Diabetes is a chronic disease that influences almost all aspects of life of an individual, especially Quality of Life (QoL). This PhD thesis is the outcome of a research that aimed to assess the QoL of people with diabetes in Greece. The study is important because the area of diabetes-related QoL is generally understudied and is the first to have investigated this within the Greek population. This work involved the creation of the Greek version of the Audit of Diabetes Dependent Quality of Life (ADDQoL-Gr) through translating, culturally adapting and validating the instrument as a QoL measure. The version was accepted by the author and the MAPI institute as the Greek version of the ADDQoL. The QoL for people with diabetes in Greece was investigated using the ADDQoL-Gr. An assessment of their health status using the SF-36, as well as the relationship of QoL and health status with medical and socioeconomic factors was also investigated. 1027 diabetes patients participated in this cross-sectional analytical study from 8 different sites from central and northern Greece. This thesis contributes to knowledge because i) identifies some characteristics of QoL predictors; ii) explores and prioritises QoL determinants; iii) reveals the complexity of the relationship between medical-socioeconomic factors and QoL; and iv) offers an instrument for measuring diabetes-related QoL for Greek speaking populations. The main conclusion drawn from this research was that diabetes seriously affects QoL, with complications (microvascular disease followed by foot amputation) having the most adverse effect. The results of this thesis are important at both theoretical and practical level because: i) they add knowledge to the diabetes-related QoL international literature ii) may have important applications for the diabetes-care system; iii) they offer a validated instrument in Greek for future investigations.

Successive “National Care of the Dying Audit for Hospitals” record that Health Care Professionals (HCPs), are recognising that patients are dying only days before their death, reducing opportunities for patient involvement in decision-making. This PhD, utilizing a mixed and iterative methodology, addresses how senior HCPs in one hospital recognise dying, and negotiate decision-making with patients and families in this process. In Study One thirteen senior HCPS undertook a Critical Incident Review. These involved the ward based senior HCP who identified dying, and the Hospital Palliative Care Team (HPCT) HCP(s) subsequently involved in the patient’s care. Interviews were recorded, transcribed and themed. In Study Two senior HCPs across the hospital were invited to four consecutive Participatory Action Research (PAR) workshops to critically reflect on the themed data from Study One. Ten HCPs took part (three HPCT HCPs were involved in both studies). The workshops were similarly recorded, transcribed and themed. The themed analysis yielded a model for decision-making but did not explain why dying was identified so late. A psychoanalytically informed psychosocial approach was taken to examine anomalies and contradictions in the data that pointed to less conscious undercurrents in the personal, professional, educational and institutional dynamics involved in the care of patients who are dying. Through this analysis, it is clear that identifying dying, and negotiating decision-making with the patient and their family at this time, is extremely anxiety provoking. Individual and social psychological defence mechanisms that avoid the recognition of dying come into play. HCPs’ experience of learning to care for the dying patient and their family is “chaotic” and anxiety provoking and leaves them ill-equipped. Complicating matters, at the point of recognition of dying, the institution devolves its responsibility for care (requirement for space and time for patient and family conversations, and emotional support for HCPs who sometimes have to deal with angry families) to individual HCPs. The argument is put forward that the HPCT have become part of modern NHS social defence mechanisms. Sensitively facilitated PAR workshops allow interested HCPs to mutually consider how to identify dying earlier; implications of this for the patient, family and themselves; the organisational resources available; and the role of education. Attention is paid to the HCPs emotional experience and psychological defences, and over time there is opportunity to negotiate sustainable practice change.

Making connections is my work in this thesis, to create a feminist affirmative diffractive reading of how practices and learning'in medical work come to matter for patient safety: a policy 'special issue'. There is a burgeoning patient safety research literature, with increased attention to medical staff working in teams, and learning to work collaboratively to improve safe practices. However, no feminist work has examined critically either patient safety discourses nor learning and practice of medical staff in specialist training who move between established collaborative teams and practice communities. I do both. My approach is a feminist interdisciplinary account of relations between learning, participation, and patient safety, and draws on ethnographic data with a female specialist GP trainee and a male specialist trainee in radiology. I consider their learning of medical work, to indicate how insights from their practices and experiences highlight some limitations of patient safety discourses. I question the discourse on eradicating errors, suggesting this forecloses iii opportunities to consider how such things as caring, tinkering, interfering, or ignoring protocols can also produce safety. I detail how situated practices can be in tension with policy. I focus on sites where gender and race can intersect with practice and learning, challenging persisting hegemonic practices and andronormativity within medical work. I consider and address the lack of attention in Situated Learning Theory {SLT} to non-human actors. I make an affirmative contribution to SLT's application in complex organisations by developing further the concept of legitimate peripheral participation {LPP}. I suggest a new concept - reciprocating participation - to draw attention to specificities of LPP in medical work and learning. I show the utility of agential realism for interdisciplinary analysis of healthcare practices and policies, and the continuing need for feminist interferences in dominant NHS discourses that overlook or erase axes of difference.

