By the next decade, 5.1 percent of the British population will be over the age of eighty years. Women will make up over half of this figure. Finding ways of helping elderly women to maintain good health and therefore well-being, will become even more critical. Exercise is increasingly being recognised as a possible way of promoting health for elderly women, as evidence is emerging of the physical and psychological benefits that accrue from exercise. However, the empirical research evidence on exercise has derived mainly from young and middle-aged males, which means little is known about the specific benefits of exercise for the elderly and there are few tools to measure accurately exercise behaviour in this population. In the few exercise studies which have been conducted with the elderly, methodological flaws have often left the results unclear. Exercise up-take and adherence amongst elderly women is also low and psychological models have so far failed to adequately explain the reasons for this. To achieve the aim of this thesis to contribute to knowledge on the relationship between physical activity and well-being in elderly women, three studies are conducted. In study one, a postal questionnaire for measuring exercise behaviour, beliefs and attitudes in this population was first developed (the London Health and Fitness Questionnaire; LHFQ) with 248 elderly women. Second in study two, a randomised controlled trial of 100 post-menopausal women assigned to either a six month brisk walking programme or homeopathic dose of exercise was conducted. Baseline and six month measures of stamina, leg strength, exercise attitudes (using the LHFQ) and subjective health status (using the Nottingham Health Profile; NHP) were taken. Finally, study three is exploratory, and examines the influences on elderly women's participation in domestic and sporting physical activity, in a sample of 820 retirees from a major national retail company. The LHFQ and the NHP were used to obtain data. In study one, the reliability and validity of the LHFQ proved acceptable. Re-test reliability was best for number of hours spent on carrying out errands and recreational exercise, but lowest for reports on past exercise experience and identifying barriers to exercise. The LHFQ appears to have satisfactory face, content and construct validity. In study two, repeated measures ANOVAs were used to detect any changes between and within the brisk walking and placebo exercise groups over the six month period. Mean scores on the NBP indicated that the brisk walking programme had a more beneficial impact on health status, with significant improvement in perceived physical mobility. Significant positive changes were also noted for brisk walkers on two exercisea ttitudes tatementsS. taminaa nd leg strengths ignificantlyi mprovedf or both groups over time. A number of threats to the internal validity of the study findings emerged and these are discussed at length. In study three, multiple regression analyses indicated that although different factors influence domestic and sporting activity, good-health status and age (being younger) are core variables influencing both these activities. In addition, positive exercise beliefs and attitudes, and past exercise experience were shown to influence exercise behaviour.

This thesis is about the pregnancy and childbirth experiences of two different groups of Asian women in Britain. It sets out to address the issues surrounding pregnancy and childbirth from the women's point of view. This is an attempt to redress the balance in the previous research on Asian women which has often portrayed them as a homogeneous group with 'problems'. An overview of the literature focuses on how Asian communities and, in particular, Asian women are portrayed. In order to provide a context for the issues which emerge in this research, attention is paid, first, to how Asian communities and, in particular Asian women, are viewed by mainstream society and, second, to cultural attitudes towards the sexual politics of reproduction. The main theme of the research is the degree of control the women were able to exercise given the constraints of western medicalised childbirth practices in Britain, traditional childbirth practices and the role played by the women's relatives during pregnancy and childbirth. The study draws on in-depth interviews (during and after pregnancy) with two samples of Asian women- the first Gujarati, the second Bangladeshi. In addition, two Gujarati case studies and two Bangladeshi case studies provide further insights into the lives of these two groups of women. The women's perceptions of their experiences of pregnancy and childbirth are emphasised by the use of the actual quotes which give some indication of the way these women conceptualised the issues which confronted them. The final chapter of the thesis concludes with a discusses of the position of Asian women within the current childbirth debate and makes suggestions for improving the delivery of maternity services to the Gujarati and Bangladeshi women in particular and to Asian women in general.

Aims: 1. To add clarity, specificity and breadth to current descriptions of the diagnostic thinking process as hypothesis generation and testing. 2. To propose possible pedagogical strategies for efficient and effective development of appropriate diagnostic thinking processes. Subjects and Methods: The study was in two complementary parts: 1. Quantitative data. Structured questionnaires in endocrinology and neurology allowed analysis of the relative contributions of (1) factual knowledge, (ii) interpretation of symptoms and. signs, and (iii) selecting and testing diagnostic possibilities, towards predicting diagnostic ability in 35 final year clinical medical students and 35 registrars per questionnaire. 2. Qualitative data. Introspective account gathering by videotape stimulated recall of clinical interviews yielded data concerning the diagnostic thinking processes of 22 final year medical students, 22 house offloers and 22 registrars. The research design allowed analysis of the development of the diagnostic thinking process, the relative effects of medical education and clinical practice and comparison of these in two specialities. Results: After parametric, non-parametric and content analyses, the results of the two studies were related to yield a unified explanation and description of the diagnostic thinking process in medical education and clinical practice. Its fundamental psychological features are identified as structure and extrapolation. Three stages are Identified and discussed In terms of wider psychological theory. Speciality specific and generalised cognitive processes are identified. Development of the diagnostic thinking process is described in terms of increasing equilibration of the skills measured in the quantitative study. The qualitative study shows that students, house officers and registrars are In command of the same range of cognitive processes although their relative contributions and associated appropriateness and accessibility of content might vary between groups yielding different degrees of diagnostic accuracy. The diagnostic thinking process in all groups of subjects is shown to be considerably more complex than previous descriptions have suggested. Pedagogical implications are discussed.

