This thesis assessed the risk of cancer in relation to exposure from benzene at work. The thesis is in three major sections. The first section consisted of a systematic review and meta-analysis to assess the risk of leukemia from occupational exposure to benzene. The systematic review confirmed leukemia to be important in relation to benzene exposure; 15 selected studies yielded 16 effect estimates with an overall statistically significant effect size (relative risk) of 1.40 (95% CI, 1.23-1.57). A dose response analysis was performed and provided evidence for a strong positive trend between leukemia risks and estimated exposure to benzene. The risk of all leukemia combined increased with a dose-response pattern with a summary effect size (ES) of 1.64 (95% CI 1.13-2.39) for low (<40 ppm-years), 1.90 (95% CI 1.26-2.89) for medium (40-99.9 ppm-years), and 2.62 (95% CI 1.57-4.39) for high exposure (>100 ppm-years). The risk of AML also increased from low (ES 1.94, 95% CI 0.95-3.95), medium (ES 2.32, 95% CI 0.91-5.94) to high exposure category (ES 3.20, 95% CI 1.09-9.45), but the trend was not statistically significant. The second section used the same method to assess other cancer risks by conducting a systematic review and further meta-analysis. The most common other cancer sites for which a possible occupational involvement from benzene has been suggested were lung, bladder, melanoma, stomach and kidney cancer. Consequently, a systematic review and meta-analysis was performed on each of these cancer sites. The results obtained did not show any clear evidence of risk for lung cancer (ES 0.99, 95% CI 0.96-1.03), bladder cancer (ES 1.00, 95% CI 0.96-1.03), or stomach cancer (ES 0.96, 95% CI 0.90-1.03). However increased risks were shown for melanoma (ES 1.25, 95% CI 1.09-1.44) and kidney cancer (ES 1.14, 95% CI 1.04-1.25). The systematic review and meta-analysis for melanoma was based on 7 available studies reporting 8 cohorts. It was not possible to conclude that benzene exposure is a cause of melanoma as many other chemicals were also used in the factories. There was no significant heterogeneity in the study-specific findings for melanoma (P=0.26). The systematic review and meta-analysis for kidney cancer was based on 22 available studies reporting 24 cohorts. There was also no significant heterogeneity in the study-specific findings for kidney cancer (P=0.41). Therefore, further research is needed to establish a strong link between exposure to benzene and risk of kidney cancer. The final section of the thesis examined the risk of leukemia, lung cancer and all cause mortality in workers exposed to benzene in a large cohort of workers employed at 233 factories during 1966/67 in England & Wales. The results however provided no clear evidence of a dose response effect for leukemia risks in relation to estimated cumulative exposure from benzene. The major limitations of the study related to the recording of limited work histories and the collection of incomplete or limited exposure assessments. The method used in recording the levels of exposure were not clear as different factories were measured by individual personnel at differing times over the years, and at differing areas within factory to factory. It was not possible, therefore, to gain a comprehensive and consistent exposure assessment throughout the factories. To obtain an accurate and viable outcome there needs to be a sound measurement of exposure technique implemented such as taking personal samples using a personal sampler for each individual and indicating specific areas where low, medium and high exposures are evident alongside adequate ventilation. Job exposure matrix also needs to be considered alongside socio-economic classification and ethnicity as this may show some effect on how different minorities may be better or worse adapted to certain chemical exposures.