Recent Department of Health publications have emphasised the desire to provide a more positive experience of the NHS healthcare system, with more choice in a patient-led NHS; improving the management of psychological aspects of a patient's experience is an important aspect to achieving this goal. With these aims in mind paper 1 reviews the published literature for the study of psychological and emotional factors relating to routine elective surgery in the U.K. The effectiveness of interventions is explored. The research methods and design are critically evaluated. Clinical implicationsExisting literature suggests that giving information about a medical procedure can, in some cases, reduce the anxiety experienced. The contribution of service-users to information provision has been largely neglected. With this in mind, paper 2 investigates service-users experience of a colonoscopy to develop an information leaflet, and evaluate its effect on anxiety in patients. No significant difference between the groups in terms of anxiety scores was found. The findings are discussed in terms of current theories in information provision, limitations of the study, clinical application and suggestions for future research. and future research ideas are discussed.

In England and Wales the demand for health care .far outweighs the ability of the National Health Service (NHS) to supply health care. In such an environment, health care decision-making is becoming increasingly influenced by considerations of clinical and cost effectiveness. The robustness and reliability that can be attached to an economic evaluation depends, to a great extent, on the nature and quality of the underlying clinical evidence. Aims: The aims of this thesis are to explore the following questions: 1. In what circumstances is it appropriate to use CMA as a methodology in the economic evaluation of health care technologies? 2. To what extent can health care professionals rely on published evidence from CMAs to inform their decision-making? 3. What specific steps can be taken to improve the conduct and the quality assessment of CMAs? Methods: Various methods have been employed to address the key issues discussed in this thesis. These methodologies include reviews of published clinical and economics literature and analyses of clinical and economic data from a randomised controlled trial.

Public participation (PP) has been promoted in Thailand in order to increase the level of democracy and human rights. However, progress has been slow and PP has done little to enhance either social or human rights development. In 1997, the Thai Ministry of Public Health (MoPH) launched a policy to promote PP at all levels of the MoPH's organisation, which resulted in a significant problem for Thai hospitals: identifying the procedure to promote PP and ways to ensure appropriate implementation in the hospital setting has proven to be a challenge. Therefore, this research aims to investigate major issues related " to PP in local health policy in Thailand. This research employed a sequential mixed-method strategy for the empirical investigation: beginning with quantitative and followed by qualitative methods. Both the ladder of participation and CLEAR models were used to complement each other: the ladder of participation model was used to identify the level of PP, and the CLEAR model was used to identify the factors that influenced the possibility for PP implementation. The quantitative stage used an online survey to review the current situation of PP at local level and to identify the hospitals with the highest levels of PP development for further investigation in the qualitative study. The on line survey was carried out at all Thai public hospitals (n=830) with a response rate of 33.86%. The qualitative stage used in-depth interviews with 25 key stakeholders at different levels (national level, hospital level and the public level) to explore in-depth detail about PP factors in the health policy-making process. Key findings showed that PP in local health policy development was either at a low level or underdeveloped. The meaning of PP was still unclear, as there was no generally agreed-to definition and there was a lack of clear procedures and models to guide hospitals in promoting PP. The hospitals were using a low level of PP activities, which focused on oneway communication. As a result the public still lacked power and opportunity to become involved in decision-making. Nevertheless, the stakeholders had a positive perception of PP as a useful practice to be developed for solving problems. The findings revealed five facilitating factors: law and international organisations, hospital policy, community context and social cohesion, relationships between the public and hospital, and the motivational factors for the public to engage in PP. Conversely, there were seven impeding factors: the government direction, national policy, leadership/director factors, staff perceptions and ability to promote PP, the representatives of the public, public factors and the response/feedback system.

My aim in this thesis is twofold: to advance philosophical understanding of the contested therapy / enhancement distinction and its ethical implications; and to achieve this via the integration of empirical data into the philosophical and ethical debate. Despite its implications for justice in healthcare, and despite the abundance of theoretical literature, little is known about how human enhancement is understood within its own context. The division between therapy and enhancement is nominally defined by whatever is identified as 'normal' health. This seems unproblematic, however it is extremely difficult to offer a clear, non-relative account of normality that is not beset by logical and semantic difficulties, or modified by historical, socio-cultural, technological, economic, and geographical contingencies. This raises a challenge: if what is 'normal' cannot be clearly identified, how can we clearly identify the difference between therapy and enhancement? Ifwe cannot clearly identify the difference between therapy and enhancement, how can we . ensure that our medical policies are ethically appropriate in distinguishing between who may and may not receive assistance? The empirical data communicate relevant views held by medical professionals whose work involves a prominent 'enhancement' drug, recombinant human erythropoietin (EPO). I use the insights gained from analysing theory and data to develop a refined account of the therapy / enhancement distinction which integrates the two. I use this as the basis for developing normative conclusions and policy recommendations in response to the ethical challenges posed by any future proliferation of enhancement technologies. I use the philosophical approach of Critical Realism for integrating the theory and data and constructing the normative conclusions developed. This is the first time critical realism has been used in empirical bioethics, and this thesis therefore also makes an original methodological contribution to the field.

