This study explores lay perceptions of embodiment and health through the narratives ofa group of 'everyday' women and men in a Canadian community. Gender, class and cultural influences on individual and collective experiences of embodiment are examined along with the ways in which these concepts evolve over the life course. The research is based on in depth interviews with a sample of forty working- and middle-class white women and men between the ages of30 and 65. I argue that notions of embodiment and health are multiple, fluid and contextual. They are shaped and reshaped over time in relation to individual biographies and social and cultural influences, and negotiated in relation to the prescribed values of the larger body politic. I suggest that research must attend to the spatial and temporal dimension of ideas about embodiment and health. In the context of this case study, I argue that everyday ideas about regional identity are enmeshed with the cultural codes which signify racial, class and gender identity. These frame peoples' understandings and representations of 'healthy selves' and 'unhealthy others' and are central to their notions of embodiment. Based on these findings, I propose a more nuanced approach to theorizing 'the body' and health in feminist and sociological theory. I argue for a closer engagement between theoretical frameworks and empirical studies with the aim of developing a more fully embodied social theory.

This thesis examines some of the implications for social policy of an account of human nature frequently associated with liberal political theory. Taking as its starting point the claim that the objectives of social policy are contested, it seeks to develop an account of autonomy that will serve as a neutral 'organizational principle' around which to construct social policy. A particular version of personal autonomy is developed and defended against both abstract Kantian moral autonomy, and the individualism often associated with liberal theories. This project is pursued first through a discussion of the relationship of autonomous persons to 'social forms', and then through a critique of libertarian and 'intellectualist' accounts of autonomy. It is argued that, since autonomy is not only employed in the making of choices, but also in the implementing of those choices, it follows that the autonomous person must, of necessity, be viewed 'holistically' for the body is the primary means of implementing the choices autonomous persons make. The health of the body, as well as that of the mind, therefore assumes importance for any social policy that takes autonomy to be a fundamental objective. The implications for such an account of social policy are then explored in two ways. First, through a discussion of the phenomenon of 'medicalization'. Second, through a discussion of the Prevention and Health campaign. In the first instance, it is argued that the assumption that medicalization systematically undermines autonomy is ill-founded because theories of medicalization misunderstand what it is to be autonomous. In the second instance, the discussion of preventive health-care policy serves to illustrate the fundamentally erroneous assumptions of individually-focussed health-care programmes. In conclusion, it is argued that a unified account of autonomous persons must inevitably lead to a more integrated social policy.

Direct patient care requires knowledge sharing between clinical professionals. However, clinicians have often been suspicious of managers' motives, this lack of trust often resulting in reluctance to share knowledge for managerial purposes. Trust is one component of the psychological contract - an unwritten set of expectations between employees and employer. There are strong links between components of the psychological contract and defensive behaviours. There is much theory to support these links but little research evidence to support and explain these links. To overcome defensive behaviours requires an understanding of how they have developed, and particularly the role played by the psychological contract. This research builds on research first undertaken by Argyris in the 1960s, enhanced and made relevant to the current business environment and organisational arrangements currently prevailing in the NHS. A model and an analytical framework were developed for this research to assess organisational, professional and employee health in two health authorities. This research concludes that organisational ill-health, and failure to ensure the psychological contract is intact, result in employees displaying defensive behaviours and keeping knowledge to themselves. Components of the psychological contract were found to have strong links with organisational arrangements. Subtle variances were found between clinical and non-clinical employees, and between Chief Executives/Directors and those below this level. This research adds to our knowledge by identifying the different ways in which these groups develop paradigms that are often in conflict, sometimes intangible, and usually difficult to change. This added knowledge will allow organisational, team and personal development to have a sharper focus, particularly with reference to development of the psychological contract in the NHS, overcoming defensive behaviours, and breaking down barriers to knowledge sharing. This will support the development of infrastructures, teams and individuals to take NHS organisations into the 21st century with added confidence.