Clinical trials are prospective studies in volunteers to test the safety and efficacy of a drug or intervention in a well-defined, controlled experiment. Pharmaceutical companies spend billions of dollars each year on clinical trials. Yet, despite the rising levels of chronic diseases and evidence suggesting that black patients may respond to treatments differently than their white counterparts, Sub-Saharan Africa is still represented in very few industry-sponsored trials. In addition to any immediate potential therapeutic benefit and the ability to grant patients greater access to drugs that they might not normally be able to obtain, clinical trials may also bring collateral benefits, such as investments in infrastructure and resources. To this end, clinical trials may be useful in helping to address the rising levels of chronic disease in the Sub-Saharan region of Africa. Additionally, it may not always be appropriate to extrapolate data from trials conducted in patients in the West and apply them to patients in other regions of the world, as the literature demonstrates that for certain medicines, treatment effects may differ due to genetic variations between ethnic groups. Aim: The aim of the study was to better understand stakeholder perceptions of the issues associated with the conduct of pharmaceutical industry-sponsored clinical trials in chronic diseases in Sub-Saharan Africa. A further goal was understanding what benefit, if any, conducting such trials could confer to the population and region. Methods: A multi-methods approach was adopted. The first part of the study focused on the use of semi-structured qualitative interviews with various stakeholders to identify the themes most relevant to the research objectives. The contents of the interview transcripts were thematically analysed, and a quantitative online questionnaire was created on the basis of the themes that emerged from the interviews. This questionnaire was then administered to a larger number of similar stakeholders to corroborate the findings from the first part of the study. Results: The interviews identified five main overarching themes. Those themes were as follows: (1) ethical, (2) commercial, (3) medical/scientific, (4) educational, and (5) practical. All five themes are closely related and oftentimes impact one another. The ethical issues largely related to the provision and availability of medicines post-trial and informed consent, as well as to the potential for corruption and fraud by both investigators and pharmaceutical companies operating outside the scope of tightly regulated Western competent authorities and ethics committees. The commercial considerations that were raised primarily centred on the fact that pharmaceutical companies are businesses, many of which have obligations to shareholders, and on the fact that drug development is tremendously expensive. The majority of the profit generated by pharmaceutical companies comes from their sales in the West, which is why their focus remains on that part of the world. The medical and scientific issues were primarily related to the evolution of Sub-Saharan Africa’s disease landscape and pharmaceutical companies’ responsibility to their global patients to ensure a robust understanding of how their drugs affect patients of varying ethnic backgrounds in different parts of the world. The educational issues were mainly linked to public awareness regarding what clinical trials are, as well as to the education of investigators, research staff, and ethics committee members. The final theme to emerge was practical issues raised in relation to a lack of infrastructure and oversight. The results of the questionnaire mostly echoed the findings of the interviews. Through their questionnaire responses, participants indicated that they felt that the pharmaceutical industry does have an ethical and scientific responsibility to do more to ensure that its drugs are tested in developing parts of the world, such as Sub-Saharan Africa. However, respondents indicated that pharmaceutical companies should not conduct trials in regions where they have no intention of selling their products and that the three largest barriers precluding the conduct of clinical trials in that part of the world are a lack of adequate infrastructure, a lack of commercial attractiveness, and concerns around unethical behaviour. Discussion: Although there are inherent risks and disadvantages associated with participating in clinical trials, the benefits are well known and understood for participants in the West. Therefore, most respondents across the stakeholder groups could see the potential benefits of research for Sub-Saharan Africa. However, many within the pharmaceutical stakeholder group exhibited unfamiliarity with the evolving disease landscape and level of infrastructure within Sub-Saharan Africa. The ethical issues and associated practicalities of conducting trials in that part of the world were likewise not well understood. The results of the study suggest that respondents across all stakeholder groups feel that the pharmaceutical industry needs to do more to make drugs available to patients in developing countries, both commercially and through research. As a justification, they pointed to the industry’s ethical and scientific responsibilities to do so. The commercial benefits that the industry could gain from conducting an increased number of clinical trials in Sub-Saharan Africa did not appear to be well understood by the research participants. The results also illustrated that the respondents did not think that chronic diseases should be prioritised over infectious diseases, or vice versa. By carrying out this research, important questions were raised regarding the capabilities of countries within Sub-Saharan Africa, and topics associated with the increasing prevalence of chronic diseases in that region were explored. All stakeholder groups agreed that pharmaceutical companies can play a role in addressing levels of rising chronic disease through the conduct of clinical trials. The findings of this research led to several recommendations, including allowing countries in the region to participate in bridging studies as a starting point, establishing national databases, and revisiting the restrictive wording in certain current ethical regulations.

A crucial contemporary public health issue is the construction and contestation of the relevance of the natural world to human health. Taking a critical approach, this thesis examines how the natural environment as a health determinant is positioned in relation to the 'social' within social epidemiological studies of health, illness and disease. Using conceptual and empirical forms of enquiry, this study shows how current constructions of natural environmental health drivers contour public health practice in the UK and that by challenging the limits of existing structures, innovative responses emerge, which can generate new frameworks for health policy and practice. Having identified a lacuna in research on the 'natural' environment in medical sociology, this inductive qualitative research project brings into conversation the findings from extensive desk and field research. Specially, a study of the elaboration of environmental health discourses within the UK public health policy arena and disciplinary wide discourse analyses of key academic journals are read together to describe the discursive practices shaping environmental public health work in the UK. Linking theory to practice, data from in-depth interviews with sixty health professionals working on health and the environment in the UK and internationally are used to investigate how public health practitioners produce the environment within their work remits. The research breaks ground for further social scientific studies of health and the environment and in particular substantiates the call for an extended notion of the 'environment' using ecological principles. Methodologically, the interdisciplinary reach of this research draws attention to the tensions that arise when working across the medical, natural and social sciences. Practical and philosophical questions about the challenge of expanding the sociological imagination in the contemporary moment are also considered. Empirically, to medical sociology the 'EcoBioPsychoSocial' framework is offered as a tool for studying health at the nexus between the 'social' and the 'natural environment.' Finally, the ways informal public health institutions are serving as 'invisible' forces impeding the uptake of prevention oriented environmental health policies are findings offered to the health policy arena.

