Some estimates suggest that as much as 70% of cancer is preventable by disease modification alone (Peto 1991). Disease prevention via behavioural change is a challenging endeavour. There is widespread recognition that for behaviour to be better understood there is a need to understand the context in which it occurs, and the beliefs that underpin it. Lay epidemiology illustrates the sophistication of belief formation. The arrival at a coronary candidate provides according to Davison, Frankel and Davey Smith (1991), a cultural mechanism that aids the estimation of risk as observed from known cases in the family and wider society. Consequently, the estimate provides the potential motivation for behavioural choices. Other studies that followed the original model of lay epidemiology have similarly described the coronary candidate (Preston 1997; Emslie, Hunt & Watt 2001a; Frich, Malterud & Fugelli 2007; Weiner 2009) and suggest that the lay public have an understanding of the risk profile for Coronary Heart Disease. This study aimed to explore the utility of the elements held within lay epidemiology in cancer beliefs. Do the lay public recognise a ‘cancer candidate’? Method: A series of 31 in-depth semi-structured interviews were conducted between November 2007 and October 2008. Interviews took place in two communities in Glasgow, Scotland – one affluent, one deprived. The sample was drawn from a number of community organisations and leisure clubs in the communities to facilitate accessing an ‘ordinary’ view. Cancer sufferers were excluded from the study. A topic guide was used to ensure consistency throughout interviews and focused on participants’ experience of cancer. Although the study did not adhere to a strict grounded theory approach, the analytic method of constant comparative analysis was followed. Findings: The complexity of the scheme described by Davison, where a wide range of sources of knowledge to inform beliefs resonated. Sophisticated and complex explanatory models of cancer were described. Cancer inhabited an important cultural position and was most commonly associated with fear and dread. Possible aetiological explanations included behavioural, environmental, biological and psychological factors. Smoking was the most widely recognised risk factor. Knowledge of other risk factors for individual cancers was patchy. Candidacy therefore was not as unequivocal for cancer. Many ‘anomalous cases’ (those without obvious explanation) were proffered. Ultimately the randomness of cancer was emphasised. Conclusion: Cancer is a more complex disease than CHD, both culturally and biomedically and this is reflected in the beliefs voiced by participants in this study. This complexity is a barrier to the adoption of a cancer candidate.

The study seeks to make two contributions. One is to participate in the development of theories and methods for the analysis of equity and efficiency in community care. The second is to yield evidence which assists policy-makers and managers to improve the effectiveness of their policies. The broad context is the évolution of the policy discourse about issues of equity and efficiency in community care of elderly people. More narrowly, the context is the implementation of the 1989 community care reforms, set out in Care in the Community: Policy Guidance (Department of Health 1990) and the government's commitment to commission research to evaluate their impact on equity and efficiency in social care. The more recent White Paper, Modernising Social Services (Department of Health 1998), is also an important element of the context. The detailed analysis in the thesis will therefore focus around two main foci: (1) the extent to which care brokered by social services departments has achieved the equity- and efficiency-related goals stated by the 1989 White Paper and developed in the 1998 White Paper; and (2) the extent to which current policies need to be adjusted in the light of understanding about how the new system produces equity and efficiency effects. 1.1 Public policy and the Holy Grail: improving efficiency in the use of public funds The Conservative administration which produced the 1989 White Paper attached a higher priority to efficiency in the use of public funds than its predecessors. However, the origins of its concerns could be traced back to the 1970s.

Consumer choice has become a key reform trend in the provision of public services in Western European welfare states. Research on the welfare effects of choice reforms – including greater provider choice for the individual and competition between providers – has largely focused on economic evaluations of the extrinsic (outcome) effects of choice, thereby leaving its intrinsic, or procedural, value unexplored. The overarching objective of this thesis is to investigate the welfare effects of choice in the provision of health and long-term care (LTC) and their implications for equity. The thesis utilises the subjective well-being approach – incorporating both procedural and outcome utility from choice – to measure welfare effects based on quantitative analysis of survey data. Welfare effects and equity implications are examined in relation to: competition in health care in the English National Health System (NHS); choice of care package in the German long-term care system; and individual preferences and views of choice as a priority in the provision of health care in three NHS countries. The thesis argues that both service characteristics – extent of competition, information availability, technical complexity – and individual capabilities – ability to process information, capacity to manage transaction costs, availability of private support – influence the benefits that individuals derive from choice. Results suggest that choice policies have an overall positive welfare effect in both health and long-term care. However, while direct evidence of outcome improvements is found, the empirical analysis only finds indirect evidence of procedural utility. Middle class characteristics, primarily income and education, are found to have a positive influence on the benefits of choice, amounting to evidence of inequitable facets of choice policies. The middle class further exhibits preferences for choice over and above other characteristics of health care systems. Overall, this thesis advocates a holistic approach to the analysis of choice, incorporating its procedural value and paying particular attention to the equity implications of the choice situation, information processing and differences in available options as well as preferences for choice.

