Public participation is an increasingly prominent policy in the United Kingdom and elsewhere. This thesis locates one example of participation within wider debates about the constitution of contemporary society, changing welfare-state governance, and the challenges of operationalizing such initiatives. It relates the particularities of this case to practical, policy and theoretical questions. The thesis begins by considering the rise of participation in historical context, relating its aims to social-theoretical commentaries on late-modern society. This framework informs an examination of rationales for participation, an analysis of policy discourses on public involvement in health, and consideration of the challenges of making participation happen. The remainder of the thesis presents the results of an empirical study of one example of participation: service-user involvement in a programme of pilot cancer-genetics services, managed by the third-sector organization Macmillan Cancer Support. Using interview, observational and documentary data collected over a three-year period, it offers a longitudinal perspective on the practice of involvement, drawing on various actors’ perspectives. Considered over five empirical chapters are competing rationales for involvement put forward by different groups of actors, the micro-processes of involvement, and the varied outcomes of negotiations across the seven pilots studied. In reconciling the theoretical and policy literatures with empirical findings, the thesis highlights certain tensions. Policy-level ambiguities permit the coexistence of multiple discourses about the purpose of involvement, the identity of those involved, and the influence it should command, resulting in conflict as participation is put into practice. Policies designed to avoid directiveness and facilitate local discretion create dilemmas for those charged with implementation, especially third-sector organizations whose intermediary role means they must reconcile divergent views of diverse stakeholders in participation practice. The result is a situation where pragmatic negotiations take precedence over any theoretical or normative vision for participation in determining its remit, scope and influence.

Background: A large proportion of ill-health is preventable (Signorelli 1993). A goal for health promoters is to provide information about health risks with the aim of persuading individuals to modify their behaviour. Previous research suggests that the readability of many health promotion materials is too low for effective comprehension. Evidence suggests that much of the health information available is written at a level that is too difficult for the target populations (e.g. Dollahite et al. 1996, Meade & Byrd 1989, Greenfield et al. 2005). Whilst this work is useful in identifying barriers to accessibility to health information, there has been little research that systematically explores the concept of usability within the context of health information. Objectives: The first objective of the thesis was to examine whether the concepts of usability and usefulness as outlined in the Technology Acceptance Model (Davis 1993) can be applied to the domain of health promotion and used to predict intentions to follow the advice given in health promotion leaflets. Second, the studies sought to make distinctions between subjective and objective usability and to explore the factors underlying subjective ratings of the usability of health information. Further, the thesis sought to demonstrate that both objective and subjective usability would influence the persuasive effect of health promotion materials. Finally, using theory from dual-processing models of persuasion (e.g. Elaboration Likelihood Model. Petty and Cacioppo 1986) it was predicted that when usability of leaflets was high, participants would be more likely to make judgements about their intentions to follow the advice given in the leaflets based on peripheral clues such as frame (Tversky and Kahneman 1981, Rothman and Salovey 1997, Levin et al. 1998). Methodology: 5 empirical studies examined the research questions. The first study consisted of two samples from working populations (n=441), and explored manual handling and use of hearing protection. Participants evaluated existing health and safety leaflets in relations to their usability and usefulness, and rated their intentions to follow the advice in the leaflets. The second study, also conducted on a working population (n=97), used experimentally manipulated leaflets on safe manual handling to test the hypothesis that framing effects would be found when usability of leaflets was high. The third study used a student sample (n=127) to explore factors that influence subjective usability. The study used experimentally manipulated leaflets about safe alcohol consumption to examine whether the concept of subjective usability is a function of reader characteristics (psychological constructs, mood, past exposure to the health problem) and leaflet characteristics (frame, objective reading ease). The fourth study used a student sample (n=238) to test the effect of objective reading ease on recall, in order to test for differences in processing of two experimentally manipulated leaflets about safe alcohol consumption. It was predicted that easy leaflets would be processed at a more shallow level than difficult leaflets. The fifth study, also conducted on a student sample using experimentally manipulated safe alcohol leaflets (n= 135), used pre and post testing to further explore the effects of usability on framing effects, and to test for a moderating role of prior knowledge on the effect of usability on intentions. Results: The studies showed that readers distinguish two separate components to health information leaflets: usability and usefulness. Subjective perceptions of usability and perceived usefulness predicted intentions to follow the advice given in the leaflets. Objective usability (reading ease) influenced the persuasive effect of the leaflets, with easy leaflets being more persuasive than difficult leaflets. Perceived usefulness partially mediated the relationship between subjective usability and intentions. Objective reading ease affected recall, with easy leaflets resulting in higher levels of both accurate and false recall of the information in the leaflets. Prior knowledge moderated the relationship between usability and intentions. Those with low prior knowledge were more persuaded when usability was high. Usability influenced the effect of frame on intentions. Framing effects were only found where usability was high. Where framing effects were found, negative frame was more persuasive than positive frame, offering support for Levin et al.'s (1998) typology of framing effects. Conclusions: Results from the studies show that the concepts of usability and usefulness, formalised in models of technology acceptance (TAM), can be applied to health information and used to predict intentions to follow health promotion recommendations. A distinction can be made between subjective and objective usability, and both of these can influence persuasion. Using theory from dual-processing models of persuasion, usability of health information leaflets can influence the effect of frame on intentions to follow the health promotion advice.

