Introduction: Alcohol is a major contributor to the burden of disease globally. In Europe, there is a long-standing tradition of drinking alcohol, with per capita consumption being the highest in the world, even if it has been declining in recent decades. Changes in per capita consumption are likely to be related to factors operating at societal level, of which globalisation has been one of the most important factors. Since early 2020, the global pandemic of the Coronavirus Disease 2019 (COVID-19) has caused serious disruptions to day-to-day and community life. As a consequence of the pandemic and the measures taken to contain the spread of the virus, patterns and levels of alcohol consumption are expected to change due to reduced alcohol availability, and according to income levels and distress experiences. Surveys are used to assess such short-term trends, but also to identify drinking patterns that cannot be derived from other sources such as alcohol purchases. However, general population surveys usually fail to capture the entire amount of alcohol consumed within a population. This inherently limiting factor of surveys is called underreporting and not well understood to date. Aims and Objectives: The overall aim of this dissertation was to provide a comprehensive and up-to-date assessment of alcohol consumption in Europe using survey data, as well as to compare survey-based annual consumption estimates with per capita consumption data, i.e., sales and other data derived. For this purpose, the following three objectives were of interest: First, to determine and to compare European drinking practices across 19 countries using survey data from 2015 (study I). Second, to examine changes in alcohol consumption during the first months of the COVID-19 pandemic in 21 European countries and whether these changes were associated with income and pandemic-related distress experiences (study II). Third, to estimate the degree of under-reporting of alcohol consumption in surveys and to study possible factors related to under-reporting based on 39 surveys from 23 European countries (study III). Design: All studies are based on individual-level data from cross-sectional pan-European surveys covering the general adult population. In study I, European drinking practices were determined by the means of latent class analysis using key indicators of alcohol consumption (past-year drinking frequency and quantity, risky single-occasion drinking, and preferred alcoholic beverage) derived from nationally representative data from 2015. In a second step, the identified drinking practices were compared across countries. In study II, self-reported changes in drinking frequency, drinking quantity, and the frequency of heavy episodic drinking over the past month were assessed in a large convenience sample collected between April and July 2020. Additionally, past-year alcohol consumption was recorded using the consumption items of the Alcohol Use Disorder Identification Test in order to obtain an estimate of alcohol consumption during the pre-pandemic period. Income and distress experiences were recorded as factors hypothesised to be associated with self-reported changes in consumption. In Study III, nationally representative surveys conducted between 2008 to 2015 were combined and compared with alcohol per capita consumption estimates for the same years and countries, in order to estimate survey-based under-reporting of alcohol consumption at the national level. Per capita consumption estimates were retrieved from sales statistics and corrected for unrecorded and tourist consumption. Data sources: Survey data were obtained from large-scale alcohol surveys covering the majority of European Union countries plus some non-European Union countries. Statistical analyses: To identify European drinking practices (study I), survey-weighted latent class models of key indicators of alcohol consumption, adjusted for respondent’s location, were conducted. The resulting class prevalence estimates were then contrasted across locations, and fractional response regression models were calculated for membership probabilities of each class (dependent variable) in explorative analysis, with sociodemographic data and individual alcohol harm experiences serving as independent variables. To identify changes in overall alcohol consumption over the past month during the COVID-19 pandemic (study II), a consumption-change score was calculated by combining the single change indicators (i.e., drinking frequency, drinking quantity, and frequency of heavy episodic drinking; range: -1 to +1). Multilevel linear regressions with the random intercept country of residence were used to test for statistical significance of the consumption-change score (dependent variable), adjusting for sample weights and past-year alcohol consumption, as well as for associations with income group and pandemic-related distress experiences. To quantify the extent to which national surveys assess alcohol per capita consumption (study III), coverage rates were calculated. Coverage is defined by dividing the survey-based annual alcohol consumption estimates by per capita consumption estimates. Using fractional response regressions, differences in coverage rates (dependent variable) across transnational regions, as well as the relative importance of heavy episodic drinking prevalence and indicators of survey methodology were tested. Results: Three latent classes of drinking practices were identified: a ‘light to moderate drinking without risky single-occasion drinking’ class (prevalence: 68.0%, 95% Confidence interval [CI]: 66.7, 69.3), a ‘infrequent heavy drinking’ class (prevalence: 12.6%, 95% CI: 11.5, 13.7), and a ‘regular drinking with at least monthly risk single-occasion drinking’ class (prevalence: 19.4%, 95% CI: 18.1, 20.9). In contrast to the former drinking practice of light to moderate drinking, the latter two were characterised by a high average amount of alcohol consumed per drink day, exceeding 100 grams pure alcohol and 60 grams pure alcohol per drink day, respectively. Regional variations in the distribution of drinking practices were observed, with the ‘light to moderate drinking without risky single-occasion drinking’ class prevailing particularly in southern European countries. In study II, an average decrease in overall alcohol consumption during the first months of the COVID-19 pandemic indicated by a negative consumption-change score was observed (-0.14, 95% CI: -0.18, -0.10). This average decline according to the consumption-change indicator was observed in all countries studied, except Ireland (no change) and the United Kingdom (increase). The most marked decrease was reported in the frequency of heavy episodic drinking (-0.17, 95% CI: -0.20, -0.14). Respondents with low- or average income, as well as those experiencing distress were more likely to increase their alcohol consumption than to decrease it. In study III, the average total alcohol consumption coverage was 36.5% (95% CI: 33.2, 39.8), with large variations in coverage rates between countries. While the prevalence of heavy episodic drinking explained up to 10% of the variance in coverage, there were no systematic variations across European regions or the survey methodologies studied, such as non-response rates. Conclusions: In many European countries, a combination of a light to moderate and risky drinking practices prevailed. With a combined prevalence of 32.0%, almost every third respondent engaged in some form of risky drinking. During the first months of the COVID-19 pandemic, overall alcohol consumption, and particularly heavy episodic drinking, appeared to have declined on average in the countries studied. On the other hand, people with low- or average incomes and those suffering from pandemic-related distress were at increased risk of escalating their alcohol consumption during this period. The results contribute both to an up-to-date assessment of alcohol consumption in Europe, including the identification of populations at increased risk of alcohol-related harm, and to the body of evidence on reducing alcohol availability as an effective measure to lower population-level consumption. Beyond consequences for alcohol policy, benefits and limitations of surveys in the field of alcohol epidemiology are discussed. In light of the substantial and apparently unsystematic under-reporting of alcohol consumption in surveys, a rethinking of this methodology is required. Presenting survey-based data and its limitations in an upfront manner, as well as applying sophisticated statistical methods are two options to address current challenges.:Statement for a publication-based dissertation I Table of contents III List of tables V List of figures VII Abbreviations IX Synopsis XI 1 Introduction 1 1.1 Determinants of alcohol consumption and alcohol-related harm 3 1.1.1 Individual vulnerability factors 4 1.1.2 Societal vulnerability factors 5 1.2 The impact of the COVID-19 pandemic on alcohol consumption 8 1.3 Strengths and limitations of survey research 11 2 Aims and objectives 13 3 Study design and methodology 14 3.1 The Standardised European Alcohol Survey 