This study looks at the nutritional literacy of20 Greek and 20 British students who were about to complete higher secondary education. The meaning ofa balanced diet is discussed and a model is proposed according to which a balanced diet aims at the promotion ofthe overall health ofthe individual and not only the prevention of diseases. The various social psychological theories that have been used in surveys and health interventions are reviewed. Nutritional literacy is analysed with regard to four issues: understanding of health, understanding ofa balanced diet, ability to make informed food choices and ability to describe and comment on one's own dietary habits. For the exploration of these issues, an interview was selected as the research instrument because it is resilient and can focus on each subject's views. The schedule ofthe interview was developed through three series ofpilot interviews. The data collected were analysed qualitatively, but some statistical methods were also deployed. Students defined health positively, i.e. in terms ofgood health rather than the avoidance ofill health, and referred mainly to bodily health. They spoke about habits that we must adopt rather than about habits that we must avoid. Diet and exercise were the most often reported health-promoting habits. For most ofthe students, bodily growth and good looks were the aims ofa balanced diet. Some students reported the prevention of cardiovascular diseases through diet, but most ofthem ignored the links between the type ofdiet and cancers ofthe digestive tract. Some students interpreted nutritional information in a way that reflected their own strongly held views about the nature of a balanced diet. Students' views and their ability to plan a balanced diet were characterized by high accuracy but low comprehensiveness. Finally, students were rather selective in the description oftheir own diet. Most ofthem reported that they are more or less committed to a healthy diet. However, they did not identify this commitment as a precaution against ill health.

This thesis presents a detailed analysis of illness related costs of human salmonellosis In England and Wales, estimated at £263 million (minimum), including intangible costs, in 1988, and explores potential benefits of preventive activities aimed at the poultry industry. To explore trends In reported infection and the factors which may influence those trends, salmonella reporting between 1960 and 1989 was examined. Trends in foodborne Illness were associated with increased reporting of salmonella infection. The factors which contributed to this increase included Intrinsic factors such as the microbiological quality of food, and extrinsic factors such as ambient temperature which may amplify intrinsic effects. Evidence that poultry products were important vehicles of human Illness was supported by trends in infections in animals and poultry, and food consumption patterns. Thus a significant decrease in human infection would result from reduction in poultry contamination. The findings of a unique and detailed survey of 1,482 human salmonella cases, presented in this thesis, indicated tangible costs of illness of £996,350 to £1,091,131. Over a third (E392,822 - £426,887) were costs related to investigation and treatment of cases and over half (E507,555 -E559,401) was production loss associated with sickness related absence from work. The remaining costs Identified represented important costs to affected Individuals and their families. Additional intangible costs of £1.57 million to £5.07 million were ascribed to value of lives lost and to pain and suffering estimates. Extrapolation of costs, utilizing an index of severity developed for this study and categorisation of cases by level of treatment demanded, indicated national, tangible, costs of £231 million to £331 million; additional intangible costs were £32 million to £119 million). The cost-effectiveness of limiting these totals was explored by two approaches. Cost reduction by changes in cases management (eg. reducing faecal specimens tested and time off work) indicated small potential savings. However, substantial benefits were indicated by cost-benefit analysis of preventive activities including irradiation of poultry carcasses and use of competitive exclusion methods in poultry rearing.

The 'sun-rise' industry of private health care, especially private hospitals, in Thailand throws many questions to the health policy forum. Will the growth of the private health sector reduce public health expenditure, or will it increase total expenditure on health? The focus of this study is on equity in health and health care: in a country where private expenditure dominates total health expenditure and the government lets the private health sector flourish, in this scenario, are the poor or the underprivileged the victims of this limited privatisation policy? The main research objective was to assess the equity of coverage of public and private health in an urban area in order to identify policies of promotion and regulation which would lead to an equitable and efficient health service system. The study used Phitsanulok municipal area as a model to develop policy recommendations for other urban areas. There were three main methods of data collection: general household survey, health diary plus household health interview and a one-day bed census of patients in public and private hospitals in the municipality. The first two methods employed multi-stage random sampling with clusters of 12 and 3 households, respectively, as smallest sampling units and these neighbourhood households were divided into three groups to represent each season in a year. The main findings were that inequalities in health existed among different household income, education and occupational groups, including these attributes of the education and occupational groups adjusted according to the household head. Unequal accessibility to health care seemed to affect both reported rates of illness within the past two weeks and hospitalisation during the past 12 months. Inequity of health care financing was obvious in that the underprivileged (the poor, the uninsured and underinsured) paid out of pocket as a percentage of their household income higher sums than the privileged groups. The private health sector (private clinics and private hospitals) was the major provider of health care to urban dwellers for both outpatient and inpatient services. Users of public facilities were the lower income groups and civil servants, while users of the private health sector were the higher income groups, the higher occupational groups and the younger age groups. Inpatients of private hospitals were more likely to be covered by health benefit schemes (civil servant benefit, private insurance, etc.) than inpatients of public hospitals. Information on the utilisation and financing pattern of private health services reconfirmed inequity of health care financing. It is obvious that the Thai health care system needs changes to reduce inequity in health and health care. Universal coverage is a way towards more equitable health care financing. While Thai citizens (in urban areas) have enjoyed a wide choice of health utilisation, a public competition model could be applied to the public health sector to make public services more competitive and more efficient.

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