psychologists and nurses. The analyses, resulting from four consultations of announcement, each one constituted of five philological interviews, showcased the sometimes surprising expectations of the patients concerning the doctors as for their way of announcing as well as the psychic effects of this revelation. The discursive strategies used by the persons present, in an unconscious perspective and even protective for most of them, are also unveiled and enable to give thorough landmarks, especially about the training of the doctors but also the other actors involved in the announcement of the diagnosis.