15 3.1.1 The RARHA SEAS questionnaire 15 3.1.2 Sampling procedure and data pre-processing 16 3.1.3 Calculation of annual alcohol consumption 17 3.1.4 Research ethics 17 3.2 Harmonising Alcohol-related Measures in European Surveys 17 3.2.1 Questionnaires 18 3.2.2 Sampling procedures and harmonising of the questionnaires 18 3.2.3 Research ethics 19 3.3 The Alcohol Use and COVID-19 Survey 19 3.3.1 Survey development and design 19 3.3.2 Survey dissemination 21 3.3.3 Calculation of survey and population weights 22 3.3.4 Research ethics 24 4 Study I – A new perspective on the European drinking culture: a model-based approach to determine variations in drinking practices across 19 European countries 25 4.1 Abstract 25 4.2 Introduction 26 4.3 Methods 27 4.4 Results 30 4.5 Discussion 35 5 Study II – Alcohol consumption during the COVID-19 pandemic in Europe: a large-scale cross-sectional study in 21 countries 38 5.1 Abstract 38 5.2 Introduction 39 5.3 Methods 40 5.4 Results 42 5.5 Discussion 49 6 Study III – Why is per capita consumption underestimated in alcohol surveys? Results from 39 surveys in 23 European countries 53 6.1 Abstract 53 6.2 Introduction 54 6.3 Methods 56 6.4 Results 62 6.5 Discussion 64 7 General discussion 69 7.1 Summary of findings 69 7.2 Strengths and limitations 70 7.3 Implications for future research 72 7.3.1 New impulses for drinking culture research 72 7.3.2 The realisation of multi-country online surveys 73 7.3.3 Consequences of low alcohol consumption coverage in alcohol surveys 74 7.4 Implications for alcohol policy 75 7.4.1 Altered availability of alcohol as a secondary outcome of the COVID-19 pandemic 76 7.4.2 Towards a comprehensive alcohol control policy for Europe 78 7.4.3 Alcohol screening and access to health care in high-risk drinking populations 7.5 Outlook 81 7.6 Conclusion 83 8 References 85 9 Appendix 106 9.1 Appendix A (study I) 106 9.2 Appendix B (study II) 126 9.3 Appendix C (study III) 152 10 Erklärung gemäß §5 der Promotionsordnung 160

Der Konsum psychoaktiver Substanzen stellt einen der wichtigsten vermeidbaren Risikofaktoren für Krankheit und frühzeitige Sterblichkeit dar. Die Weltgesundheitsorganisation (WHO, 2009) berichtet im Rahmen ihrer Schätzungen zur weltweiten Morbiditäts-und Mortalitätsbelastung, dass die legalen Substanzen Tabak und Alkohol zwei der fünf wichtigsten gesundheitlichen Risikofaktoren darstellen. ...

Anorexia nervosa (AN) is an eating disorder characterized by severely low bodyweight, fear of weight-gain, and a subjective believe to be “fat”. An elevated need for control and fear of losing control are considered core aspects in the development and maintenance of AN and restricting food intake is thought to function as a means to gain feelings of control (Fairburn, Shafran, & Cooper, 1999; Schmidt & Treasure, 2006). Feelings of inefficiency (i.e. lack of control regarding personal goals) have been found to predict longer duration of treatment and worse treatment outcome, underlining the relevance of the need for control in AN (Olatunji, Levinson, & Calebs, 2018; Pinto, Heinberg, Coughlin, Fava, & Guarda, 2008; Surgenor, Maguire, Russell, & Touyz, 2007). The constant striving for control could lead to rumination and negative affect – two further important symptoms associated with AN. The Goal Progress Theory of rumination (GPT; Carver & Scheier, 1990; Martin & Tesser, 1996) proposes that perceived discrepancies between desired goals (in the case of AN e.g. goals regarding lowest possible calorie intake, weight, etc.) and the current state (in the case of AN e.g. the subjective conviction of having eaten or weighing too much) trigger ruminative thoughts, which subsequently lead to negative affect. Following this theory, it could be suggested that gaining feelings of goal-progress and control could lessen the burdening repetitive thoughts and negative affect and that individuals with AN try to achieve this by restricting food intake. This dietary restriction requires self-control. However, previous research has shown that patients with AN typically not only show such elevated self-control, but also display rigid habitual behaviours and routines, struggle with set-shifting, and often display comorbid obsessive-compulsive symptoms (Treasure & Schmidt, 2013; Halmi et al., 2003). This raises the question of whether food restriction in AN is indeed an act of self-control or rather a habit. Recent scientific development has challenged the traditional dichotomy between controlled and automatic processes (Shiffrin & Schneider, 1977), instead suggesting that they are