The randomised controlled education intervention study recruited 430 adults aged 25-65 years with established diagnosis of T2DM (M = 130, F = 309) via a multi-stage double-blind stratified sampling procedure from 22 hospitals and health centres in Doha, Qatar. The intervention group (n = 215) were assigned to a six-week, 2-hourly structured educational class based on the specifically designed DPET, plus their usual one-to-one routine clinical care; the control group (n = 215) used the DPET for home self-study, plus their usual one-to-one routine clinical care. Adherence to the programme in the intervention group (n = 109; M = 40, F = 69) was 50.7% compared to 84% among controls (n = 181; M = 50, F = 131); an overall non-adherence rate of 32.6%. Repeated measures ANOVA showed a highly significant change in each of diabetes knowledge, attitudes and practice among intervention compared to controls at 12 month follow-up (p<0.0001). The intervention had no significant overall impact on systolic blood pressure (p = 0.632) nor diastolic BP (p = 0.421) but improvements in BMI among the intervention group (p = 0.001). Repeated measures ANOVA also showed differences in overall change in HbA1c (p = 0.012), fasting blood glucose (p = 0.022), HDL-cholesterol (p<0.0001) and albumin-creatinine ratio (p<0.0001) in the intervention group but not total cholesterol (p=0.204), LDL-cholesterol (p = 0.203) and total triaclyglycerol (p = 0.200) from baseline values after 12 months follow-up. Post-sessional self-assessment tests of knowledge, attitudes, practices and goal-setting used as a proxy measurement of empowerment showed a significant improvement in the empowerment scores from baseline in the intervention group (p<0.0001).

Background: Ethnicity is associated with childhood obesity, with Black African origin girls in particular being more vulnerable to overweight and obesity than their White European peers. In the UK, ethnic minorities often live and attend school in poor urban areas which may influence their opportunity for physical activity and a healthy diet. Aim: To examine neighbourhood and school effects on ethnic differences in Body Mass Index (BMI) and waist circumference trends in adolescence. Methods: Multilevel analysis of longitudinal data on BMI and waist circumference [standard deviation scores (SDS)] from 3401 adolescents in the Determinants of Adolescent Social well-being and Health (DASH) Study (870 White UK, 778 Black Caribbean, 504 Nigerian/Ghanaian, 386 Other African, 418 Indian, and 445 Pakistani/Bangladeshi). Forty-nine London schools participated in the study and the same pupils were surveyed at 11-13yrs and 14-16yrs. Neighbourhood measures included deprivation, crime, and ethnic density; school measures included ethnic density, school socioeconomic status (SES) (academic performance, free school meals, unauthorised absence) and ethos. Individual and family characteristics were also examined (including dietary and physical activity measures, family SES, and parental overweight). Results: Between 11 and 16yrs ethnic differences in BMI emerged in boys and persisted in girls; compared to their White UK peers Black Caribbean and Nigerian/Ghanaian boys and girls, and Other African girls, had a greater mean BMI SDS. These patterns were not observed for waist circumference, signalling ethnic differences in fat distribution or body composition. The DASH pupils overall had large waists compared to the 1990 Growth Reference population. The ethnic minority pupils, with the exception of the Indians, were more likely to live in more deprived, higher crime, less green areas than their White UK peers. However the ethnic minority pupils often attended better performing schools than the White UK pupils. The overall variance in body size at neighbourhood level or school level was small (<4%), and area or school context measures had little or no effect on ethnic differences in body size. Individual characteristics (such as age, pubertal status, and skipping breakfast) and maternal overweight were strong correlates of body size but did not explain the ethnic differences observed. Conclusions: There were significant ethnic differences in BMI in adolescence, emergent in late adolescence for boys. Neighbourhood and school contexts did not explain the ethnic differences in BMI age trends.

This thesis presents research on the epidemiology and transmission dynamics of healthcare-associated infections (HCAI) and focuses on the antibiotic resistant hospital pathogen methicillin-resistant Staphylococcits aureus (MRSA). First, a stochastic mathematical model of MRSA transmission dynamics is developed in which patient movement within and between both hospital and community populations is considered. The effects on transmission of both surveillance and control within this setting are explored. Significant interplay is found to exist between surveillance and control; surveillance is shown to be essential to control success and in addition allows quantification of the level of control achieved. Furthermore, patient movement between hospital and community populations is shown to have a considerable impact on transmission dynamics and on the success of infection control strategies. Analyses of the demographics of a hospital population using a real hospital dataset are presented and the heterogeneous nature of the patient population described. Differences in admission patterns and length of hospital stay between age groups, gender and speciality are explored. Combining these analyses highlights the patient groups constituting the majority of patient days. Further to this, the heterogeneous nature of patient readmissions is described and the existence of a 'core group' of most frequently readmitted patients is illustrated. Overall, readmissions are found to be far more likely than previously thought, with the majority of patient admissions to hospital being readmissions. Given this finding of increased readmission, the hospital admission data is used to inform the development of a model in which real patient movements between the hospital and community are simulated and transmission within this setting explored. Endemic behaviour results and the change in movement patterns is found to influence control strategy success. Further to this, the model is extended to simulate transmission within a multi-centre setting where patient movements within a three-hospital and community network are simulated. This increase in heterogeneity within the patient population appears to allow endemic behaviour throughout all hospitals 11 within the network.