This thesis examines representation, a key but relatively neglected issue in contemporary democratic theory, through an ethnography of engagements between indigenous representatives and the state in the Brazilian health sector, which has pioneered the adoption of participatory and deliberative “new democratic spaces”. Part I, “Locating Representation”, argues that contemporary debates that privilege the creation of new democratic spaces as a response to the shortcomings of representative democracy ignore the importance of these spaces' own issues of representation. The section goes on to outline the context for the research (which was conducted at the national level and in two sites in the Amazon region), describing the process of action research and multi-sited ethnography. The main body of the thesis makes the case for developing a situated understanding of three dimensions of representation: the representation of issues for political debate and policy deliberation; the representation of different social groups in relation to the state; and the representation of the process of democratic engagement itself. Part II, “Representing Health” examines the contrasting understandings of health expressed by two groups of policymakers and bureaucrats – those managing Brazil's national health system, the SUS, and those responsible for the Indigenous Health Subsystem of the SUS – and by shamanic practitioners and other indigenous health experts. Part III, “Representing People” examines the discourses and mediation roles of indigenous representatives operating in new democratic spaces, and the contrasting representation strategies of two regional indigenous movement organisations who took on management of outsourced services within the Indigenous Health Subsystem. Part IV, “Representing Democracy”, examines three cases of indigenous representatives' engagement with the state through new democratic spaces in the health sector, and concludes by analysing the potential for new approaches to representation to contribute both to the political inclusion of marginalised minorities and to the broader reinvigoration of democracy.

This thesis looks at the subject of old age and retirement in the later years of the Scottish Enlightenment. These subjects are examined in relation to the final years of the physician and natural philosopher, Professor William Cullen (1710–1790). The Cullen Consultation Correspondence digital database (http://cullenproject.ac.uk/) is used to examine letters between the doctor and some of his elderly patients and a study of the botanical materia medica prescribed for this patient group is made. There follows an examination of Cullen’s personal retirement project, his improved farm and designed landscape at Ormiston Hill in West Lothian. The thesis examines the double meaning of the word ‘retirement’, both in its eighteenth-century sense as a retirement from active life, and its modern sense as the concern of old age. Even if Cullen’s notion of old age and retirement represented the concerns of an elite, it carried with it a broader social and moral responsibility. I show how Cullen and his peers sought to develop a programme of improvement which included how to live ‘a good life’.

Universal health coverage (UHC) has been identified as a priority in the sustainable development goals (SDG3), but it is argued here that this is only possible if the health workforce is educated in, and values a public health approach at the primary health care (PHC) level. Encouraging community participation by developing a critical awareness of the social determinants of health and supporting communities to take action is needed. Community health workers (CHWs) have the potential to act as agents for social change to improve the health of rural communities if trained and supported appropriately. This study investigates the optimization of public health skills, knowledge and practices of health workers at the PHC level in rural Cambodia. It is anticipated that this study will afford new insights to inform stakeholders of the factors impacting on the development of public health workforce capacity. The research engaged twenty CHWs over two studies using a participatory action research approach. Over eight participatory workshops and a two-day training session CHWs identified (using photovoice), implemented and reflected on solutions to community health problems. In addition, ten semi-structured interviews were undertaken with key stakeholders from government and non-government organisations (NGOs) to gain an understanding of current methods used to develop the public health capacity of health workers in Cambodia. The public health skills gaps identified at provincial and community levels included planning, communication, community engagement techniques and using initiative to identify and implement solutions. These gaps are intrinsically linked to Cambodian social and political structures, and cultural values which promote a hierarchical working environment. In addition, aid dependency and a lack of ownership has created a new patronage which encourages further disempowerment and an apathetic approach to independently tackling community health issues. Fragmented public health training mainly directed by international agents and a lack of financial support to develop sustainable training, supervision and monitoring negatively impacts public health skill development. Health promotion and prevention training is provided to health facility workers, but there is a ‘know-do’ gap. They view their role as purely curative and removed from the community public health agenda, thus devaluing the application of new public health skills. The implementation of community participation policies in Cambodia is hindered by a reliance on external agencies and cultural norms of respect, obedience and fear of challenging the elite. The capacity for CHWs to act as agents of social change is unlikely given the current policy structure and implementing environment. The health workforce in Cambodia has the potential to contribute significantly to the goal of UHC, however factors affecting their desire and ability to implement a public health approach need addressing. Although many health systems are hierarchical in nature, the degree to which people can innovate, openly analyse processes and procedures and suggest solutions needs to be considered. Identifying ways of supporting CHWs to mobilise and enable communities to be empowered within the contextual environment is required, as is a better understanding of how to close the know-do gap in health facility workers.

