In this thesis we explore innovation in general practices in Ireland. Drawing on an encompassing equilibrium, disequilibrium and learning-by-using model of adoption, we examine the influences of general practitioner (GP) and practice characteristics, strategic behaviour, learning and knowledge spillovers, and cumulative learning from previous adoption decisions on the perceived benefits of adopting and using innovations in general practices. Ours is the first application of this theoretical framework to timing of adoption, multiple technology adoption and intensity of adoption decision-making in a health care setting. Our examination focuses on three innovations, prescription drugs, medical equipment and Information and Communications Technology (ICT). Our analysis is based on two data sources, a secondary dataset which brings together GPs prescribing history over a 4½ year time period with information on the characteristics of the 625 GPs themselves, and a cross-sectional primary dataset which provides us with information for 601 general practices concerning practice structure and use of medical equipment and ICT. Employing duration analysis, multivariate Probit and ordered Probit econometric techniques, we examine the adoption, use and intensity of use of prescription drugs, medical equipment and ICT respectively. Irish GPs exhibit notable innovative behaviour with respect to prescribing innovation and practice development. Our research demonstrates that Irish GPs respond to informational stimuli with respect to adoption and use of new prescription drugs, medical equipment and ICT. Furthermore, Irish GPs are incentivised by commercial and market considerations. In addition, we find the extent which a practice adopts technologies and learns from that experience influences both ensuing prescribing and investment decision-making. Our empirical findings support an economic approach to examining decision-making in a health care setting and the application of our encompassing theoretical model to examinations of adoption and use of innovations by health care professionals.

This thesis analyses the aspirations and achievements of the lay women who were active in the campaign to improve women's health, and of those women who sought entry into paid occupations in the health services. After an introduction, Section One is intended to place the substantive data in context. Middle-class women's enthusiasm for voluntary work and the terms on which women entered national politics are discussed. These issues are used to illustrate the effects the maintenance of rigid social-class divisions had on the unity of the women's movement and the implications for the future of the movement of the decision to seek entry to the public domain on the grounds that women could make a unique contribution. Section Two is devoted to the lay women. First, the effect of the maintenance of rigid social-class divisions on the women's health campaign and on women seeking a career in the health services is discussed. Secondly, the consensus between both middle-class and working-class women, the medical profession and the Ministry of Health on the need to extend medical services is analysed, revealing an eagerness to follow technical advice which affected the strategy of the lay campaign and meant support for women workers in the health services was often circumspect. Thirdly, the reasons for the collapse of this consensus in the l93Os are discussed. This section is concluded with an assessment of the lay women's health campaign and a discussion of the impact the campaign had on women health workers. In Section Three, women's position as paid employees in the health services is analysed, and three occupations, midwifery, medicine and health visiting, have been selected. Difficulties these women encountered establishing themselves in paid employment, and their status and their relations with male colleagues and with the Ministry of Health are assessed. The differences between these three occupations, which prevented a sense of solidarity and an identification with the goals of the women's movement, are discussed. Their achievements during the period are assessed, and the effects of the medicalisation of childbirth and the increasing involvement of the state in maternity and child welfare are investigated. A fourth, concluding section draws these strands together. The lay women's health campaign and the goals and tactics of the women health workers are related to the maintenance of the existing social-class divisions, the ideological splits within the women's movennt and the persistence of barriers preventing women from competing on equal terms with men in the public domain. Although the number of women working in the health services increased dramatically and women's place in these services was assured, women generally remained in subordinate positions, excluded from the prestigious and lucrative posts, while they achieved only a statutory presence on decision-making bodies.

This thesis uses Habermas' arguments concerning the public sphere and Nancy Fraser's concept of counter-public spheres as a framework to explore how changes in the representation of mental illness occurred between 1870 and 1970. Within this period, the nineteenth-century polarisation of sanity and madness that had led to the segregation of the mentally ill within the asylum gave way to the belief that mental health and illness formed a continuum. Psychiatry extended beyond the walls of the asylum into the community, expanding its scope to incorporate the nominally healthy. These developments, which culminated in the creation of community mental health services and the closure of the asylums, suggest that mental disturbance was no longer seen solely as the problem of sick individuals but of the public at large, and points to a potential destigmatisation of mental illness. To examine if the representation of mental illness matched these developments in practice and to explain why, this thesis studies how groups directly connected to the mentally ill, conceptualised as sub-public groups, sought to represent mental illness. The groups studied are the Medico-Psychological Association in Chapter One, the National Asylum Workers' Union in Chapter Two, The Association of Psychiatric Social Workers in Chapter Three and a charity, the Mental After Care Association, in Chapter Four. The fifth chapter explores patients and the representation of mental illness. It is argued that such sub-public groups helped initiate a debate about mental illness and enabled a broader spectrum of people to participate in the debate. However, it is suggested that private and professional motivations impinged upon how groups chose to represent the mentally ill. The thesis argues that the difficulties groups experienced balancing the representation of their own interests with those of the mentally ill, combined with the negative perceptions some sub-public groups held regarding the general public's capacity to participate in a debate on mental illness, obstructed their efforts to communicate with the public and to represent the interests of the mentally ill. Finally, the thesis uses the case study of the BBC to explore the factors that influenced the media to cover the issue of mental health and illness. This final chapter illustrates the interactions that occurred between media organisations and sub-public groups.