This thesis shows how it was possible to listen to health visitors relate their personal views about their work in such a way that new insights on being a woman as a health visitor have been identified. This contributes to the debate about the 'invisibility' of health visiting as a reality and also shows invisibility to be a metaphor for care and the caring aspects of the work, for the management of personal lay knowledge rooted in experience and for gender blindness in client relations based on surveillance. It shows health visiting operating on three levels that represent the public face of the work, the private lay knowledge and the hidden personal feelings. The thesis highlights the importance of remaining open to new ways of viewing and interpreting practice and makes suggestions for educational changes in the preparation of health visitors. The study draws upon qualitative data from semi-structured interviews with 35 health visitors. It examines ways in which professional and personal experiences contribute as resources to the activity of health visiting in a public work arena where the emphasis on identifying targets and measurable outcomes increased during the 1990s. The health visitors who participated in this research all identified private and personal experiences which contributed to the process of their work but without any model to validate these as legitimate resources for their clients. The findings suggest that without a transformed outlook these potential resources will continue to be hidden and undervalued. The analytical tools, drawn from feminist theories of care, epistemology and power relations were each applied to the data and demonstrated ways in which feminist understandings could lead to a heightened sense of being a 'woman worker'. It is suggested that becoming more aware of gender in client interactions can lead to a model of practice which values the needs of women and would enable health visitors to improve their practices with women.

This study considers the social history of the Birmingham and Midland Hospitals for Women Incorporated between 1871 and 1948. The hospitals were an integral part of the voluntary hospital system in Birmingham, where two general infirmaries and a range of smaller specialist institutions had been set up to deal with the health care needs of a growing population during the period of industrialization. Two underlying historiographical themes are discussed throughout the thesis; the motivation of those that founded and supported such institutions and the feminist critique of the developments in the practice of gynaecology. Much of the current literature on women's health in this period concentrates on the underlying ideology rather than health care. Here the emphasis is reversed; it is to the medical care and treatment of diseases associated with women's sexual and reproductive organs that this thesis is directed. I have adopted a broadly chronological approach, with Chapters 1 to 4 exploring the founding of the hospital in 1871 and the important early years during which it became established. Chapters 5 to 7 consider developments during the Edwardian period and the inter-war years. In the organization of the individual chapters I have adopted a thematic approach considering the association that different group of people had with the hospital; the governors, medical staff and patients, both within the context of their health care and the lives and circumstances of working-class women in the wider sense. To provide an analytical framework for this study, the dominant historiographical paradigms in the field of women's health are discussed in the introduction to this thesis.

In this thesis we explore innovation in general practices in Ireland. Drawing on an encompassing equilibrium, disequilibrium and learning-by-using model of adoption, we examine the influences of general practitioner (GP) and practice characteristics, strategic behaviour, learning and knowledge spillovers, and cumulative learning from previous adoption decisions on the perceived benefits of adopting and using innovations in general practices. Ours is the first application of this theoretical framework to timing of adoption, multiple technology adoption and intensity of adoption decision-making in a health care setting. Our examination focuses on three innovations, prescription drugs, medical equipment and Information and Communications Technology (ICT). Our analysis is based on two data sources, a secondary dataset which brings together GPs prescribing history over a 4½ year time period with information on the characteristics of the 625 GPs themselves, and a cross-sectional primary dataset which provides us with information for 601 general practices concerning practice structure and use of medical equipment and ICT. Employing duration analysis, multivariate Probit and ordered Probit econometric techniques, we examine the adoption, use and intensity of use of prescription drugs, medical equipment and ICT respectively. Irish GPs exhibit notable innovative behaviour with respect to prescribing innovation and practice development. Our research demonstrates that Irish GPs respond to informational stimuli with respect to adoption and use of new prescription drugs, medical equipment and ICT. Furthermore, Irish GPs are incentivised by commercial and market considerations. In addition, we find the extent which a practice adopts technologies and learns from that experience influences both ensuing prescribing and investment decision-making. Our empirical findings support an economic approach to examining decision-making in a health care setting and the application of our encompassing theoretical model to examinations of adoption and use of innovations by health care professionals.

