The present study was undertaken to provide an understanding of the processes underlying health visiting practice. The research strategy selected was grounded theory (Glaser and Strauss 1967, Strauss 1987, Strauss and Corbin 1990). A total of 21 female health visitors from a District Health Authority in the North West of England participated in the study. Data was collected by means of 20 formal interviews and 41 days of participant observation in four different health centres. To recognize the basic social process in any interaction is one of the major aspects of grounded theory. This requires the identification of the "Phenomenon" which motivates the development of a process and the conditions under which it operates. The basic problem or phenomenon in health visiting uncovered in the data was "Securing Life Trajectories". This forms the core of the health visitor's work. The general set of conditions that influence health visiting work was identified as "Working Between Two Worlds". This is used to describe the health visitor's position between the policy agenda and the client's agenda. The process revealed in the data that health visitors use to respond to this overall problem was "Marketing Health Visiting". This refers to the different tactics that they use to introduce the policy agenda into the client's domain. During this process the policy agenda is adjusted to fit the client's circumstances. Three major strategies are identified in this process: 1) Promoting the service, 2) Adjusting delivery and 3) Tailoring the content. This study found that "Marketing Health Visiting" is a gradual process in which the health visitor wins grounds as time passes. As marketing strategies are implemented the conditions influencing the interaction change. Hence it moves from taking place in what is labelled in this study as "Dissociated Context", to a "Convergent Context" and finally to a "Shared Context". The final consequence of implementing marketing strategies is that of constructing "A Common Agenda" with clients. This agenda is basically the personalisation and contextualization of health visiting services. To build this common agenda it is of crucial importance that the client should see and feel the need for the health visiting service as well as the development of trust between the professional and the client. Hence the relationship that is developed between them acts as an enabling factor for reaching mutual collaboration. The discussion of the study focuses on its significance within the actual debate on health visiting about introducing new ways of practice. The health visitor's overall role is examined and the importance of developing relationships with clients is also highlighted.

This thesis addresses from within the research paradigm of Conversation Analysis (CA) the question "How are interactions between patients and general practitioners organised? ". CA is a relatively recent tradition within the "interpretative paradigm" of sociology, growing out of the ethnomethodology of Garfinkel. The thesis first reviews the relevant literature of CA and medical interactions, and critically discusses the methodology. The empirical analysis used naturally occurring consultations in British general practice, video-recorded in five practices, involving 14 doctors, and about 50 hours of recording, made between 1987 and 1992. Recordings were observed first in an unmotivated way, to note occurrences of interesting interactional phenomena. Objects for further study were copied onto secondary "collection" tapes, which were then examined in depth, and transcribed in detail using conventions developed within CA. The analyses described here are: the use of time in the consultation; the impact of medical records on the interaction; prescribing and associated talk; the phenomenon of "facilitation", how doctors appear to enable patients to talk; patient-initiated questions, and rejection of patients' ideas by doctors; and finally the use of the word "we". The aim was to describe and explore, but not necessarily to explain, although in describing the mechanism of interaction in these areas of activity, empirical evidence is advanced for particular explanations. The phenomenon of patients raising new topics at the end of consultations is described, with its interactional implications: the "by-the-way" phenomenon is explored and documented. Case-notes are seen to contribute to consultations in a complex way, and like talk, are both context-dependent and context-forming. Utterances such as "right", "uhuh", "mmhm" which appear on the face of it to be facilitatory, can be the reverse. The phenomenon of dispreference for disagreements by patients is re-examined, and contexts in which patients do disagree are explored. Doctors' rejections of patients' ideas are described, and implications for teaching about the consultation are drawn. Finally the various ways in which the word "we" is used by doctors are described and critically appraised, in the context of a philosophical understanding of "intersubjectivity". The study adds to the body of transcribed interactions drawn from general practice, and sheds some light on ways in which general practitioners and patients structure their consultations. It has implications for the way medical students learn how to consult, and for how research on the consultation can be conducted. Conversation analysis is shown to be a powerful qualitative analytic methodology, relevant to the study of medical interactions.

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