Gene expression studies have revealed that there is more than one cellular pathway governing growth inhibition and apoptosis. Mutations in the ras oncogene that(activate ras) are known to lead to the inactivation of genes that are directly involved in these pathways of growth inhibition and apoptosis. Oncogenic activated ras inhibits TGF-P signalling through the down-regulation of RII expression and abrogates apoptotic pathways through down-modulation of PAR-4 gene expression. A majority of pancreatic turnours harbour K-ras point mutations and these mutations dysregulate, the growth inhibition and apoptosis processes. This leads us to hypothesize that K-ras mutant phenotype status in pancreatic turnours will alter the expression of the RII and PAR-4 genes, and would further dysregulate growth inhibitory and apoptotic processes. In this study, the majority of pancreatic turnours showed down-regulation of RII and PAR-4 gene expression. A strong correlation of down-regulation of RII and PAR-4 with K-ras mutational status was observed. In particular, down regulation of PAR-4 correlated with poor survival in patients with pancreatic adenocarcinomas. Blocking the function of oncogenic ras by using a famesyltransferase inhibitor (Frl) restored RII expression and TGF-P signalling, and this caused enhanced sensitivity of cell lines to radiation. The restoration of RH function by FrI was linked to down-modulation of DNA methyltransferase enzyme that is often implicated in hypermethylation of promoters. Over-expression of RII in pancreatic tumour cells led to the restoration of TGF-P signalling and enhancement of radiation sensitivity. Induction of the pro-apoptotic effector gene, bav (bcI-2 family member) by radiation in RII over-expressed pancreatic cancer cells, was found to be a key mechanism involved in radiation sensitivity. Overexpression of PAR-4 sensitized the cells to radiation and this sensitization was linked to down-modulation of radiation induced Bcl-2 protein. Together, these findings strongly suggest that the restoration of function of the key growth inhibitory and cell death genes RII and PAR-4, which are affected by oncogenic ras mutations in pancreatic turnours will restore and enhance cellular responses to radiation induced clonogenic inhibition and apoptosis.

This thesis explores the motivation and goals of NHS Trusts which were set up under statutory instrument from 15t April 1991 by Margaret Thatcher's Conservative Government and which continue to have a role under the Labour Government elected in 1997. The research question asks 'What are the objectives of Trusts? What is the extent of the constraints under which they operate?' The central piece of empirical work uses a questionnaire survey to explore individuals' objectives, yielding 1,577 responses. A second exercise uses cost and volume data to review the performance of 100 Trusts. A third strand uses a case study to consider the behaviour of Trusts within their external environment. Consultants, or 'doctors', and managers are identified as the main power coalition within Trusts. Empirical findings are consistent with the hypotheses that, firstly, doctors and managers have different sets of objectives and that, secondly, doctors are interested in production, in particular maintenance of service quality, while managers are interested in the 'bottom line', defined as financial break-even. Under financial conditions described as 'bad times' where the interests of doctors and managers conflict, evidence suggests that doctors tend to dominate the performance of Trusts. It follows that Trusts will pursue a service objective, defined mainly through quality, rather than a financial goal. This dynamic is reinforced by the environment which sends signals to actors about how they should behave and, through lack of market exit, weakens the financial motivation of Trusts. While such behaviour is coherent in terms of the dominant actors, it is at odds with the overall goals of the Trust organisation which are perceived by doctors and managers alike to be the single-minded pursuit of financial targets. The thesis finds that this driver is not owned or acted upon by either doctors or managers and that, in accordance with the balance of its internal motivation, the Trust's primary objective is to maintain service quality.

The thesis will highlight both qualitatively and quantitatively that during the twentieth century the English population experienced unprecedented improvements in mortality and particularly morbidity, which has provided a substantial boost to standards of living and economic development. Despite the extensiveness of these health improvements, there have been a very limited number of attempts to evaluate and quantify these valuable improvements. None of the existing studies that quantitatively assess improved health actually measure health per se, as they all utilise mortality as a proxy. Furthermore, there have been no historical studies that aim to map the evolution of improving health from the perspective of quality of life for illness sufferers. The thesis will fill all of these voids through developing a quantitative health (mortality and morbidity) measuring tool that is capable of providing (monetary) estimates about the contribution of improved health to standards of living and economic developments in twentieth century England. This will be applied to key case study illnesses (blindness, breast cancer, stomach cancer and tuberculosis) and then extrapolated forward to include all illnesses which will be combined with mortality in order to provide an aggregate health index for twentieth century England. The results of this exercise provide a significant contribution to the twentieth century health and economic history of England. The thesis findings that, at a most conservative estimate, the value of twentieth century health improvements is in excess of 33 billion (1990 international $) substantially adds to a new view of the economics of health and provides very valuable historical detail. This new view is that improvements in health have been a major contributor to economic welfare in twentieth century England. Put another way: the thesis will highlight that during the twentieth century increases in life expectancy and improvements in the quality of life associated with morbidity have provided a considerable contribution to standards of living and the growth of GDP defined on a utility, 'Fisherian' basis, whereby economic growth nearly doubles, from 1.4 percent for GDP only versus 2.6 percent when GDP is adjusted for improved health.