This thesis analyses the aspirations and achievements of the lay women who were active in the campaign to improve women's health, and of those women who sought entry into paid occupations in the health services. After an introduction, Section One is intended to place the substantive data in context. Middle-class women's enthusiasm for voluntary work and the terms on which women entered national politics are discussed. These issues are used to illustrate the effects the maintenance of rigid social-class divisions had on the unity of the women's movement and the implications for the future of the movement of the decision to seek entry to the public domain on the grounds that women could make a unique contribution. Section Two is devoted to the lay women. First, the effect of the maintenance of rigid social-class divisions on the women's health campaign and on women seeking a career in the health services is discussed. Secondly, the consensus between both middle-class and working-class women, the medical profession and the Ministry of Health on the need to extend medical services is analysed, revealing an eagerness to follow technical advice which affected the strategy of the lay campaign and meant support for women workers in the health services was often circumspect. Thirdly, the reasons for the collapse of this consensus in the l93Os are discussed. This section is concluded with an assessment of the lay women's health campaign and a discussion of the impact the campaign had on women health workers. In Section Three, women's position as paid employees in the health services is analysed, and three occupations, midwifery, medicine and health visiting, have been selected. Difficulties these women encountered establishing themselves in paid employment, and their status and their relations with male colleagues and with the Ministry of Health are assessed. The differences between these three occupations, which prevented a sense of solidarity and an identification with the goals of the women's movement, are discussed. Their achievements during the period are assessed, and the effects of the medicalisation of childbirth and the increasing involvement of the state in maternity and child welfare are investigated. A fourth, concluding section draws these strands together. The lay women's health campaign and the goals and tactics of the women health workers are related to the maintenance of the existing social-class divisions, the ideological splits within the women's movennt and the persistence of barriers preventing women from competing on equal terms with men in the public domain. Although the number of women working in the health services increased dramatically and women's place in these services was assured, women generally remained in subordinate positions, excluded from the prestigious and lucrative posts, while they achieved only a statutory presence on decision-making bodies.

This thesis uses Habermas' arguments concerning the public sphere and Nancy Fraser's concept of counter-public spheres as a framework to explore how changes in the representation of mental illness occurred between 1870 and 1970. Within this period, the nineteenth-century polarisation of sanity and madness that had led to the segregation of the mentally ill within the asylum gave way to the belief that mental health and illness formed a continuum. Psychiatry extended beyond the walls of the asylum into the community, expanding its scope to incorporate the nominally healthy. These developments, which culminated in the creation of community mental health services and the closure of the asylums, suggest that mental disturbance was no longer seen solely as the problem of sick individuals but of the public at large, and points to a potential destigmatisation of mental illness. To examine if the representation of mental illness matched these developments in practice and to explain why, this thesis studies how groups directly connected to the mentally ill, conceptualised as sub-public groups, sought to represent mental illness. The groups studied are the Medico-Psychological Association in Chapter One, the National Asylum Workers' Union in Chapter Two, The Association of Psychiatric Social Workers in Chapter Three and a charity, the Mental After Care Association, in Chapter Four. The fifth chapter explores patients and the representation of mental illness. It is argued that such sub-public groups helped initiate a debate about mental illness and enabled a broader spectrum of people to participate in the debate. However, it is suggested that private and professional motivations impinged upon how groups chose to represent the mentally ill. The thesis argues that the difficulties groups experienced balancing the representation of their own interests with those of the mentally ill, combined with the negative perceptions some sub-public groups held regarding the general public's capacity to participate in a debate on mental illness, obstructed their efforts to communicate with the public and to represent the interests of the mentally ill. Finally, the thesis uses the case study of the BBC to explore the factors that influenced the media to cover the issue of mental health and illness. This final chapter illustrates the interactions that occurred between media organisations and sub-public groups.