intertwined in such a way that often self-control works via the establishment of goal-serving habits and routines (Gillebaart & de Ridder, 2015; Galla & Duckworth, 2015). These theoretical considerations can generally draw support from previous research, but have not been investigated explicitly in the context of AN. It was the main goal of this thesis to analyse associations between feelings of inefficiency, rumination and negative affect, controlled and habitual behaviour, and eating behaviour to establish an empirical foundation for the proposed relationships between these aspects of AN. Study 1 (Fürtjes, Seidel, et al., 2020) employed ecological momentary assessment (EMA; data collection several times a day over a period of several days in the natural environment of the participants) to investigate associations between feelings of inefficiency, rumination, and affect in a sample of individuals with a history of AN who had recovered from the disorder in terms of eating behaviour and bodyweight and age-matched healthy control participants (HC). AN participants displayed elevated rumination about bodyweight/figure (but not food) and negative affect compared to HC, suggesting that these cognitive-affective symptoms are persistent even after recovery. Analyses investigating associations with inefficiency showed that inefficiency was associated with heightened rumination and negative affect, which is in line with the GPT. Furthermore, AN participants showed higher levels of inefficiency than HC and stronger associations between rumination and negative affect. These findings indicate that feelings of lack of goal-progress and control are a central aspect of AN, likely contributing to maintenance of the disorder by triggering dysfunctional cognitive-affective processes. The fact that these associations were still present in a sample of recovered individuals underlines the persistence of these processes, suggesting that they might not only maintain the disorder but could also present a vulnerability factor or contribute to risk of relapse. Study 2 (Fürtjes et al., 2018) made use of EMA and leptin, an endocrinological marker of undernutrition, to further investigate associations between rumination and affect in a sample of patients with acute AN, once at the beginning of treatment and again after weight-restoration. In line with Study 1, results confirmed that rumination about bodyweight/figure and negative affect are closely linked in AN and that this association persists even after weight-gain. Thoughts about food on the other hand were associated with leptin levels, declined with weight-gain, and showed weaker associations with affect. This suggests that thoughts about food may reflect a physiological symptom of the disorder, connected to undernourishment, whereas thoughts about bodyweight/figure might present a cognitive-affective symptom which could be involved in maintenance of the disorder (as suggested by Study 1). To test supporting evidence for the interaction of self-control and habits in the regulation of eating behaviour, Study 3 (Fürtjes, King, et al., 2020) employed task-based measures of controlled and automatic processing as well as self-report measures of self-control, habitual behaviour, and eating behaviour in a large female sample representative of the general population through an online study design. Results obtained via structural equation modelling (SEM) revealed that eating behaviour appears to be largely guided by habits and automatic behavioural tendencies, whereas controlled aspects have an indirect influence via this association. These findings could be interpreted as support for the proposal that self-control might work via the establishment of goal-serving habits and routines, which outlines the possibility that the restrictive eating behaviour in AN might be achieved and maintained via a combination of self-control and rigid routines and habits. Taken together, the research presented in this thesis was able to demonstrate how striving for control as a core aspect of AN might play a role in triggering dysfunctional cognitive-affective processes, likely contributing to development and maintenance of the disorder, and that self-control and habitual behaviour interact inguiding human eating behaviour, carrying implications for the mechanisms behind restrictive eating in AN. Clinical implications that can be derived from this research include addressing need for control and feelings of inefficiency in therapy to enable improvement of dysfunctional cognitive-affective processes as well as eating behaviour.