This thesis addresses the challenges of producing digitally mediated healthcare information, a high-stakes arena which is conceptualised as a complex discourse and its diverse producers as interlocutors within this discourse. The study is located theoretically in the tradition of universal or formal pragmatics, the foundation of Habermas’s theory of communicative action. Building on this theoretical core a conceptual framework is developed that integrates insight from several other traditions, including communication studies. The notion of communicative transparency is aligned with the idealised goal of a rich informational context supporting a range of perspectives in movement towards a balanced and consensual understanding by lay and expert actors of healthcare in our world. The central research question is: Can digital mediation increase the transparency of healthcare communication? The empirical focus rests on two organisations involved in the creation of digital information products. Key mediators of meaning in digital healthcare information are identified as the diverse types of expertise of its producers, the materiality of digital artefacts, and the communicative mechanisms, processes and practices that often lead to departures from the normative idealised standard of transparency. The methodology is a comparative case analysis based on field research employing principally interviews to build a rich corpus, analysed using a recursive in-depth thematic coding procedure to reveal the ways in which digitally mediated healthcare meanings are shaped and shared. The study demonstrates how communicative transparency emerges from shared frames of reference and common models of communication. It is concluded that digital mediation can indeed increase the transparency of healthcare information by supporting the deepening of Habermasian rational discourse, providing that validity claims to truth, truthfulness, and rightness can be raised and resolved at all stages in the discourse among all interlocutors, whatever their role and status.

Persons from the former USSR constitute a significant proportion of the migrant population in contemporary Germany. Current research on their health is scarce and carried out from a medical perspective, mostly focusing on health outcomes and patterns of healthcare utilisation. In contrast, this thesis is based on a sociological approach to health as a phenomenon embedded in a complex system of social stratification and cultural traditions. The research question of this thesis is about the relationship of identity to health beliefs and help-seeking practices, and they ways migration transforms ways people think of themselves and their health. To answer this question, qualitative research needs to establish migrants' own interpretations of health and illness in the biographical context. Setting out to identify and explain a variety of native conceptualisations of health, this thesis, on the one hand, seeks to establish differences between migrant and non-migrant population, and, on the other hand, to reflect on heterogeneity of health beliefs and help-seeking behaviours across different sub-groups of former Soviet citizens in Germany. In order to pursue these research objectives, comparative qualitative research design was employed, whereby different groups of migrant population were compared with each other and contrasted to native Germans. The empirical fieldwork was carried out in Berlin in 2009-2010, and included 35 semi-structured interviews (of which 8 were carried out with experts). This thesis suggests that health beliefs and help-seeking practices of migrants from the former USSR in Germany are highly heterogeneous. Attitudes to health make up components of diverse identities acquired in the sending country and that are transformed throughout the migratory processes. First, these findings argue against generalisations about 'fatalistic' health beliefs resulting from communist ideology, a stereotype appearing in some Western literatures. Second, this thesis draws attention to the effects of socialisation in the sending country on conceptualisations of health in the country of immigration, suggesting prospects for research in future migrant generations. And third, it demonstrates that folk conceptualisations of health are hugely heterogeneous, and diverge greatly from medical views of health as an absence of illness.

