This study critically engages with the concept of ‘recovery’ which has become a dominant discursive feature in the UK mental health policies. It asks ‘what people recover from’ through a case study of Chinese mental health service users in the UK. The dominant recovery approach under the dominant neo-liberal context tends to promote individualistic recovery strategies. It fails to address the structural inequalities that give rise to distress and mental ill health or place sufficient emphasis on the diversity of intersectional inequalities among service users that shape recovery journeys. To make visible what recovery means for ethnic minorities, Chinese mental health service users were chosen as the case study to explore how structural factors such as class, gender and ethnicity, contribute to their diverse recovery journeys. A synthesis of the Capabilities Approach and Intersectionality Analysis was developed as an alternative framework to shed light on the complex interplay of structure and agency in shaping recovery journeys. They were adapted as evaluation and analytic tools to reveal the social conditions that facilitate or hinder a meaningful recovery for Chinese mental health service users. Repeat in-depth life history interviews were carried out with twenty two Chinese people having received a psychiatric diagnosis, recruited from three cities in the England. Their recovery journeys were analysed thematically. Findings showed how the participants strove, sometimes cautiously, to retain and exercise agency to move from patienthood to personhood. Their journeys were shaped by social inequalities demonstrating that targeting social inequalities is essential for facilitating and nurturing meaningful recovery. Class, gender, ethnicity, ageism, and other forms of discrimination contributed to the diminishment or deprivation of capabilities, resulting in distress and mental ill health among the Chinese mental health service users in this study. The different ways that these inequalities intersected gave rise to the variations in what they needed to recover from and hence also the directions of their recovery journeys. The process of becoming a psychiatric patient can help develop capabilities for some but it could also result in a diminishment of other capabilities. While striving to rebuild a life they value, ableism and sanism intersect with other inequalities to constrain their life chances. While the way ‘hope’ was ‘adapted’ to limited perceived life chances and dominant ideologies of class, gender, and ethnicity could be capability diminishing and detrimental to nurturing their aspirations.

UK ethnic minority patients are reported to be under-represented in clinical trials. Under-representation of any patient group within an Randomised Clinical Trial can bias trial results and subsequent extrapolation into the general population. However, the true extent of ethnic minority representation in RCTs is masked by the poor quality of ethnicity data. This thesis investigates ethnicity data collection in healthcare and the representation of ethnic minority patients in RCTs in the UK. A systematic literature review of ethnicity data collection identified a paucity of published evidence. Self-reported ethnicity was recognised as the optimal method of data collection but training is needed to raise awareness of the importance of such data. Reasons for the gaps in ethnicity data were explored through a healthcare professional survey and focus groups with lay South Asian volunteers. The majority of healthcare professionals agreed it was important to collect ethnicity and emphasised the need for training. The focus groups revealed a willingness to provide these data, subject to being given information regarding their use. A second systematic literature review of interventions to improve recruitment and retention of ethnic minorities to RCTs found a dearth of literature from the UK. US studies reported financial incentives, government grants and the involvement of community representatives to be effective. Census data, hospital episode statistics data, clinical trials recruitment and reasons for non-participation, collected in one cancer research network, were used to assess the local representation of ethnic minorities within RCTs. The results did not show ethnic minorities to be under-represented, but there was insufficient evidence to rule out under-representation as a problem. Reducing inequalities in participation in clinical trials is dependent upon having accurate and complete ethnicity data. A change in policy to mandate the collection of ethnicity data in primary care and linked through to other healthcare service providers is required.

My substantial, original contribution to mental health research, education and practice spans 17 years, from the mid 1990s to the present day. It is a journey on which I consider I am still travelling, during which the landscape of mental health services and the workforce that delivers them has changed in an unprecedented fashion. It has been a privilege to have contributed to this metamorphosis which began with my research into diversion schemes for mentally disordered offenders (MDOs) moving onto interdisciplinary mental health education/training and workforce redesign. Latterly, my to contribution promoting service user-led research has revisited the care and treatment for MDOs, focusing on the effectiveness of participatory action research (PAR) for effecting improvements in care delivery for individuals with complex mental health needs.

This Health Services Research PhD, funded by the Chief Scientist Office (CSO), investigated the psychosocial aspects of obesity in a community sample of men and women aged 30-60 living in deprived and affluent areas of Greater Glasgow. The study incorporated a mixed method design and combined a community health survey and semi-structured interviews with a purposively selected sub-sample of questionnaire respondents. 52% of the participants who completed the questionnaire were either overweight or obese and 16% were defined as obese. Obesity and body image were not significant predictors of poor psychological health. Furthermore, low self-esteem was the most significant predictor of poor psychological health for both men and women. The quantitative and qualitative findings demonstrate that obese individuals are aware of their current weight status and express a desire to lose weight. Potential motivating factors for weight loss included health concerns, appearance, special occasions and psychological factors such as increased self-esteem and self-confidence. Participants were knowledgeable about the causes of obesity and had absorbed and understood health promotion messages regarding healthy eating and physical activity. However, they identified a number of barriers, which prevented them from fully implementing health promotion advice. The qualitative findings suggest the possibility of a cyclical relationship between dieting depression and emotional eating. In addition, the findings demonstrate that weight cycling – losing and regaining weight – was a common experience for the interviewees. As weight cycling is a potentially damaging health problem, it might be more appropriate to encourage obese individuals to maintain a stable weight and improve their health by re-focusing the issue on fitness rather than fatness.