Die seit März 2020, mit strengen Schutzmaßnahmen in Form von Kontaktreduzierungen und Einschränkungen im öffentlichen Leben, in Deutschland einhergehende Covid-19-Pandemie löste bei vielen Menschen individuell ausgeprägte Sorgen und Ängste innerhalb diversen Lebensbereichen aus. Ein, den Kriegszeiten ähnlicher, Zustand trat ein und nach Worten der Politikvertreter/innen ging es um Leben oder Tod, Arbeitsplatzsicherheit oder Arbeitsplatzlosigkeit sowie Geborgenheit oder Isolation. Gegenwärtige Schlagzeilen wie „Die Corona-Krise führt immer häufiger zu psychischen Problemen (Haas, C., Kunz, A. 2020: www.welt.de)“, „Eine Herausforderung für Menschen mit Depression (Moghimi, J. 2020: www.rnd.de)“ oder „Menschen mit psychischen Erkrankungen leiden am meisten (Pingel, S. 2020: www.msn.com)“ lassen auf eine starke Betroffenheit von psychisch erkrankten Menschen im Kontext der COVID-19-Pandemie schließen. Ziel dieser Arbeit ist es, die individuelle Betroffenheit von depressiv erkrankten Menschen zu untersuchen. Findet die Annahme, einer steigenden Tendenz psychischer Belastungen, fortwährend Bestätigung, ist eine unmittelbare Reaktion professionellen Handelns durch die Soziale Arbeit notwendig, um mögliche soziale Folgen aufzufangen und gleichzeitig präventiv für Betroffene Unterstützung anzubieten. Insbesondere Menschen mit einer Depression sind, aufgrund von (Vor-)Erfahrungen hinsichtlich ihres Krankheitsbildes, Experten im Umgang mit Isolationserlebnissen. Gelten sie demnach als Meister der Isolation im Umgang mit der Covid-19-Pandemie?:Inhaltsverzeichnis Abkürzungsverzeichnis 1 Einleitung 2 Die COVID-19-Pandemie 2.1 Das SARS-CoV-2-Virus 2.2 Die COVID-19-Chronik und die Maßnahmen zum Eindämmung des Virus 2.3 Die gesamtgesellschaftliche Situation 3 Die Auswirkungen der Pandemie auf das psychische Wohlbefinden 4 Depressionen während einer Pandemie 4.1 Betroffenheit der Menschen mit der psychischen Krankheit Depression während der COVID-19-Pandemie 4.2 Die Krankheit Depression 4.2.1 Krankheitsbild 4.2.2 Ursachen 4.2.3 Behandlungsmöglichkeiten 4.3 Forschungsstand 4.3.1 Historische Epi-/Pandemien 4.3.2 COVID-19-Pandemie 5 Die subjektive Wahrnehmung von Betroffenen mit einer Depression 5.1 Methodisches Vorgehen 5.1.1 Qualitativer Forschungsansatz 5.1.2 Erhebungsmethode 5.1.3 Zugang zum Feld 5.1.4 Durchführung der Erhebung 5.1.5 Auswertungsmethode 5.2 Darstellung der Ergebnisse 5.3 Diskussion mit der Gegenüberstellung eigener Forschungsergebnisse und externen Erhebungen 6 Der Umgang mit Lebenskrisen 6.1 Psychosoziale Krisen 6.2 Lebensbewältigung 6.3 Resilienz 6.4 Eine konstruktive Bewältigung psychischer Folgen der Pandemie 7 Handlungsempfehlungen im Umgang mit der COVID-19-Pandemie 7.1 Psychosoziale Notfallversorgung durch Intervention 7.2 Bewältigung im privaten Kontext 7.3 Adaption des Versorgungssystems 7.3.1 Fortbestehen von Angeboten 7.3.2 Entwicklung und Anpassung neuer Angebote 7.4 Öffentlichkeitsarbeit 8 Professionalisierungsdiskurs für die Soziale Arbeit 9 Schlussfolgerung Quellenverzeichnis Anhang

The purpose of this thesis is to investigate how experiences of violence, which have been secret in the past, can be articulated that they may become resources for theological reflection and Christian action. The research technique employed is ethnography, which is used to uncover the violence experienced in the lives of Dalit Christian women in Kerala State of India. Part one of this thesis concerns methodology. Chapter two examines how other women theologians working amongst poor and marginalised women from non-western cultures have sought to make women’s experience visible and have emphasised its theological significance. This chapter explores what I can gain from the work of these women that will help me to develop my own research on Dalit Christian women. Chapter three describes the research setting by explaining the context for this research, the researched community of Dalits and the location, where Dalit women gathered together. This chapter demonstrates my relations, as an ethnographer, to Dalit Christian women who have converted to Christianity from the Pulaya caste. Finally, this chapter justifies the research strategies employed in this research. Part two of this thesis contains my field research. Chapter four is about meta-ethnography generated at a one-day seminar and two Bible studies. In chapter five Dalit Christian women, who are the survivors of various kinds of violence, tell their life stories in their own words. In this way Dalit women started to uncover the secret and hidden experience they had in the past. Part three of this thesis is the analysis of data and conclusion. Chapter six analyses the significant themes, which have emerged from my research into the life experiences of Dalit women. It demonstrates that Dalit women’s experience and the cultural traditions of Dalit community are important resources for the development of a Dalit Feminist Practical Theology. Finally, in the light of my research, I make concrete strategies for action that could bring hope and transformation in the lives of Dalit women who are experiencing violence.