Policy makers have increasingly regarded user involvement as an important dimension of service development. Current government policy advocates the involvement of service users in healthcare service development across all levels of an organisation, ranging from the level of individual service user to the development and improvement of health services (DoH 1992, 1999, 2001a, 2001b, 2003a, 2003b, 2004, 2005a, 2007a, 2007b, 201Oa, 201Ob, 2011, 2012). This has manifested in the creation of a number of public and patient involvement initiatives including Patient Advocacy and Liaison Services (PALS), Locals Involvement Networks (LINks), Patients Forums and more recently Healthwatch Organisations. User movements and policy pressures have also led to the formation of user led groups pushing for changes in health and social care. However, these groups often operate on the margins, and as such, lack the legitimacy to work alongside professionals in service development and improvement. Despite involvement being driven by policy, research suggests that user involvement is often tokenistic, unrepresentative (Contandriopoulos et al. 2004; Harrison and Mort 1998; Rowe and Shepherd 2002) and subject to a selection of those users deemed to be a 'safe pair of hands' (Hogg 1999, p. 100). Furthermore, user involvement has been exacerbated by the 'tick' box culture in healthcare and the growing managerialisation of public services, creating a smokescreen to authentic user involvement. A recent study (Lakeman et al., 2007) suggests that a hierarchy of service users has emerged based on knowledge and authority in the service user community resembling stratification akin to the profession of psychiatry. This study is a platform for this research which aims to offer empirical analysis to illuminate the processes of stratification which give rise to this hierarchy of service users, which Lakeman et aI.'s work suggested existed, but which was not empirically supported. In doing so, discussions centre along three main themes; knowledge, representativeness and the 'professional' user. Policies on user involvement have led to health organisations developing strategies around involvement where users are involved at all levels of the organisation. As well as these, a plethora of grass roots groups have gained momentum over the past twenty to thirty years (Hogg 1999, p.127) and in recent times with the support of user involvement legislations have gained greater legitimacy amongst professionals. However, organisations are in constant flux and as they become more embedded in the system and established, user-led groups may become 'professional' working closely with 'sympathetic' professionals (Hogg 1999, p.127). By applying theories from the sociology of professions on expert knowledge and jurisdiction in the context of user involvement policy and practice, I describe the processes that lead to the stratification of users and ultimately to unrepresentative involvement. Using two comparative cases of user involvement, one a top down initiative in mental health service provision and the other a user led stroke group with a focus on stroke service development and improvement, I examine the processes of involvement that give rise to unrepresentative user involvement. In doing so I hope to contribute to theories on user involvement by illuminating the processes which lead to the stratification of users and unrepresentative user involvement. The thesis beings by exploring the historic context of public participation and user involvement, the involvement process and debates around representativeness. This framework informs an analysis of rationales for user involvement and the challenges of involving the 'right' user. Using 40 in-depth semi-structured interviews, observations and documentary analysis the study presents insights of various actors' perspectives of the involvement process, non-representative involvement and the professional user. The remainder of the thesis presents and compares the empirical results from the two cases in mental health and stroke. The study draws on theories from the sociology of professions to highlight the processes which lead to the stratification of service users including their professionalisation. Akin to professionals, users were found to delineate jurisdiction using their expert knowledge and education, gained through the involvement process but also by drawing on their social status and previous professional work. The theoretical and policy literatures coupled with the empirical findings present a number of tensions. Policy directives on user involvement are awash with ambiguities resulting in different ideas of how involvement activities should be played out in practice. This is aggravated by the increasingly target driven NHS culture, where professionals often choose the easier option and involve those users who are known to them and who are usually more articulate and able. This results in the repeated involvement of a certain 'type' of user and the marginalisation of other 'lay' users leading to a hierarchy of users where a cadre of professional users dominate the user community casting other 'lay' users as amateurs.

The National Health Service (NHS) holds an esteemed position within Britain's `welfare state'. Since its inception, however, it has been subject to near constant reforms, seemingly intended to balance public expectations with available resources. Successive governments have required professional collaboration to gain crucial popular support, and increasingly, general practitioners have been prioritised within reform initiatives. Sociologists assert that professionals' reactions to reforms are often shaped by estimations of such reforms' influence on claims to professional status. Professionals react particularly defensively when they estimate that reforms challenge the foundation of status based on professional identity. Indeed, professions perceived as having `weaker' professional claims may engage more diligently with such defensive work, and general practitioners have been particularly virulent opponents to reforms. I spent eighteen months conducting ethnographic research into the role of GPs in the implementation of the reform initiative, ‘The New NHS: modern, dependable' (1997). I explored the translation of policy ideas into `real' working structures, seeking to address a gap in the literature between considerations of the formulation of official policy rhetoric and evaluations of reform effectiveness. Data revealed `clinical governance' and `delegation of authority to local professionals' as key concepts in shaping local reform implementation. In particular, official policy rhetoric outlined initiatives as unproblematic, whereas the data illustrated their complexity. Furthermore, contrary to expectation, interaction between GPs and the state was not overtly confrontational. Rather, local actors engaged multiple strategies seemingly intending to maintain locally formulated co-operation. Policy implementation was shaped more by efforts to protect existing local networks, than by professional efforts to defend against any one reform initiative. Professionals' engagement with policy objectives to protect their privileged status served to facilitate the operationalisation of ideas. The influence of particular local actors being such that they were often able to mould policies to serve their own agenda.