This thesis sought a greater understanding of the social variables that influence diet and dietary change using a repertoire of research methods. The studies of the present thesis, like all studies, have methodological limitations and possible biases. However, after considering the problems of each study, it seems reasonable to make the following conclusions; 1) the poor were spending a greater proportion of their income on food, than people living on higher incomes; 2) providing food (and therefore health) for the family was the main responsibility of a woman in the household; 3) that all the individuals in the Income Charge study were meeting their basic food needs; 4) there was a strong desire to maintain 'mainstream' or 'normal' social eating practices following an involuntary decrease in household income; 5) there is an 'inverted V' relationship between income and variety with £20,000 as a turning point; 6) lower income families focus on meals rather than on the individual value of individual foods and on cost and taste of the food rather than its nutritional content; 7) the impact of a change in income on meal patterns, although variable from one individual to the next, was significant in most cases; 8) income was associated with dietary variety per se; 9) food changes evidence from the Income Change Study may support the view that less healthy eating in low-income groups may be a consequence of less healthy eating when a household income decreases involuntarily and 10) different subtle calculations of measures of income were found to have little notable impact on results and it was assumed that these measures could be used interchangeably in future studies as equivalence was good. For future research into the area of income and 'healthy' eating practices, the following recommendations were made: 1) studies need to have a fully comprehensive list of income and outgoings; 2) dietary interventions and health promotion activities need to consider advocating variety at each mealtime wherever possible; and 3) studies need to examine the possibilities that a change in income affects weight management in greater depth using objective tools where possible.

The increasingly important role of the family in providing home care for a relative diagnosed with dementia has become a recognised feature of contemporary heahh care. Few studies exist, however, that have examined the relationship these carers develop with the professional assigned to help them undertake care-giving. The relationship held with a key-worker may significantly influence their ability and motivation to undertake the tasks and lifestyle changes necessary for this role. This study's aim was to examine this relationship in detail and generate a theoretical explanation allowing a clearer understanding of the influential factors associated with creation and enhancement of this relationship. Grounded theory was considered the methodology best suited to this aim. Its principal advantage is that it allows the researcher to generate rather than simply test theory and it also provides the necessary degree of flexibility essential for such an exploratory study. In order to meet ethical approval requirements a purposive, rather than theoretical, sampling approach was used for the selection of carers. Approach into the carer sample was through the consultant psychiatrist who forwarded research packs to potential participants via the person with dementia. Eighteen carers met the entry requirements and were subsequently included within the study; along with their chosen key-workers who numbered eleven in total. The key-worker group were all front line workers from either a health or social care background. Nine of this key-worker group were qualified and registered worregistered workers while the remaining two were unqualified care workers working under the direct supervision of a registered social or health care professional. The carerlkey-worker pairs were interviewed in tandem and all interviews recorded. These were then analysed using the constant comparative method, a process helped by the use of NUD*IST computer software. The analysis progressed from initial data categories through to the final core category that provided an explanation of all subordinate data. This core category became the title for the theoretical framework that eventually emerged. Subsequently, a theoretical explanation of the relationship's development was generated along with how it impacted upon the care-giving environment. The theory began with the major category 'The Enhanced Relationship Drivers', which highlighted that while characteristics associated with this relationship were often obscure, there were significant qualities and actions that clearly enhanced the relationship. Once these were engaged both parties moved towards the closer 'therapeutic alliance' contained within the second major category area, 'Models of Action'. Here shared qualities and attributes were more successfully directed towards the care of the person with dementia. A direct outcome of this alliance was a potentially closer and more productive working relationship for both the carer and key-worker. This could result in the creation of an improved therapeutic milieu, minimising the more negative interpretations associated with care-giving. These more negative perceptions of care-giving were highlighted within the third major category 'Impact upon the World of Caring'. However, when the enhancing influences of the preceding major categories were enacted, a more 'Rewarding Care Experience' was possible. External mediators could impinge upon the relationship, either impeding or enhancing its development. These included factors such as the management style of the key-worker's employing authority, the availability of alternative support networks for the carer, as well as the educational/life experience of both members of this dyad. The derived theory has been diagrammatically represented to provide a clear demonstration of all theoretical links between codes and categories, facilitating a better understanding of the developed theory. The study provided a clear insight into the interpersonal processes associated with the carerlkey-worker relationship and how this relationship may more effectively be initiated, managed and strengthened. This theory has important implications for future research into similar psychosocial aspects of care-giving. These findings have ramifications for carer training as well as education and training courses preparing professionals to work more effectively with carers. It has implications for health and social care managers in terms of their level of awareness of the importance of this relationship and the need for investment in it. lt is important that this theory is exposed to more rigorous empirical study allowing for a more confident prediction that its propositions will produce the direct benefits for this relationship that this theory suggests.

