Since 1979, the organisation of Chinese health care has undergone extensive changes as the result of government health reforms. These changes have particularly affected the '3-tier health network' of rural health care organisation. The '3 tier health network' which is a vertically organised linkage of village, township and county health units, has formed the basic health structure for the rural areas since the early 50's. The '3 tier network'(3TN) has been subject to the introduction of a market competitive system which is the economic responsibility system. Township hospitals have been placed under the control of township government, and a decision has been made to introduce a county level hospital of Chinese traditional medicine(CTM) for each county. Changes in the basis of health care financing and the encouragement of private practice have accompanied the decline of the co-operative medical system (CMS), a system of health insurance set up in the 1960's. On the basis of the empirical study described below, this thesis argues that there is an urgent need to evaluate these reforms, and develop policies for China's 800 million rural residents, focussing in particular on the 3TN. In 1989,7 counties, 12 townships and 30 villages were chosen by a structured random sampling technique in Jiangxi Zhejiang and Shandong provinces in East-China. A survey was carried out, covering health organisation, health personnel, the economics of rural health and health services for rural residents in county, township and village. In this survey, a comparison was made of the various types of health system, including those that have come into being since reform policies were instituted. In addition, the survey also considered the general influences of health reforms on the health service for rural residents and the management situation of the 3TN. This study found that in general the health reforms weakened the 3 tier health network in the rural areas. The health status of rural residents has deteriorated due to privatisation of the rural health care market. The main effects observed were the financial crises of township hospitals, high turnover and lack of health personnel in the rural areas, a standstill in preventive health, and the limited utilisation of health services by rural residents, since private health care replaced the CMS. The thesis argues that the main cause of these negative developments is health policies because the process of health policy making is 'top-down' in China, lacks community participation and is affected by political factors. The policies made during health reform actually worsened the already uneven allocation of health resources between urban areas and the rural areas. Urban areas have an inequitably large share and the gap continues to widen. The thesis suggests that Chinese health policy and organisation should put the stress on the rural areas once more, as happened during the 1960's and 70's. The reestablishment of the CMS is a better way to guarantee the health of rural residents and to implement primary health care. This method of health financing could be applied not only in China but throughout the developing world.

This thesis presents a critical ethnography of decision making with respect to the assessment of health care needs in the UK health system. Theories of need, justice and rights are reviewed in relation to structural changes to the National Health Service, together with the different theoretical approaches underpinning health policy based on human needs. The research on which this thesis is based focuses on a case study of an independent review of renal services in London, concentrating on the needs assessment work of the review group set up by the government and the decision making debates this review group engaged in. The methods used are based on a participatory, critical ethnography. The review process is evaluated critically by relating the technical knowledge produced by the group to a theoretical framework for assessing needs and by using a Habermasian perspective to investigate the ways in which the language of need is used to legitimise the agendas of various vested interests. This work is linked with an analysis of quasi-markets in the health service to explore the capacity that the technical discourses of markets and contracting have for reinforcing the ideological distortions identified in the analysis of the group's debates concerning need. Finally, by linking an analysis based on a case study of renal services to theoretical understandings of health care needs and health policy, a general critique of the UK health system is constructed.

Diet is an important determinant of health, especially during adolescence when growth and development are critical. Many young people continue however to eat a diet that does not conform with current dietary recommendations Relatively little research has been carried out into adolescent dietary behaviour change. The Transtheoretical Model of Behaviour Change has been developed and tested with a range of health related behaviours and indicates that change is a dynamic non-linear process involving several distinct stages (Prochaska and Diclemente, 1991). The aim of this study was to investigate adolescent dietary behaviour change amongst a sample of 513 fourteen year olds attending six schools in North London. The objectives were to assess the key features, patterns and characteristics of the sample's dietary behaviour, to establish the nature and extent of change of diet; and to investigate the context, influences and processes involved. A three phase study design was developed which utilised both quantitative and qualitative methods. Results from the quantitative phase revealed that over 50% of the sample had experience of changing either their fat or sugar intakes. Application of the Transtheoretical Model of Behaviour Change revealed very similar patterns of change for both fat and sugar, although differences in the distribution of stages between females and males was apparent. Multiple logistic regression analysis showed that adolescents who were female, perceived themselves to be overweight, were involved with cooking and ate a home based lunch were more likely to have changed their diets. Data from the semi-structured interviews revealed the complex processes and social influences involved in changing eating behaviours. Concern with body appearance was the major motivation for change, with direct health considerations being less important. The socio-structural context greatly influenced young eoleabilitY to successfully modify their eating patterns. These results have important implications for the future development of appropriate and effective health promotion dietary interventions aimed at young people.

Introduction: Health outcomes for people with Type 2 diabetes could be improved if people engaged in appropriate levels of physical activity. Aim To explore Type 2 diabetic patients’ compliance with lifestyle recommendations and to inform the development of an intervention to increase walking. Method A systematic review was conducted to identify evidence for interventions to improve compliance with lifestyle recommendations. Semi-structured interviews using the Theory Domain Framework (TDF) were undertaken with Type 2 diabetic patients and their household member. Participants were identified from the Scottish Diabetes Research Network (SDRN), a Diabetes Clinic, and the community. The household members were identified by each Type 2 diabetic patient. A questionnaire, derived from the results of the systematic review, interviews, and TDF, was mailed to 1000 Type 2 diabetic patients (and their household member), registered with the SDRN. Results: The systematic review identified no single effective intervention. The interviews identified that “environmental context” and knowledge were the domains most frequently perceived as barriers to increasing walking. The Health Action Process Approach (HAPA) was identified as the most appropriate model to inform the questionnaire. The questionnaire response rate was 44.1% (426/965). Only patient-data were analysed. A minority of respondents (40%) were compliant with physical activity. Those who were more likely to be compliant had fewer co-morbidities, higher action control and a lower coping plan. Illness perception was associated with compliance with physical activity recommendations. Patients with a higher duration of walking had fewer co-morbidities, fewer negative beliefs about consequences, and higher self-efficacy and action control. Conclusion The HAPA model explains and predicts compliance with physical activity. This model should be used to inform the development of an intervention to improve physical activity in Type 2 diabetic patients.

