Low socioeconomic position is known to be associated with greater coronary heart disease (CHD) risk in most developed countries. However, studies have largely focused on the association between socioeconomic position and CHD in middle-aged populations and little is known about the extent to which socioeconomic position affects CHD risk in later life. This thesis uses the British Regional Heart Study, a populationbased cohort of British men to investigate the extent of socioeconomic inequalities in CHD in older age and the possible pathways to these inequalities. Issues addressed in detail include trends in socioeconomic inequalities in CHD with increasing age and over time, the extent of socioeconomic inequalities in CHD in older age (60-79 years), the contribution of established and novel coronary risk factors to these inequalities, and the influence of early life socioeconomic position on CHD risk in later life. Although CHD mortality declined over the last two decades in Britain, relative social class differences in CHD did not narrow between 1980 and 2005. With increasing age (from 40-59 years to 65-84 years), relative social class inequalities in CHD narrowed, although absolute differences widened with age. Marked socioeconomic differences in CHD were present in older age; CHD risk increased from the highest to the lowest social class group. Socioeconomic differences in behavioural coronary risk factors (particularly cigarette smoking) could explain at least a third of these inequalities; inflammatory markers made some additional contribution. Lower socioeconomic position in childhood was associated with increased CHD risk in older age; part of this association was due to the relationship of childhood socioeconomic position with adult behavioural factors. Appreciable socioeconomic inequalities were also present in disability among older men with CHD. The results suggest that important socioeconomic inequalities in CHD persist in older age; the implications for public health and further epidemiological research are discussed.

Validity and reliability of self-reported sexual behaviour in epidemiological surveys are suboptimal, particularly among young people. 1495 rural Zimbabwean youth were randomly allocated to one of the following: self-administered questionnaire (SAQ=373), SAQ accompanied by an audio soundtrack (Audio-SAQ=376); face-to-face interview using an informal confidential voting box (ICVI=365); and audio computer-assisted survey instrument (ACASI=381). Biomarkers for sexual activity included HIV, HSV-2 and pregnancy test in females. Key questions were selected a priori to compare item non-response and rates of reporting sensitive behaviours between questionnaire delivery modes. Additional qualitative and quantitative data were collected on method acceptability. Item non-response was significantly higher with SAQ and Audio-SAQ than with ICVI and ACASI (p<0.001). After adjusting for covariates, Audio-SAQ and ACASI users were twice as likely to report sexual activity when compared to SAQ users, with no reporting difference between ICVI and SAQ users. ACASI users reported a lower age at first sex (p<0.045). ACASI users reported increased ability to answer questions honestly (p=0.004) and believed their answers would be kept confidential. Participants claimed increased comprehension when hearing questions while reading them. ICVI users expressed difficulty answering sensitive questions, despite understanding that their answers would not be known by the interviewer. As a result, two methods, Audio-SAQ and ACASI were chosen to complete the final survey. In this larger sample we found evidence that the effect of mode differed by gender. There were fewer ACASI users with a positive biomarker for sexual activity that did not report sex (p<0.001). These results coupled with a systematic review of effect of questionnaire delivery mode on sexual behaviour reporting from developing countries provide strong evidence that ACASI significantly reduces bias, is feasible and acceptable in resource-poor settings with low computer literacy. Its increased use could improve sexual behaviour data quality.

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This study aims to examine the impact of the NHS Reforms on doctors and nurses in two North London hospitals, in relation to both changes to the nature of professional practice, and the effect on quality of care offered by professionals to their patients. A case study approach is utilised, combining quantitative and qualitative methodologies to explore the consequence of the policy implementation. A survey was carried out to examine the nature and scope of the effects on professional practice, of the NHS Reforms, and to collate examples of improvements and deteriorations in quality of care offered to patients. In-depth interviews were carried out with senior managers in both hospitals and also their purchasing Health Authority, to identify key features of the policy implementation process. In-depth interviews were also carried out with doctors and nurses in both hospitals, working in a range of clinical specialities to explore the experience of professional practice within a changing policy environment. It emerged that there was a shared experience, across both hospitals and professions, of increasing levels of stress, increasing workload and increasing levels of conflict with managers. There is evidence of both improvements and deteriorations in the quality of care offered to patients, but whereas improvements were largely related to the quality element of structure, the deteriorations were closely related to the process element. Analysis of the interview data revealed three distinct responses by professionals to the NHS Reforms, and these related to the differing values and belief systems which were held. Two groups of professionals – the Traditional and the Transformed - have adapted to the changing milieu of the NHS, but the third - the Transitional - have become disenfranchised from the system within which they practice.

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