There is accumulative evidence and successive government policy to suggest that the health and social care professions need to provide integrated services to the public. Interprofessional education is regarded as a solution to the problem and has developed from this demand. Educational initiatives of an interprofessional nature are now a regular occurrence. The role of the teacher in facilitating these programmes has been largely overlooked. The purpose of this thesis was to address this imbalance. The study adopted the illuminative evaluation paradigm to investigate the teachers' perceptions of interprofessional education and shared learning milieu. It took the form of three surveys. The first survey addressed the perceptions of the course leaders in centres for teacher education. The second survey involved new teachers, mentors and managers in colleges for nursing and midwifery education at that time. The third survey addressed interprofessional education from the perceptions of teachers of health and social care professions who were involved in IPE programmes in higher education. The central research question underlying the study was how do teachers view and implement IPE? Essential to this was the question are teachers prepared for their role in interprofessional education? Multiple methods were used to collect the data and both quantitative and qualitative methods were used in analysis. Non parametric statistics were applied to quantitative data. Computer assisted analysis was used for the qualitative data through a purpose built database using ACCESS software. The results showed that teachers or students did not have preparation for interprofessional education while the majority of teachers felt that they required it. The evidence suggested a lack of commitment at strategic level, and a lack of structuring and planning of resources to accommodate this type of education. Teachers were aware of the benefits interprofessional education could offer, but were sceptical as to the motives underlying it. In reality, interprofessional education was less than the proposed principles behind it.

Der Konsum psychoaktiver Substanzen stellt einen der wichtigsten vermeidbaren Risikofaktoren für Krankheit und frühzeitige Sterblichkeit dar. Die Weltgesundheitsorganisation (WHO, 2009) berichtet im Rahmen ihrer Schätzungen zur weltweiten Morbiditäts-und Mortalitätsbelastung, dass die legalen Substanzen Tabak und Alkohol zwei der fünf wichtigsten gesundheitlichen Risikofaktoren darstellen. ...

This thesis assessed whether rape is an adaptive mating strategy. which was naturally selected for in our ancestral past. It investigated a number of constructs. namely: fertility value; victim-offender relationship; socio-economic status; rape proclivity; actual sexual aggression; and sociosexual orientation. There were two types of studies: studies 1-3 involved archival data, e.g. the use of criminal statistics. and studies 4-7 assessed participant data, e.g. rape attitudes. Study 1 found that fertility value (FV) was related to rape prevalence, as was reproductive value (RV). In addition, offenders with a nonreproductive sexual preference tended to rape a victim with a low FV. and offenders who committed a secondary offence tended to rape a victim with high FV. Study 2 found that there was a smaller number of offences committed against strangers and partners, and a larger number committed against step-relatives and acquaintances. More rapes were committed by low status than high status men. even when the base rate was accounted for. Study 3, showed that there was a relationship between the population gender ratio and rape prevalence. However. the covariable population density was positively related to rape prevalence. Study 4- found that there was more disapproval of a depicted rape committed by a low status offender. A low status offender who raped a victim with low RV attracted more disapproval. Study 5 showed that marital rape was disapproved of more than both stranger and acquaintance rape. Individuals with a short-term mating strategy disapproved of rape more than those with a long-term strategy, and a long-term strategist disapproved of a marital rape less than a short-term strategist. Study 6 found that those who possessed a promiscuous ideology perceived their future life to be limited, in particular the likelihood of being happily married. There was no relationship found between perceived future life and sexual aggression. In study 7. it was found that those who had a more unrestricted sociosexual orientation were more likely to have asymmetrical bodily traits (e.g. ear height. finger length). and that the right hand 20:40 digit ratio (a measure of prenatal testosterone)was significantly related to actual sexual aggression. Overall. there was partial support for rape as an adaptive mechanism. but the studics wcre also consistent with a by-product explanation of rape.