This study investigates the manner in which intensive care nurses perceive, and take action to meet, the needs of the critically ill child, with the aim of answering three research questions: 1. What care is provided for the critically ill child in the intensive care unit? 2. How do nurses identify and act on the needs of the critically ill child? 3. What dimensionso f knowing underpint he way in which nursesp erceivea nd act on the needs of the critically ill child? A modified Delphi technique was used to provide an expert opinion on the needs of the critically ill child. A case study approach, informed by ethnographic principles, was used to structure observationsa nd interviewsi n one paediatrici ntensivec are unit (ICU) and two general ICUs. Carper's (1978) four dimensions of knowing (aesthetic, ethical, empiricala nd personakl nowing) underpinnedc ases tudy data collectiona nd analysis. The study findings expanded Carper's original work by identifying an additional dimension of knowing, referred to as contextual knowing, which nurses used to relate empirical and aesthetic knowledge to the individual child. This influenced their perception of whether a changed situation constituted a need. The five dimensions of knowing were used in an inter-related way by the nurses; no hierarchy was evident as priority was given to the dimension most relevant in a given situation. The findings highlight the key role of the nurse at the bedside (the allocated nurse) in identifying, legitimising and acting on the needs of the child. The importance of experience and confidence in enabling the nurses to undertake activities such as gate-keeping andprioritising in order to meett he needso f the child was also emphasisedT. he shift leader supported the nurses and co-ordinated the overall activity on the Unit. There was no overall difference in the role adopted by families in the General and Paediatric ICUs. Nursing records were an historical record of care, rather than a plan of care, and did not detail decision-making and prioritising activity frequently observed in the intensive care units. Recommendations are made for strategies to retain experienced nursing staff at the bedside, the active promotion of learning through experience, incorporating prioritising of care in records and a more inclusive framework for measuring and costing nursing workload in ICU

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This research arose from concerns over the marginal position of speech and language therapists within the UK health care system, at a time when a case based on equal pay legislation comparing their work with that of clinical psychologists nears completion. While quantitative data confirm a difficulty for the NHS in recruiting and retaining speech and language therapists, no qualitative research has explored their work experiences within a sociological framework. The present study aims to address this gap. The empirical findings are based on qualitative interviews with forty speech and language therapists which employed feminist principles in research methodology including open-endedness, disclosure of values and reciprocity. Themes emerging included the 'invisibility' of the profession in accessing careers advice and gender-stereotyping of subject choices and careers advice at school. In contrast to the humanistic elements which led people into speech and language therapy, the professional education emphasised the scientific aspects of human communication, reflecting a medicalised view of health. Lesser attention was paid to humanistic subjects such as counselling and to the therapeutic applications of formal teaching. Therapists' clinical experiences focused on the relationship between work in the public and private spheres, organisational concerns and the nature of clinical practice. For instance, treatment for people with communication impairments was regarded as a low priority owing to the tendency of formalised health care to prioritise bodily health over mental and communicative well-being. The research considers whether the 'scientisation' of the profession is an effective route to counteract its marginalisation, since in pursuing this route it is required to distance itself from the female-gendered elements of its practice. This dilemma is examined against wider social concerns in which the work of women in the 'reproduction' of people is devalued on a global scale while the 'mainstream' activity of scientific work continues to be highly-prized.

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This study investigated the teaching, learning and support of pre-registration nursing students in medical and surgical wards of two Scottish hospitals. The research was qualitative in nature and used a grounded theory approach, as described by Glaser and Strauss. Data were collected using non-participant observation of the students and their preceptors as they went about their daily ward routines and semi-structured interviews with subjects. The sample population comprised twenty-one students, twenty-one preceptors, six mentors, six mentees and two link teachers. Students and preceptors were a purposive sample though mentors, mentees and link teachers were identified using the theoretical sampling techniques of grounded theory research. Analysis of the data revealed two major descriptive categories called "relationships" and "environment", and six sub-categories labelled "student relationships with preceptors and supervisors", "mentoring relationships", "theory-practice relationships", "learning and teaching", " 'good', 'bad' and 'poor' learning and teaching experiences" and "preceptor-student interactions". From these the following three conceptual themes emerged: "control of learning opportunities", "mentoring and preceptoring" and "the theory-practice interface". The findings showed that control over the use of student learning opportunities was limited and that students learned specific aspects of ward work and patient care more often by chance than by planned experiences. It was also evident that students sought help from nurses other than those appointed to be their supervisors on any particular placement. They did this by identifying someone who they believed would be most able to answer their questions or understand their concerns. In comparison with studies conducted in the 1980s, the critical influence of the ward sister on the ward learning environment generally and on individual student learning opportunities was found to be much less significant. Evidence of different types of theory-practice gap is presented and it is suggested that generally students deal well with these when they encounter them.