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Efforts to control and eradicate infectious disease have concentrated on the provision of childhood vaccination. Unfortunately, the uptake of childhood vaccination continues to vary and infectious diseases continue to cause differential morbidity and mortality. Limited research has assessed the factors that underlie the uptake of vaccination. The present research undertakes an analysis of the patterns and determinants of vaccination uptake within the Portsmouth and South East Hampshire Health Authority, located in the south of England. In so doing, the research employs different analytical approaches, from the traditional ecological analysis through descriptive mapping and multivariate regression, to the innovative multi-level analyses. The ecological analysis shows a distinct geography to the uptake of vaccination which reflects characteristics of socioeconomic deprivation. Further analysis through multilevel modelling, emphasizes two influences on the uptake of vaccination. First, parental characteristics, which affect their role as decision maker and their ability to overcome certain time-space constraints to attend. Second, the ways in which the service is provided, including the influence of the health professional as adviser and provider of vaccination and the initiatives employed to improve uptake. These findings have implications for the future provision of childhood vaccination. Specifically, the research provides the opportunity to identify and target children unlikely to complete their vaccination schedule and the need to improve and standardise health professional knowledge and advice to parents.

This thesis assesses the participation of the medical profession in the development of the structure of the health system in Mexico between 1917-1988. The thesis considers that the major variable that influenced the development of the health system was the participation of the State as its most important financer, provider and regulator. The shaping of the health system in turn determined the mode of participation of doctors. The period is divided in three subperiods: 1917-1943; 1944-1970 and 1971-1988. The first describes the efforts of the profession to gain control over the demand for health services which remained private after the end of the 1917 Revolution. The second describes the way in which the State intervened in the redefinition of the health system, the achievement of the legal control of professions and the way in which medical work began to be determined by the constraints of institutions despite doctors' efforts to defend their autonomous status. Finally, the third period is characterised by a crisis of the economic and political system with repercussions in the definition of the educational and health policy, and the way doctors were faced these conditions. The thesis also points out the major changes during the period in four of the most important characteristics of the medical profession: professional organization, education, employment and geographical distribution. An analysis is finally presented where theoretical elements are used to interpret the historical events that characterized the participation of the Mexican medical profession in the development of the health system.

This study investigated the sources of anxiety for patients in the Accident and Emergency Department and explored how patients' anxiety was influenced by their experiences in the department and the attitudes, behaviour and communication patterns of nurses and other staff. The research was carried out in twO Accident and Emergency Departments and consisted of three stages. Stage One employed structured interviews with 96 patients to identify sources of anxiety for patients in the Accident and Emergency Department and to examine the relationship between anxiety and the patient variables of age, sex, condition and department. In Stage Two in-depth interviews were conducted with 21 qualified nurses to explore their perceptions of their work and patients. Stage Three was an observational study, involving 23 patients, which examined the nature of nurse-patient communication in the Accident and Emergency Department. A Symbolic Interactionist framework was used in order to understand events from the perspective of those involved. Patients appeared to view their stay in the Accident and Emergency Department as an event occurring within the wider context of their daily lives and were concerned with social factors related to admission and the consequences of their illness or injury. Nurses held a different perspective and were more concerned with physical care and the organisation of the patients' stay in the department. In contrast to the patients, the nurses were concerned with short-term problems. Interaction between nurses and patients consisted predominantly of brief encounters which focused on the patients' illness or injury and their progress through the department. There was little attention explicitly directed towards dealing with patients' anxieties. A complex range of factors - interpersonal, cultural, interprofessional and structural - were found to influence communication. A number of recommendations are made identifying ways to enhance nurses' ability to deal with patients' anxieties.

This thesis represents over five years of research focusing on the development and implementation of information systems within the National Health SefV1ce. It aims to contribute towards a better understanding of the information systems development process from inception through to system evaluation and review. Five long-term interventions have been undertaken in a range of National Health Service sites, examining different aspects of information provision. The length of the interventions ranged from nine months to almost two years. The five sites were all at different stages of system development. The research has been carried out using a combination of participant observation and action research. This has meant working with National Health Service staff on a series of system projects. The aim of the research is to try and help National Health Service (NHS) organisations deal more successfully with their information provision. The research question asks, "how can NHS organisations think about, and hence go about their information provision in such a way that successful information systems are introduced'!". Information systems development has generally been regarded as a technical discipline. This has led to a narrow view being taken of a number of areas that may affect the success or otherwise of system projects. Historically, the system development process has been concentrated in the hands of a small number of experts even though the implementation of systems can have far-reaching consequences for the organIsation. The output of the research is a set of issues that should be addressed when introducing information systems within the NHS. These have been translated into the OASES materials which form the appendices. OASES is not a prescriptive methodology but a set of principles and guidelines to try and improve the way that information systems are developed within the NHS. It IS hoped that the outcome of the research will be a situation in which effective information systems are developed that take account of the behavioural, cultural, and organisational issues that are important within complex organisations.