Scottish convalescent homes, established between 1860 and 1939, provided short-term care for around two to three weeks for patients recovering from trauma, surgery, or illness either at home or in hospital. In 1870, there were just seven convalescent homes, mainly in the West of Scotland, with an annual admission rate of 4000 patients. By the 1930s this had risen to over sixty convalescent homes that cared for more than 34,000 people annually. Despite the massive growth of Scottish convalescent homes, lack of accurate data about the topic has led to a variety of misunderstandings over their origins, purpose, function and development. This thesis reclaims the hitherto forgotten or misunderstood history of the convalescent homes in Scotland between 1860 and 1939. An extensive survey of the convalescent homes uncovered a wide diversity of individuals and organisations involved in their sponsorship. This ranged from independent promoters, hospitals, religious and temperance organisations, to Co-operative and friendly societies. The survey also revealed considerable geographical and chronological diversity in the extent of overall convalescent home provision. During the nineteenth century, few doubled their purpose was to return the deserving sick poor to health and productive life. Confusion over their definition arose during the twentieth century when various mutual assurance organisations began to sponsor homes. The mutual assurance societies were less willing to associate their convalescent homes with institutions for the poor. They were also more flexible in their admission homes with institution for the poor. They were also more flexible in their admission policies and admitted patients for both rest and recuperation from illness. Sponsors of new children’s convalescent homes during the twentieth century were also reluctant to differentiate between those in convalescence and ailing children needing a country break. An association thus developed between holidays and time spent an convalescent homes. Although there were similarities between the experience of a holiday and the regime of a convalescent home, such as the focus on fresh air, healthy diet, recreation and exercise, in other respects they were quite different. The structured routine provided by most convalescent homes centred on a return to health whereas holidays stressed freedom and recreation.

A randomised controlled trial design was chosen to compare a model of community pharmacy based clinical medication review (CMR) with no access to information from patients’ medical records (active) with a model which had access to information from patients’ medical records (control). Four hundred and eighty patients registered with 20 general practitioner (GP) practices received their allocated intervention across 16 pharmacies. There were no statistically significant differences between the groups for the two primary outcome measures used, with 1.7 and 1.9 clinical drug therapy problems (cDTPs) identified at baseline and a cDTP resolution at follow up of 61% and 57% for the active and control groups respectively. There were no significant differences between the groups in the three secondary outcome measures of GP agreement, change in number of repeat medicines and change in utilisation of healthcare services. The cost effectiveness of the two models was compared with the active group found to have a lower cost per cDTP resolved compared with the control group (£46 v £67). Thirty three patients participated in four focus groups with views expressed under the themes of change, empowerment and relationships. Fifteen pharmacists participated in two focus groups and expressed views under the themes of confidence, communication, logistics and empowerment. The hypothesis was accepted such that ‘community pharmacy based CMR of older patients (= 65 years) receiving multiple repeat medicines (= 4) identified and resolved clinical drug therapy problems irrespective of access to information from patients’ medical records’. Both models were well received by patients and practitioners.

Public Health has re-emerged as a driver of food security in British Columbia. Food security policy, programs and infrastructure have been integrated into the Public Health sector and other areas of government, including the adoption of food security as a Core Public Health program. This policy analysis of the integration merges findings from forty-eight key informant interviews conducted with government, Civil Society, and food supply representatives involved in the initiatives, along with relevant documents and participant/direct observations. Findings were analyzed according to “contextual”, “diagnostic”, “evaluative” and “strategic” categories from the Ritchie and Spencer framework for Applied Policy Research. While Civil Society was the driver for food security in British Columbia, Public Health was the driver for the integration of food security into the government. Public Health held most of the power, and often determined the agenda and the players involved. While many interviewees heralded the accomplishments of the incorporation of food security into Public Health, stakeholders also acknowledged the relative insignificance of the food security agenda in relation to other “weightier”, competing agendas. Conflict between stakeholders over approaches to food insecurity/hunger existed, and it was only weakly included in the agenda. Looking to consequences of the integration, food security increased in legitimacy within the Public Health sector over the research period. Interviewees described a clash of cultures between Public Health and Civil Society occurring partly as a result of Public Health’s limited food security mandate and inherent top down approach. Marginalization of the Civil Society voice at the provincial level was one of the negative consequences resulting from this integration. A social policy movement toward a new political paradigm - “regulatory pluralism” - calls for greater engagement of Civil Society, and for all sectors to work together toward common goals. This integration of food security into the government exemplifies an undertaking on the cutting edge in progress toward this shift. Recommendations for stakeholders in furthering food security within the government were identified. These include the development of food security policy alternatives for current government agendas in British Columbia, with a focus on health care funding, Aboriginal health and climate change.