This qualitative study examines how parents have conceptualised the MMR controversy and offers an assessment of parents’ perceptions of vaccine-preventable diseases and childhood immunisation. Methods-Eighteen focus groups were conducted in central Scotland between November 2002 and March 2003, with a diverse range of parents to ensure maximum variation in terms of age, socio-economic circumstances, likely views about vaccination and family circumstances. Findings-There are some potentially serious misunderstandings and gaps in knowledge about many of the diseases, which generally led to a diminished sense of urgency for vaccination. Parents deciding about MMR vaccination have to balance the perceived risk of disease against the perceived risk of MMR, and the perceived ability of their child’s immune systems to cope with the challenge of vaccines, or to fight the disease. Parents often questioned the safety of combining several antigens into one vaccine, as they were concerned it could be too potent for their child’s immune system and could potentially cause long-term damage. In some circumstances parents preferred to withhold MMR vaccination because it was easier for them to live with the risk of their child naturally contracting one of the diseases than with the risk of causing their child permanent damage as they perceived other parents may have unwittingly done. There is also a need for further research to investigate how parents caring for autistic children have been affected by the debate and to reassure parents based on sound evidence that giving these vaccines in a combined form is safe. Indeed, as the new pentavalent vaccine (DtaP/IPV/Hib) is introduced into the programme, it is crucial that these concerns about immune overload are taken into account to reassure parents in their wider reappraisal of vaccine risk.

In Scotland, life expectancy and health outcomes are strongly tied to socioeconomic status. Specifically, socioeconomically deprived areas suffer disproportionately from high levels of premature multimorbidity and mortality. To tackle these inequalities in health, challenges in the most deprived areas must be addressed. One avenue that merits attention is the potential role of general medical practitioners (GPs) in helping to address health inequalities, particularly due to their long-term presence in deprived communities, their role in improving patient and population health, and their potential advocacy role on behalf of their patients. GPs can be seen as what Lipsky calls ‘street-level bureaucrats’ due to their considerable autonomy in the decisions they make surrounding individual patient needs, yet practising under the bureaucratic structure of the NHS. While previous research has examined the applicability of Lipsky’s framework to the role of GPs, there has been very little research exploring how GPs negotiate between the multiple identities in their work, how GPs ‘socially construct’ their patients, how GPs view their potential role as ‘advocate’, and what this means in terms of the contribution of GPs to addressing existing inequalities in health. Using semi-structured interviews, this study explored the experience and views of 24 GPs working in some of Scotland’s most deprived practices to understand how they might combat this growing health divide via the mitigation (and potential prevention) of existing health inequalities. Participants were selected based on several criteria including practice deprivation level and their individual involvement in the Deep End project, which is an informal network comprising the 100 most deprived general practices in Scotland. The research focused on understanding GPs’ perceptions of their work including its broader implications, within their practice, the communities within which they practise, and the health system as a whole. The concept of street-level bureaucracy proved to be useful in understanding GPs’ frontline work and how they negotiate dilemmas. However, this research demonstrated the need to look beyond Lipsky’s framework in order to understand how GPs reconcile their multiple identities, including advocate and manager. As a result, the term ‘street-level professional’ is offered to capture more fully the multiple identities which GPs inhabit and to explain how GPs’ elite status positions them to engage in political and policy advocacy. This study also provides evidence that GPs’ social constructions of patients are linked not only to how GPs conceptualise the causes of health inequalities, but also to how they view their role in tackling them. In line with this, the interviews established that many GPs felt they could make a difference through advocacy efforts at individual, community and policy/political levels. Furthermore, the study draws attention to the importance of practitioner-led groups—such as the Deep End project—in supporting GPs’ efforts and providing a platform for their advocacy. Within this study, a range of GPs’ views have been explored based on the sample. While it is unclear how common these views are amongst GPs in general, the study revealed that there is considerable scope for ‘political GPs’ who choose to exercise discretion in their communities and beyond. Consequently, GPs working in deprived areas should be encouraged to use their professional status and political clout not only to strengthen local communities, but also to advocate for policy change that might potentially affect the degree of disadvantage of their patients, and levels of social and health inequalities more generally.