In common with other areas of public services, recent years have seen a shift in the National Health Service (NHS), with increased power and authority transferring from professionals towards the users of services. As a result, user involvement has come to form a central element of government policy on public services, and health in particular, with a series of specific policy commitments to give users a stronger voice and to involve them in the health service having been published by both the Westminster and Scottish parliaments. These seek to increase users’ involvement in making decisions about their own care and treatment, in examining and improving the quality of services and in policy and planning activity. In doing so, this policy aspires to respond to the changing culture of personal and societal expectations of health and the health service; to build democratic participation in the difficult targeting and rationing decisions faced by health agencies and, thus, to help renew public trust and strengthen confidence in the NHS. These are ambitious aims with far-reaching implications as they represent a transformation in the interaction between users, health professionals and health policy makers. This thesis examined how this policy has been understood and implemented in the NHS by exploring the scope, relevance and quality of the user involvement processes available in three health service settings. In order to develop a better understanding of the issues in user involvement it explored the nature of user participation; the character of user representation and the barriers and facilitators to user involvement in maternity, gynaecological oncology and mental health services. The study examined the response to this policy within these three settings; the functioning of existing user involvement mechanisms and their capacity to involve users in determining their individual health care and in shaping health services and policy to their definition of need. From this examination it defined the key features of a model process for user involvement within the professional service culture and organisational ethos of the NHS. The study then drew conclusions on the capacity of these current user involvement processes to deliver on the policy directive to develop both individual treatment and health services in ways that are responsive and accountable to users. Finally, the thesis identified those areas that require further research before proposing the lessons for the further development of this significant and potentially influential policy directive.

POPULATION AGEING IN SCOTLAND - IMPLICATIONS FOR HEALTHCARE EXPENDITURE Population ageing is a major concern for developed countries in terms of public expenditure required to pay for health care (HC). The broad aim of this thesis is to contribute to and expand the debate on the independent effects that population ageing and the time immediately before death (TTD) have on HC expenditure in Scotland. This study analyses, for the first time in Scotland, how HC expenditure projections are influenced through the application of two approaches; the first only accounting for an increasing proportion of the elderly population, and the second also implementing a TTD component. Several issues that are under-researched or have not been addressed in TTD studies previously, are explored and alternative approaches are presented. Utilising two large linked datasets this thesis addresses important methodological issues. Alternative methods to cost inpatient hospital stays are examined as this has pivotal implications for any analysis undertaken to estimate the independent effect of TTD and age on HC expenditure. Explanatory variables that have previously not been considered, such as health risk and health status measures at baseline, are included in these analyses. The issue of sample selection, arising through the inclusion/exclusion of survivors in a TTD study is investigated and the impact of individuals’ socio-economic status on costs is examined. The analysis of alternative costing methods clearly showed that any inference that can be made from econometric modelling of costs, where the marginal effect of explanatory variables is assessed, is substantially influenced by the chosen costing method. The application of a Healthcare Resource Group (HRG) costing method was recommended. This study found that TTD, age and the interactions between these two factors were significant predictors for HC expenditure. The analysis further identified some of the health status and health risk measures to be important predictors of future HC expenditure. An examination of how sample selection impacts on estimated costs at the end of life showed that if survivors were excluded from the analysis, costs might be overestimated. Drawing on a representative sample of the Scottish population, the investigation of the association that the socio-economic status had with HC costs suggested that less is spent on individuals from more deprived areas. This might partly be explained through the decreased probability of accessing hospital services for individuals from more deprived areas. Furthermore, results showed that projected HC expenditure for acute inpatient care for the year 2028 was overestimated by ~7% when an approach that only accounts for the higher proportion of elderly people in a population in the future is being used as compared to an approach that also accounts for the effect that remaining TTD has on costs.