Policy makers have increasingly regarded user involvement as an important dimension of service development. Current government policy advocates the involvement of service users in healthcare service development across all levels of an organisation, ranging from the level of individual service user to the development and improvement of health services (DoH 1992, 1999, 2001a, 2001b, 2003a, 2003b, 2004, 2005a, 2007a, 2007b, 201Oa, 201Ob, 2011, 2012). This has manifested in the creation of a number of public and patient involvement initiatives including Patient Advocacy and Liaison Services (PALS), Locals Involvement Networks (LINks), Patients Forums and more recently Healthwatch Organisations. User movements and policy pressures have also led to the formation of user led groups pushing for changes in health and social care. However, these groups often operate on the margins, and as such, lack the legitimacy to work alongside professionals in service development and improvement. Despite involvement being driven by policy, research suggests that user involvement is often tokenistic, unrepresentative (Contandriopoulos et al. 2004; Harrison and Mort 1998; Rowe and Shepherd 2002) and subject to a selection of those users deemed to be a 'safe pair of hands' (Hogg 1999, p. 100). Furthermore, user involvement has been exacerbated by the 'tick' box culture in healthcare and the growing managerialisation of public services, creating a smokescreen to authentic user involvement. A recent study (Lakeman et al., 2007) suggests that a hierarchy of service users has emerged based on knowledge and authority in the service user community resembling stratification akin to the profession of psychiatry. This study is a platform for this research which aims to offer empirical analysis to illuminate the processes of stratification which give rise to this hierarchy of service users, which Lakeman et aI.'s work suggested existed, but which was not empirically supported. In doing so, discussions centre along three main themes; knowledge, representativeness and the 'professional' user. Policies on user involvement have led to health organisations developing strategies around involvement where users are involved at all levels of the organisation. As well as these, a plethora of grass roots groups have gained momentum over the past twenty to thirty years (Hogg 1999, p.127) and in recent times with the support of user involvement legislations have gained greater legitimacy amongst professionals. However, organisations are in constant flux and as they become more embedded in the system and established, user-led groups may become 'professional' working closely with 'sympathetic' professionals (Hogg 1999, p.127). By applying theories from the sociology of professions on expert knowledge and jurisdiction in the context of user involvement policy and practice, I describe the processes that lead to the stratification of users and ultimately to unrepresentative involvement. Using two comparative cases of user involvement, one a top down initiative in mental health service provision and the other a user led stroke group with a focus on stroke service development and improvement, I examine the processes of involvement that give rise to unrepresentative user involvement. In doing so I hope to contribute to theories on user involvement by illuminating the processes which lead to the stratification of users and unrepresentative user involvement. The thesis beings by exploring the historic context of public participation and user involvement, the involvement process and debates around representativeness. This framework informs an analysis of rationales for user involvement and the challenges of involving the 'right' user. Using 40 in-depth semi-structured interviews, observations and documentary analysis the study presents insights of various actors' perspectives of the involvement process, non-representative involvement and the professional user. The remainder of the thesis presents and compares the empirical results from the two cases in mental health and stroke. The study draws on theories from the sociology of professions to highlight the processes which lead to the stratification of service users including their professionalisation. Akin to professionals, users were found to delineate jurisdiction using their expert knowledge and education, gained through the involvement process but also by drawing on their social status and previous professional work. The theoretical and policy literatures coupled with the empirical findings present a number of tensions. Policy directives on user involvement are awash with ambiguities resulting in different ideas of how involvement activities should be played out in practice. This is aggravated by the increasingly target driven NHS culture, where professionals often choose the easier option and involve those users who are known to them and who are usually more articulate and able. This results in the repeated involvement of a certain 'type' of user and the marginalisation of other 'lay' users leading to a hierarchy of users where a cadre of professional users dominate the user community casting other 'lay' users as amateurs.