Purpose. This study explored the following research questions: 1. What are the normal and sensory-overloaded behaviours exhibited by adults living with neuropalliative conditions? 2. How does engagement in casual leisure alter with different levels of sensory attributes? It did this to determine whether there might be an approximate optimal level of sensory attributes that maximises occupational-engagement while minimising the potential for sensory-overload. The aim therefore was to create an occupational environment that participants could handle competently and enjoyably. This sensory threshold can only be approximate, since each individual has unique sensory preferences, interests and experience. Method. The preliminary study involved a structured interview with a Residence Manager in order explore the normal and sensory-overloaded behaviours exhibited by nine adults living with neuropalliative conditions. The second study built upon this by conducting a multiple, case quasi experimental study involving marginal-participant time-sampled observations of engagement of individuals with neuropalliative conditions, with casual leisure occupations using the Individual Child Engagement Record. This study investigated whether engagement occupations alters with different levels of sensory attributes. Observations were made of 14 participants engaging in eight cases, who experienced profound levels of disability, each case differed (as part of the replication logic) by having different levels of sensory attributes. Results. Analysis suggests that the symptoms of sensory-overload may be experienced by adults living with neuropalliative conditions. The effects of sensory-overload appears similar to definitions of a passive state (of engagement or non-engagement). The thesis therefore presents the linkage between passive engagement/ passive non-engagement and an individual's behaviour when experiencing sensory-overload, hopefully leading to increased vigilance and therefore avoidance. Furthermore, engagement was shown to alter with a combination of different levels of sensory and non sensory attributes, including supporter facilitation and with the potential for active participation. These contextual factors are proposed to pertain to the individual, the occupation itself, and to the physical and social environment; the role offered or level of support available. Therefore, enhancing active leisure engagement requires consideration of the occupation, the individual and their sensory preferences and the occupational environment. Conclusions. Despite the reporting of sensory-overload symptoms by the participant of the preliminary study, the results showed that the anticipated reduction in engagement at the higher levels of sensory attributes (given the effects of sensory-overload) did not occur. In fact, engagement with leisure occupations appeared to increase as the sensory attributes levels increase, with larger differences in engagement level occurring where there are larger differences in the combined level of sensory attributes involved, a range of factors in the occupational context, are suggested to influence engagement, some of which pertain to the individual, the occupation and the environment. Clinical Messages. The role of the leisure supporter was suggested to include adapting leisure to fit the person, including offering the choice of what, when, where, with whom and how to "do" their leisure occupations, including offering active participation and a sense of choice.

The population of the United Kingdom (UK) is ageing; the already substantial burden of musculoskeletal disorders on health and social care systems will increase over time as the population ages. Social inequalities in health are well documented for the UK in general but little is known about social inequalities in musculoskeletal ageing. Using data from the 3,225 ‘young-old’ (age 59 to 73 years) community dwelling men and women who participated in the Hertfordshire Cohort Study, this thesis has explored social inequalities in musculoskeletal ageing: specifically, loss of muscle strength and physical function (PF); falls; Fried frailty; and osteoporosis. Socioeconomic position was characterised by age left full-time education, parental social class at birth and own social class in adulthood, and current material deprivation by housing tenure and car availability. Not owning one’s home was associated with lower grip strength and increased frailty prevalence among men and women and with poorer self-reported short-form 36 (SF-36) PF among men. Reduced car availability was associated with lower grip strength and poorer SF-36 PF among men and women and with increased falls and frailty prevalence among men. There was no convincing evidence for social inequalities in fracture, dual-energy x-ray absorptiometry (DXA) total femoral bone mineral density (BMD) and bone loss rate, or peripheral quantitative computed tomography (pQCT) strength strain indices for the radius or tibia. This thesis has argued that social variations in height, fat mass, diet and physical activity are likely to have mediated these results. Moreover, evidence for a social gradient in grip strength but not BMD is consistent with ageing skeletal muscle remaining highly responsive to physical activity in later life in a way that ageing bone does not; the impact of lifecourse customary and occupational physical activity on social inequalities in musculoskeletal ageing merits further research. The results presented in this thesis suggest that any clinical interventions designed to reduce the loss of muscle mass and function with age should be targeted proportionately across the social gradient; strategies to reduce fracture and osteoporosis should continue to have a universal population focus. Finally, this thesis suggests that there exists a subgroup of older men and women in the UK who face the multiple jeopardy of increased levels of material deprivation combined with greater loss of muscle strength and physical function; these men and women urgently need the government to commit to reform of the funding system for adult care and support.