Institutional Ethnography (IE) is a method of inquiry into the social organisation of knowledge. It begins with a disjuncture/troubling experience impacting a specific group of workers and adopts their standpoint/subject positon to look out into the wider institution and trace the work and textual practices that organised (and produced) the disjuncture under investigation. The study took the standpoint of Senior Social Care Workers (SSCWs) from one RCH in Scotland to uncover the complex social organisation of “abandonment” SSCWs described when there was insufficient support from NHS services to care appropriately for sick and dying residents. The focal point of inquiry was on SSCWs descriptions of being “pushed” into “difficult” decision-making conversions with family members about “serious illness” andthe Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) – without the support of doctors (or nurses).To inquire into how SSCWs work had become tied into the medical, legal and bureaucratic practices that rule death, dying and Do Not Attempt Cardiopulmonary Resuscitation (DNACPR) decision making in Scotland's RCHs the study drew on ten open-ended interviews (SSCWs, n= 4 and others whose work influenced SSCWs working practices, n= 6). Interview transcripts were examined to uncover SSCWs accounts of their knowledgeable work related to managing illness, death and dying - along with the characteristic tensions,frustrations and contradictions embedded in those accounts. The study traced how doctors and nurses were routinely, and systematically, absent from RCHs - leaving residents systematically excluded from the level of care that they needed. It also traced how SSCWs work with “serious illness” and “difficult” conversations was co-ordinated in disquieting ways in an apparent commitment to high quality “palliative care”.What was discussed between SSCWs and family members during conversations about “serious illness” and the DNACPR form was out of step with the DNACPR policy, the rhetoric of palliative care, and the actual needs of SSCWS, family members, and residents for medical support. However, the study shows that what happened in the RCH was not simply an error of practice. This is becauseit was textually planned, organised, and co-ordinated across healthcare institutions, professional groups, the regulatory body acting on behalf of the Scottish Government and the management and care staff of the RCH itself. SSCWs - and others – were organised to take up the powerful ruling discourse of palliative care in ways which treated residents and family members withincreasing objectivity, where institutional needs to reduce NHS spending and to protect the income generating potential of the care home as a business ruled over individual needs. In taking up and enacting the powerful ruling discourse of palliative care, SSCWs – and others- (intentionally but unknowingly) took up the very tools of oppression that dominated and overpowered their own and others lives. The knowledge generated by this research can be used to show SSCWs and others how they unknowingly participate in taking up actions that are not in their own or others interests. This is the basis of changing the conditions of SSCWs and others lives thereby advancing anti-oppressive work.

This thesis focuses on quality improvement in local NHS services in response to national legislation. The preparatory literature search of healthcare, change and quality theories identified the common theme of participation for success as well as a distinct gap in quality management models suitable for healthcare. Action research was used to develop, implement and evaluate such a model, combining qualitative and quantitative methods, enabling ownership of the model by participating stakeholders, and facilitating change by reflection and action. The thesis is organised into three main parts from which key themes emerge. The first section establishes health and its care as the most basic of human needs. Healthcare delivered through public provision has a medically dominated hierarchy of stakeholders with different expectations: users pursue a social model of care, managers a business model, and providers a scientific model. The lack of evidence on which to base provision has resulted in autonomous clinical practice which, without reference to guidelines, is difficult to assure. In a culture of professional awareness, autonomy can provide an opportunity for service improvement The second section describes the development of the Quality Synthesis Model through participant involvement. Recent experiences of change in the NHS provided direction through: the need for clarity and agreement over quality issues, vision and values; a strategic approach; and capacity and empowerment to respond. In addition, these followed generic best practice of a conducive culture, communication, commitment and measures of progress. Finally, in the third section, the empirical chapters describe implementation and analyses of the model in the sample semi-profession service of chiropody with older people. Quantitative and qualitative data was collected through records, repeat surveys and sub sample telephone interview. Evaluation of the model was against: • operational criteria requirements • compatibility with commissioning • sound methodology • changes in stakeholder culture. The results suggest that the Quality Synthesis Model is a cost-effective answer to local quality management in a culture of professional awareness, respecting the influence of the ultimate power of medicine. Together with the principles of change management, and particularly the lessons learned from the implementation of previous initiatives, local NHS units could successfully move towards a sustained responsive culture through the use of the model.