No description available.

The assessment of need underpins the delivery of community-based care. Following the NHS and Community Care Act (1990), the principle of needs-led assessment was reinforced as it applied to the assessment and care management process. Translation of needs-led assessment into practice in Scotland has been further influenced by policy-based organisational change including the introduction of Single Shared Assessment and Community Health Partnerships. This study seeks to describe the political and practice landscape within which needs-led assessment exists, identify and explore factors which influence needs-led assessment, and consider the practice implications of the policy driver for community-based practitioners across the main disciplines of health and social care. Following a short pilot, the main study was undertaken using sequences vignettes within a semi-structured interview involving 105 social workers, health and housing staff. Key findings indicated a cloak of consensus around definitions of need and assessment with perceptions based upon a medical or social model of care or a professionally or personality-driven assessment of need. A preoccupation with the outcome of assessments caused many respondents to describe needs with reference to the interventions or resources required to address them. The practice of needs-led assessment, according to study results, was hampered by an awareness of resource availability, concerns over client compliance and risk and, an underlying alignment to the values and principles upheld by the employing discipline.

In April 2002, five years after the Blair government’s proposals to create a ‘New NHS [National Health Service]’, the government outlined the key priorities that would mark the NHS reform. The main reforms involved patient choice supported by a system of ‘Payment by Results’ (PbR) under which hospitals would be funded on the activity they undertook. PbR is a case based payment system, a type of system increasingly being adopted as the main form of provider payment across industrialised countries. The literature on this type of payment system and experiences from other countries identifies many di!erent behavioural incentives that can have both positive and negative impacts on quality of care. This thesis investigates the quality implications observed so far in England, for seven conditions which represent a spectrum of important clinical areas that are admitted through both emergency and elective admissions. In order to identify changes in quality, this thesis first considers how to construct an appropriate measure of quality. The first part of the thesis utilizes two di!erent methodological techniques used for quality measurement; a latent variable approach and a technique put forward by McClellan and Staiger (1999) using Vector Autoregressions. The results from these techniques indicate that quality measurement approaches di!er markedly with regards to how much measurement and systematic error they are able to filter out of raw outcome data. Finally, the new indicators created by these techniques are used to evaluate the quality impact the introduction of PbR as the main form of hospital payment has had in England. The analysis indicates that since the policy’s implementation, there have been di!erential quality e!ects on the di!erent conditions. However, for the most part this indicates an improvement in mortality outcomes, and a reduction in the variation of outcomes across hospitals. As found, the interpretation of readmissions has to be approached with caution as more severe patients being kept alive through quality improving measures on mortality create more mixed signals for the readmission indicators. In two conditions we find changes in activity that are indicative of e"ciency gains, in the form of better coding and adoption of new technology, both as a result of differences in reimbursement categories.

This thesis explores conceptualisations of ethical subjectivity in the stories of people who have, or have had, cancer and who use complementary therapies and self-help (complementary self-health). In England the increasing emphasis on individual responsibility and choice in healthcare means that those with cancer are now in the position where they have to make many of their own decisions about their treatment. For the people with cancer in this research this included choosing complementary self-health. The thesis explores the stories and experiences of people with cancer who used complementary self-health. The aim of the thesis is to document and make visible the many original ways people come to understand themselves as able to ‘heal’ their health, self and life. The thesis also reflects on the highly unusual position of the author, who was himself diagnosed with cancer mid-way through his fieldwork. The problems and challenges to the research are explored in the thesis, which became a story in itself. The thesis finds the ‘price that is paid’ for the way that the interviewees came to think of their selves in their subjectivity. The interviewees told open and ongoing stories of ‘balanced living’ and how they found ways to listen to their ‘embodied guides’. They also described how understanding ‘cancer as an opportunity for change’ helped to transform and transcend their previous ways of living. In doing so they provided themselves with new narratives of the past and future, which were situated by ‘living in the now’. The thesis explores the ethico-political repercussions of these new formations of subjectivity. In doing so it argues that the ‘spiritual’ component of the stories remains unaccounted for and under conceptualised in contemporary sociological theory of health. It concludes with suggestions of how to move contemporary analysis beyond its present ethical concerns with the subject.