The National Health Service (NHS) holds an esteemed position within Britain's `welfare state'. Since its inception, however, it has been subject to near constant reforms, seemingly intended to balance public expectations with available resources. Successive governments have required professional collaboration to gain crucial popular support, and increasingly, general practitioners have been prioritised within reform initiatives. Sociologists assert that professionals' reactions to reforms are often shaped by estimations of such reforms' influence on claims to professional status. Professionals react particularly defensively when they estimate that reforms challenge the foundation of status based on professional identity. Indeed, professions perceived as having `weaker' professional claims may engage more diligently with such defensive work, and general practitioners have been particularly virulent opponents to reforms. I spent eighteen months conducting ethnographic research into the role of GPs in the implementation of the reform initiative, ‘The New NHS: modern, dependable' (1997). I explored the translation of policy ideas into `real' working structures, seeking to address a gap in the literature between considerations of the formulation of official policy rhetoric and evaluations of reform effectiveness. Data revealed `clinical governance' and `delegation of authority to local professionals' as key concepts in shaping local reform implementation. In particular, official policy rhetoric outlined initiatives as unproblematic, whereas the data illustrated their complexity. Furthermore, contrary to expectation, interaction between GPs and the state was not overtly confrontational. Rather, local actors engaged multiple strategies seemingly intending to maintain locally formulated co-operation. Policy implementation was shaped more by efforts to protect existing local networks, than by professional efforts to defend against any one reform initiative. Professionals' engagement with policy objectives to protect their privileged status served to facilitate the operationalisation of ideas. The influence of particular local actors being such that they were often able to mould policies to serve their own agenda.

This study focuses on the way in which rapid structural changes (such as economic development, urbanisation and other demographic factors, and the economic crisis of 1997) have raised issues that are seen to require a social policy response in the mental health care arena under Confucian governance in South Korea. These structural changes happened over a couple of hundred years in Western Europe but have taken place over only the past 40 years in Korea. The main thrust of the study is on the extent to which the decisions about policy responses to perceived social problems, especially the increasing number of people with mental health problems, are structurally driven or the extent to which they are informed and shaped by Korean politics and culture. The industrial and economic base of Korea grew dramatically until the late 1990s. This facilitated the development of social policies - particularly in areas such as education, health and housing, which support economic growth. However, although the structure of the family changed to be closer to its structure in the West, it could be argued that evidence pointing to a broader ‘Westernisation’ of Korean society was premature. Confucianism may have been a factor in Korea's development, but it may yet prove a hindrance to any further moves to modernity and equalisation of life chances amongst its citizens. Since the economic crisis of 1997, Korea has experienced a rapid expansion of social welfare provision following a series of reforms. These reforms have gone beyond the functional minima necessary to deal with social problems caused by the economic crisis. However, the government has tended to stress the greater role played by family members, particularly women, in providing care to their elderly relatives, and the desirability of multigenerational households over nuclear families. A similar emphasis on the caring roles of the family and community is also seen in the Korean state's renewed public emphasis on the country's Confucian cultural tradition. As a result of this, there has been a tension between the increased emphasis given to the role of the informal carer within mental health policy as the Korean government has introduced a community-based scheme which assumes that families want to care and those with mental health problems want to be cared for by their families. Accordingly, the main burden of care falls upon women. This still tends to be ignored by policy makers. Despite the country's rapid demographic, economic and social changes, there has been a widening gap between the population's expectations and needs and health and social service provision in the mental health arena. Neither long-term care services nor personal social services are well developed for those with long-term mental health problems. In addition there is a marked disparity between the acute services, which are predominantly provided by private sector organisations in a highly competitive market and broadly achieve high standards, and public primary care and rudimentary residential services in the mental health arena. In this context, it could be argued that Korean mental health policy is concerned with maintaining social order rather than care and treatment of those with mental health problems.

There are various views towards Attention Deficit Hyperactivity Disorder (ADHD) and the recent introduction of the disorder for adults has added to the controversies. I intend to explore variation in clinicians’ perception and approach towards adults with ADHD. I produced a vignette describing an adult with a diagnosis of ADHD and sent it to 150 clinicians. I received 44 replies, and performed 16 semi-structured interviews. I found participants suggested various diagnoses, causes of the problem, treatments, and the appropriate professional group for the vignette. Participants confirmed the existence of variation in the clinicians’ perception and approach. Their views also suggested that the different characteristics of clinicians, diagnostic methods, psychiatric disorders, the possibility of access to different information and social factors were contributing to the variation. In addition, my analysis indicated that participants might have different perceptions according to their experience, awareness and work-settings. I found that the variation might be also related to the inclination of participants towards particular disorders or styles of practice, and hermeneutical factors. Finally, I produced a model that illustrates a relationship between different factors with the variations in clinicians’ perception and approach. In conclusion, I suggested the dependency of diagnosis on clinicians, the possibility of a variation in their knowledge, and gaps between research and practice. I described different types of competition that exist in the process of the medicalization of ADHD. Finally, I discussed directions for future investigations.