This research details the development of a new model for analysing organisations and will demonstrate its subsequent use in an investigation of the NHS. The objective of the research is as follows: • To develop a model of research based on two existing systems approaches; Beer's Organisational Cybernetics (1979) and Checkland's Soft Systems Methodology (1981) and to use this model within a complementarist frame of reference. In presenting its arguments, this work is organised as follows. Chapter One provides a perspective of the English NHS. This will give the reader an insight of the organisational context in which the research took place. Chapter Two gives an overview of the key philosophical and epistemological positions within the field of organisational analysis. This is an important chapter, since the issues which are raised in it begin to argue the case for complementarism, rather than studying organisations through mutually exclusive theoretical paradigms. Chapter Three argues the case for studying organisations through a systems approach and then using these approaches within a complementarist format, thereby ensuring that more than one approach can be used. Thus, Chapter Three will provide an argument which develops the ideas generated in Chapter Two. Chapter Four will continue to build on the arguments raised in the third chapter by using two specific approaches to promote a complementarist-based systems approach for organisational analysis. Following this. in Chapter Five one case study will be analysed using three different approaches; the Viable Systems Model. Soft Systems Methodology and the integrated approach developed in Chapter Four. Finally. Chapter Six draws together the findings from each of the case studies and endeavours to show how the Viable Systems approach and Soft Systems Methodology compliment each other.

This thesis examines the medical institutions and practitioners of Shropshire during the nineteenth century. Topics include the market-orientated attitude of society; the medical practitioners; competition to the medical profession from advertised medicines and retail sales; the Salop Infirmary and other voluntary institutions; the statutory systems of the Poor Law and Lunatic Asylum; and conflicting attitudes to water in public health and as a therapeutic agent The research shows that though Shropshire practitioners vigorously participated in demands for reform and protective legislation they dissented from opinions voiced in the metropolis. Like their provincial colleagues elsewhere. Shropshire practitioners saw themselves as surgeons whose practices involved much 'medical' work. They called for broadly-based education for their profession, and demanded protection from untrained competitors through medical registration. They pressed their claims in memorials to government and medical corporations and by combining in professional and social groups, especially the Provincial Medical and Surgical Association. Using Shropshire as a medical microcosm. it is postulated that the notions of 'medical practitioner' and 'medical orthodoxy' evolved in the manner described by Charles Darwin in 'The Origin of Species', rather than according to Lamarck's theory of the inheritance of acquired characteristics.

The children of people with severe mental health problems are considered to be a high-risk group because of elevated rates of emotional and behavioural problems in childhood, increased exposure to a variety of other known risk factors, and poor adjustment in adult life. Amongst the many possible mechanisms mediating between the mental health difficulties of the parent and the adjustment problems of the child various aspects of parenting occur repeatedly in the literature. Research in the field of childhood resilience indicates the importance of a good, secure relationship in protecting children exposed to various types of risk or challenge to their development. Another commonly researched protective factor for children is social support and there have been suggestions in the literature that early attachment to the mother is the precursor of perceived social support later on. The goals of this study were both service related and theoretical. From the point of view of delivering services to this group of children an audit of the active cases of the adult community mental health teams in an inner London borough was carried out to provide a description of the children under 17 years of age who were living with parents who were receiving support from these teams. A Subsample of the children between 8 and 16 years (N = 20) participated in the second phase of the study looking at the theoretical relationships described above but also to give their opinions on what could be changed to improve their lives. The section of the study exploring factors associated with the adjustment of this group had a within-group, cross-sectional design and was based on three self-report questionnaires of the children's relationships with adults; perceived social support; and, adjustment. The service-related findings illustrate the lack of systematic recording of the offspring of adult clients and suggest that the children themselves express needs similar to other children their age and do not necessarily look to services to fulfil those needs. The more theoretical section of the study indicated that the presence of one good relationship with an adult was not related to the children's adjustment. Post-hoc analyses suggested that a very good relationship with the mother (rather than a'good-enough' relationship with an adult) was more closely related to children's social adjustment. In addition, the overlap between indicators of attachment and perceived social support was largely confined to perceptions of support from family members with only a tendency for this to be generalised to other support providers in the child's network.