Three different derivatisation procedures were evaluated for their general applicability to systematic toxicological analysis (STA) involving (a) acylation with pentafluoropropionyl anhydride (PFPA) and pentafluoropropanol (PFP-OH), (b) acylation/esterification (methylation) with pentafluoropropionyl anhydride (PFPA) and a novel methylating agent trimethylsilyldiazomethane (TMS-diazomethane), used as a chromatographic derivatisation reagent for the first time in this study, and (c) silylation with tertiary-butyldimethylsilyl-trifluoroacetamide (MTBSTFA). Model compounds were selected for the evaluation process including a primary amine (amphetamine), a secondary amine (methamphetamine), alicyclic and aromatic hydroxy compounds (morphine, tetrahydrocannabinol), and carboxylic acids (benzoylecgonine, 11-nor tetrahydrocannabinol-9-carboxylic acid). For method (a) derivatisation was successful for all of the test compounds and mass spectra were obtained for each of them. For method (b), the novel methylating agent trimethylsilyl-diazomethane was used to convert carboxylic acids into the corresponding methyl esters. This reaction was found to proceed rapidly and quantitatively at room temperature and holds potential for future use in toxicology to replace diazomethane, a hazardous and toxic material. Method (c) gave derivatives with all test compounds except the secondary amine, methamphetamine, and the alcohol, morphine. The gas chromatographic behaviour of these derivatives was good and the mass spectra had prominent ions suitable for GC-MS-SIM. The extraction of multiple drugs from blood was evaluated using the novel polymeric SPE sorbent Strata-X. The same test compounds were used to assess the extraction step in terms of recovery and variation (within day and between days). The extracts were analysed by GC-MS-SIM using each of the three types of derivative. Recoveries of the test compounds were in the range of 50-100 percent depending on the analyte and its concentration in blood. All calibration curves were linear and had correlation coefficients higher than 0.99. Within day variations and between day variations were in the range of 2-22% relative standard deviation. Limits of detection and quantitation were measured for the model compounds and were found to be in the ranges of 0.4-7.3 ng/ml and 1.1-24.4 ng/ml respectively. The full method, combining extraction with each of the derivatisation reactions was finally evaluated for the presence of interferences with real case blood samples. The three derivatisation procedures were evaluated using four test compounds comprising diazepam plus its three metabolites nordiazepam, temazepam and oxazepam. The hydroxylated metabolites (temazepam and oxazepam) formed derivatives readily with all three reagent mixtures but nordiazepam (secondary aromatic amine) did not react except with MTBSTFA. Based on the work of this study it is concluded that a method is possible for STA based on a polymeric sorbent, to give a general extract, followed by a generalised derivatisation procedure such as acylation, with PFPA/PFP-OH prior to GC-MS.

Measuring health system performance is essential for improving health and quality of care. It is relevant in any context, but especially in countries whose health care systems have undergone major changes. The 1989 transition from communism to democracy in Czechoslovakia followed by the 1993 split into two independent countries (the Czech Republic and Slovakia) have been studied extensively but little research has addressed the effects of these events on health and the quality of care provided. The overarching objective of this thesis is to examine pre- and post-transition health system performance at three levels: i) overall health and well-being, ii) quality of the health care system, and iii) quality of outpatient care. This is a policy piece intended to demonstrate the usefulness of various performance indicators, while applying a range of quantitative methods from different disciplines to unique datasets. The macro level findings suggest that the transition was not detrimental to overall health and wellbeing in neither of the two countries as demonstrated by a small continued height increase. Slovakia showed a larger capacity to benefit from the transition. The overall quality of the health care systems is measured by ‘avoidable’ mortality and also shows improvements. For some ‘avoidable’ mortality conditions Slovakia continues to lag behind the Czech Republic, while for others it outperforms its neighbour. The thesis also provides evidence on the absence of a significant relationship between health care inputs and ‘avoidable’ mortality. Finally, the assessment of the quality of outpatient care in Slovakia, using preventable hospitalisations and selected processes of care, shows that inappropriate care may be provided for asthma and diabetes. The findings also indicate a link between appropriate and inappropriate care and preventable hospitalisations. Overall, the results of this thesis provide the basis for policy makers to better understand the changes in health outcomes and quality of care in these two settings but also to inform future quality improvement efforts.