This thesis has two aims: First, to demonstrate that there is in the current medical model of transsexuality conceptual incoherence. Second, to establish an alternative model for understanding transsexuality: the model of authenticity. The current medical model is based on an assumption that the sexed body and gender identity are distinct, so that gender is different to sex, which forms the basis of transsexuality. The tension in transsexuality between sex and gender gives rise to suffering. Surgery unifies sex and gender and is offered as the humane response. It is this move from separation to unification of sex and gender that constitutes the conceptual incoherence in the current medical model. Suffering is then explored as a potential justification for surgery. It is argued that it is not obvious that suffering must be alleviated. Indeed, suffering may be valuable, and where this is the case there is no moral imperative to remove it. So, whilst there is a serious moral duty to respond to suffering there is no absolute duty to alleviate it. An alternative model is then explored. A model of authenticity, which can replace the medical model, better enables the freely chosen identity and goals of the transsexual to be respected, without compromising the ends of medicine.

Childhood obesity is a recognised increasing public health problem in Iran, but no evidence for effective prevention strategies is available. The aim was to inform the development of an obesity prevention intervention for Iranian school children. A quantitative analysis was used to examine the pattern and associated factors with obesity and a qualitative study explored the beliefs of parents and school staff about the causes of childhood obesity and potential interventions. Overall 28.2% of the children were overweight or obese and there was a non-significant tendency for increased energy intake with higher weight status. Measures of body fat were highly positively correlated with blood pressure. There was generally accurate body size perception among children and no relationship between weight status and quality of life scores. Focus group participants identified a range of perceived obesity risk factors related to diet and physical activity at the micro and macro levels. In terms of interventions, the importance of macro level activities was highlighted. The study confirms that childhood obesity is an important health problem in Tehran and highlighted socio-economic variations in prevalence, which will inform the targeting of prevention interventions. Important contextual information was obtained to inform the development of a prevention intervention.

This PhD by Publication has investigated contemporary management of change practice in health and social care. Through eight case studies it explores change within different sectors, roles and organisations within national, regional and local systems. More successful change programmes are better able to understand their contexts, to design change theories that will work within these contexts, to fully implement the activities planned on the basis of these theories, and to have the resources and autonomy to complete the programme to its conclusion. Despite the relative success of some programmes, there are common opportunities for change management practice to be improved. These include -the meaningful engagement of service users throughout the process; setting of intermediary and final outcomes that provide opportunity for formative and summative evaluation, and in the use of relevant data to enable reflective change practice. It would also appear that despite the considerable body of knowledge regarding management of change this rarely explicitly influences change programmes and therefore stronger collaboration between academia and practice is still required. A pragmatic approach in which different academic fields collaborate to directly respond to the problems faced in practice would be beneficial.

This research empirically examines and compares the adoption of health technologies through case studies. The health technologies under review are assisted reproductive technologies, cochlear implants, haematopoietic stem cell transplantations, caesarean section deliveries, Gamma knife units and kidney transplants in four countries: Japan, Korea, the UK and the US. The interactions between the micro factors of health technologies and the macro environment in the adoption of health technologies are examined on the basis of a literature review and analysis of data. The micro factors were evaluated in terms of economic, clinical and technical aspects. In assessing the macro factors, payment systems and regulations related to the selected health technologies were taken into account. To examine the micro factors, the results of health technology assessments in earlier studies were reviewed. In order to explore the macro factors, historical changes in the payment systems affecting the selected health technologies and legal regulations, including legislation, directives, guidelines and court orders related to the technologies, were investigated. The adoption level of health technologies was evaluated in time-series and cross-sectional terms, measuring the trend of technology adoption and comparing the experience of the four countries under review. This research suggests clustering health technologies into “welfare oriented technology” and “private benefit oriented technology” by considering the economic incentives of adopters, individual desires of consumers and public concern over the technology. Private benefit oriented technologies are those which adopters expect to increase income from the providers or which meet the personal desires of the consumers. For welfare oriented technology, the decision is dominated by the aims of public welfare. As the model predicted, the adoption of welfare oriented technologies was higher in the health systems under national planning, while that of private benefit oriented technologies was higher in the systems whose health provisions accept market conditions.