The present study was undertaken to provide an understanding of the processes underlying health visiting practice. The research strategy selected was grounded theory (Glaser and Strauss 1967, Strauss 1987, Strauss and Corbin 1990). A total of 21 female health visitors from a District Health Authority in the North West of England participated in the study. Data was collected by means of 20 formal interviews and 41 days of participant observation in four different health centres. To recognize the basic social process in any interaction is one of the major aspects of grounded theory. This requires the identification of the "Phenomenon" which motivates the development of a process and the conditions under which it operates. The basic problem or phenomenon in health visiting uncovered in the data was "Securing Life Trajectories". This forms the core of the health visitor's work. The general set of conditions that influence health visiting work was identified as "Working Between Two Worlds". This is used to describe the health visitor's position between the policy agenda and the client's agenda. The process revealed in the data that health visitors use to respond to this overall problem was "Marketing Health Visiting". This refers to the different tactics that they use to introduce the policy agenda into the client's domain. During this process the policy agenda is adjusted to fit the client's circumstances. Three major strategies are identified in this process: 1) Promoting the service, 2) Adjusting delivery and 3) Tailoring the content. This study found that "Marketing Health Visiting" is a gradual process in which the health visitor wins grounds as time passes. As marketing strategies are implemented the conditions influencing the interaction change. Hence it moves from taking place in what is labelled in this study as "Dissociated Context", to a "Convergent Context" and finally to a "Shared Context". The final consequence of implementing marketing strategies is that of constructing "A Common Agenda" with clients. This agenda is basically the personalisation and contextualization of health visiting services. To build this common agenda it is of crucial importance that the client should see and feel the need for the health visiting service as well as the development of trust between the professional and the client. Hence the relationship that is developed between them acts as an enabling factor for reaching mutual collaboration. The discussion of the study focuses on its significance within the actual debate on health visiting about introducing new ways of practice. The health visitor's overall role is examined and the importance of developing relationships with clients is also highlighted.

This thesis addresses from within the research paradigm of Conversation Analysis (CA) the question "How are interactions between patients and general practitioners organised? ". CA is a relatively recent tradition within the "interpretative paradigm" of sociology, growing out of the ethnomethodology of Garfinkel. The thesis first reviews the relevant literature of CA and medical interactions, and critically discusses the methodology. The empirical analysis used naturally occurring consultations in British general practice, video-recorded in five practices, involving 14 doctors, and about 50 hours of recording, made between 1987 and 1992. Recordings were observed first in an unmotivated way, to note occurrences of interesting interactional phenomena. Objects for further study were copied onto secondary "collection" tapes, which were then examined in depth, and transcribed in detail using conventions developed within CA. The analyses described here are: the use of time in the consultation; the impact of medical records on the interaction; prescribing and associated talk; the phenomenon of "facilitation", how doctors appear to enable patients to talk; patient-initiated questions, and rejection of patients' ideas by doctors; and finally the use of the word "we". The aim was to describe and explore, but not necessarily to explain, although in describing the mechanism of interaction in these areas of activity, empirical evidence is advanced for particular explanations. The phenomenon of patients raising new topics at the end of consultations is described, with its interactional implications: the "by-the-way" phenomenon is explored and documented. Case-notes are seen to contribute to consultations in a complex way, and like talk, are both context-dependent and context-forming. Utterances such as "right", "uhuh", "mmhm" which appear on the face of it to be facilitatory, can be the reverse. The phenomenon of dispreference for disagreements by patients is re-examined, and contexts in which patients do disagree are explored. Doctors' rejections of patients' ideas are described, and implications for teaching about the consultation are drawn. Finally the various ways in which the word "we" is used by doctors are described and critically appraised, in the context of a philosophical understanding of "intersubjectivity". The study adds to the body of transcribed interactions drawn from general practice, and sheds some light on ways in which general practitioners and patients structure their consultations. It has implications for the way medical students learn how to consult, and for how research on the consultation can be conducted. Conversation analysis is shown to be a powerful qualitative analytic methodology, relevant to the study of medical interactions.

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