Previous research in the UK and elsewhere has found that housing tenure (i.e. whether the dwelling is owned or rented) predicts mortality and morbidity. This thesis aims to explain whether ontological security (a long term tendency to believe things are reliable and secure as opposed to threatening) is more likely to be associated with owner occupation, and therefore whether it helps to explain the observed association with tenure and health. For the purposes of this study ontological security was operationalised as being formed of three components: protection, autonomy and prestige. A scale was devised to measure ontological security arising from the home through these three components. This scale was included in a postal survey that also included questions on health, housing area, psychological and sociodemographic characteristics. The postal survey was sent to a random sample of adults in the West of Scotland and nearly 300 completed questionnaires were returned. I found that ontological security was associated with owner occupation but not independently of features of housing. Ontological security was not independently related to housing tenure itself. Owner occupiers reported more ontological security from their homes because their homes were in better condition, situated in better areas and of higher value than social renters. Ontological security appeared to be related to health particularly through psychological characteristics. Other reasons for the associations between tenure and health were that owners were on average younger and richer than social renters. This study suggests that social meaning per se may not be health damaging, but that social rented homes might put their occupants at greater health risk because they are in poorer condition, located in more poorly resourced and problem ridden areas and of lower status. These features of social renting may also be observed in other countries (e.g. USA).

Over recent years, designing technologies to promote health-related behavioural change has been an area of growing interest in HCI. Given the prevalence of self-monitoring and social facilitation in emerging designs, the assumption appears to be that increasing an individual’s awareness of his or her behaviour and the behaviour of others will promote behavioural change. This thesis argues that while this is true to some extent, this represents a somewhat naive view of how individuals come to make decisions regarding their health-related behaviours. Three qualitative studies within distinct health domains illustrate the complex nature of health-related behavioural change. Weight Management was an inherently social activity, albeit subject to selective disclosure and incremental participation. Individuals were generally motivated by appearance rather than health, implementing change based on exposure and orientation to alternative strategies. In Families at Risk, caregivers were highly motivated by a desire to safeguard the health of their children but were restricted by a lack of financial and strategic resources. Lack of trust and a transient community contributed to social isolation, thus inhibiting opportunities for collaboration. In Cardiac Rehabilitation, behavioural change efforts were prompted by an acute health crisis and guided by health professionals. However, behavioural change efforts were sometimes restricted by a desire to return to normal, tensions arising when what was considered normal was composed of risk behaviours. Family involvement varied greatly, ranging from disregard to facilitating change, and a desire for independence and ownership of the rehabilitation sometimes restricted the active involvement of peers. Informed by the findings of these studies this thesis highlights the strengths and limitations of current technological approaches to promoting behavioural change, provides implications for design, and supported by the sociomedical literature, identifies alternative avenues of technological innovation. The thesis reflects on technology’s role in health-related behavioural change and considers associated ethical implications. Overall, the main contribution of this thesis is a reframing of the problem of promoting health-related behavioural change as more than a matter of behavioural awareness and personal motivation. While it is understandable that technologists would look to the clinical domain to inform initial investigations in this area, this thesis argues that technologists should be cautious about blindly adopting its prescriptive paradigm. As an alternative to persuasion, this thesis offers negotiation as a potential model for future innovations in this area.