This thesis examines the health-seeking behaviours of Korean migrant women living in the UK. Theoretically, it argues for treating migration as a process of 'subjectivisation', in the specific sense in which this concept is employed in the work of Michel Foucault, and cliams that migrants' health-seeking behaviours always presuppose and refer back to a fundamental process of assuming, appropriating and manifesting the dominant form(s) of subjectivity within the domain of medicine of the host country-in the case of the UK, the medical subjective form of the 'active patient' and/or 'healthy citizen'. In the present work I show that Korean migrant women tend to resist this process of becoming subject to the ideal active patient model until they happen to undergo some profound and life-altering experience that forces them to come to terms with the British system and its ideal forms of knowledge and behaviour. For (but not all) Korean migrant women, this life-altering experience is that of pregnancy, delivery and childbearing. Pregnancy and childbirth constitute the turning point in a process of subjectivisation and culminates in the institution of a dual medical citizenship. In other words, while they never totally reject their former autochthonous mode of medical subjectivity ('good patient'), they nevertheless come more and more to appoximate the British model subjective form. On the other hand, when it comes to their children, who are ethnically Korean but born and raised in the UK, they tend almost fully to surrender to the British ideal, recognising that their childrn, while Korean, nevertheless possess originally British bodies that demand British treatment. This causes them to become extra vigilant and resourceful regarding their health-seeking behaviours, bringing them more fully in line with the ideal form of medical subjectivity of the active/healthy citizen.

The toxicological investigations demonstrated quite clearly the different toxicological properties of the MA, CRS and ANR. The CRS proved to be fibrogenic in rat lung with a 5.0mg single instillation dose after long-term (1 year) exposure whereas ANR was minimally bioreactive. The MA did not cause inflammation in the lung until 49 weeks post-instillation even though size augmentation with granuloma formation in thoracic lymph nodes were recognised at 13 weeks. These findings suggested that the size and granuloma formation of thoracic lymph nodes were good early markers to assess the toxicity of crystalline silica containing volcanic ash. Histopathological and physicochemical investigations confirmed that the particles drained from the lung were deposited in mainly the granulomatous areas in the nodes. Furthermore, the crystalline silica content of the MA in the nodes was greater than that noted in the MA in the lung tissue and the original instillate. The macroarray technology has provided additional information on MA and CRS induced inflammation. A number of candidate inflammatory markers were identified

Background and Importance: comparative evidence generated using systematic reviews and meta-analyses can form the basis of high quality prescribing decisions in clinical practice. Such evidence is imperative when choosing a first-line treatment among multiple alternatives, particularly in the United States where there is no single national authority responsible for providing practice guidelines for prescribers. Objective: Using cholesterol-lowering statins as a case study, this thesis set out to evaluate the comparative clinical benefits and harms of statins for the prevention of coronary heart disease. Novelty and Empirical Contribution: The empirical work presented in this thesis was based on a systematic review and network meta-analysis, for the first time combining the placebo-controlled and active-comparator trials of statins. Using 184 randomized trials including 260,630 individuals with or without cardiovascular disease, this thesis makes four major contributions to the literature on the comparative effectiveness and safety of statins, showing the following:(1) cholesterol-lowering effects of statins are less pronounced than suggested by the previous reviews; (2) statins potentially differ in terms of their comparative effects on clinically meaningful benefit outcomes, which are not fully explained by their cholesterol-lowering effects;(3) harms associated with statins are rare; still, some statins are safer than others; and (4) unlike previous findings in the literature, there is no evidence of industry sponsorship bias affecting the trials of statins. Implications for Clinical Practice: Although there are statistically detectable and clinically relevant differences among individual statins, the empirical work presented in this thesis does not conclusively identify a clear winner among statins that should be favored in clinical practice. Future&Research Directions: The potential mechanisms underlying the observed differences between individual statins should be investigated in future studies. Policy Relevance: The findings presented in this thesis suggest that statin prescribing patterns over the past decade – and in particular atorvastatin’s exceptional sales performance despite its equivalence to simvastatin – are not supported by the current best evidence. A proposed policy option is to raise the bar for market entry of new drugs by requiring comparative evidence at the time of approval decisions. Network meta-analysis methods can be used at the United States Food and Drug Administration setting, thereby making comparative evidence available before prescribing patterns are established.