The main questions of this thesis are how a period of in utero malnutrition can impact the health of young children and their later development, and how job promotions can affect health. In the first chapter I analyse to what extent the South-East Asian financial crisis affected the height of Indonesian children who had in utero exposure to the crisis. I find that they are significantly shorter than children who were exposed at later ages. There is a large difference in effect for urban and rural children. This finding helps attribute the detrimental health effects to the crisis and not other events which occurred during the period of analysis. The second chapter exploits the exogenous shock of the crisis to analyse how early childhood height causes later cognitive development. I argue that this question should be analysed using instrumental variables. The results show a large and significant effect of early childhood height on cognitive ability and the use of instrumental variables changes the results significantly compared to OLS with or without fixed effects. Lastly, I analyse how on the job promotions of British civil servants affect health. In a cross-section, the direction of causality is almost certainly two-way. I argue that the use of individual fixed effects will alleviate this concern. The results show a large, positive effect of a job promotion on health in the subsequent survey phase.

In this thesis I advance a socio–representational perspective on sexual and reproductive health as constructed by indigenous Mexican adolescents. The social and psychological literature on health among indigenous populations and on adolescent sexual health is reviewed. It is argued that a socio–psychological perspective is needed to understand the resources through which contemporary indigenous youth, a population overlooked by research, make sense of their sexual and reproductive health. In generating the theoretical tools to tackle this issue, I adopt a dialogical approach to social representations theory to sharpen Jovchelovitch’s (2007) model of knowledge encounters by proposing a typology of potential outcomes of these encounters. The empirical research involved female and male indigenous adolescents in two social contexts: rural and urban. In–depth individual interviews, focus group discussions and unstructured observations were employed for data elicitation. Results from the interpretative thematic analysis performed are presented through a ‘funnelling’ approach whereby the interdependent engagements of indigenous adolescents with their social context, their partners and specific health beliefs are discussed by highlighting nuanced differences in relation to social context and gender. Key findings are related to the understanding of romantic relationships in terms of stability and continuity, which impacts on the way that sex and contraception are perceived and experienced. Results also reveal that, in dialogue with others, adolescents come to identify alternative ways of positioning themselves with regards to customary discourses about sexual health. Focus group discussions are further examined through a dialogical analysis of interactions that aim to identify, in sociodialogue, the outcomes of knowledge encounters initially proposed. A further data–driven outcome is subsequently added to the typology and analytical categories are refined. Implications for health promotion in terms of the reflexion entailed in dialogue are offered in the conclusion chapter.

This dissertation presents the findings of a project where, following investigation and assessment, a million tonnes of sand and gravel at a contaminated former US Air Force Base was excavated for use as aggregate. The process required on-site screening for petroleum hydrocarbons of over 7,000 soil samples and provided an opportunity to assess the efficiency of the investigation, assess the application of geophysics of hydrocarbon contaminated sites, and look at the role of aggregate extraction in the contaminated land industry.

This thesis consists of five elements which, when taken together, articulate the journey of personal and professional development I have undertaken as an action researcher, and convey the emotional context of this type of work. The foundation for my development journey was the undertaking of a three year action research study which aimed to improve the care for older people on two rehabilitation wards in an acute NHS trust. Analysis of findings provided theoretical explanations of what helped and hindered staff from engaging in practice change,with the report presenting a neat and straightforward process of investigation. My experience of undertaking the study was, however, far from the neat and straightforward process articulated, with it being a complex, difficult and painful undertaking which had a personal impact on me. The thesis progresses from the research report to explore and critically reflect on my personal experience of undertaking the action research study, and engages with the experience of other action researchers through a secondary analysis of the literature. Through this work the emotional context of action research is highlighted for all those involved in the process. It is argued that attention to emotions throughout the action research process is essential for both participants and researchers to ensure that the care and support required to manage them can be provided, and to enable such emotions to be used as data that can further inform the field of study. Although the importance of recognising the emotional context of action research is articulated in this thesis, there is a dearth of literature in relation to it. It is concluded that more needs to be written on this aspect of practice so that those new to action research can be made aware of the importance of the emotional components inherent within it, and can ensure that appropriate strategies are in place to enable them to engage with, learn from, and utilise such emotions to further inform their work. The messages in this thesis will be of relevance to those considering, undertaking, supporting and supervising action research studies. In addition, due to the similarities of action research processes, contexts and topic areas to other methods of practice change, they will also be relevant to those involved in general practice development activity.