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This study aims to explore the healthcare experiences of people with learning difficulties and their carers. This area has become highly topical as a result of recent national health and social care policies that have emphasised the social inclusion agenda and the right of individuals to have a say in decisions that directly affect their health and wellbeing. This study exposes tensions between individual and social models in accounting for the healthcare experiences of people with learning difficulties. The decision-making process is complex and traditionally many people with learning difficulties have been judged incompetent to make their own healthcare decisions. However, the recent Mental Capacity Act 2005 proposes that people with learning difficulties should, like other people, be presumed to be competent (to make decisions) unless there are strong contraindicators. This proposition is tested in the study. To capture the voices of people with learning difficulties, particularly those with limited articulacy and no speech, ethnographic and narrative methods are used to include voices that may otherwise remain unheard. These methods were informed by a constructivist approach that involved working as closely as possible with informants in order to reach a shared understanding of their experiences. Recent policy proposals suggest that all parties within the healthcare encounter need to work 'in partnership' and 'collaboratively' to provide a more 'person-centred' healthcare encounter for people with learning difficulties. An attempt is therefore made to deconstruct these ideas and to examine what light they shed on the lived experiences of people with learning difficulties in relation to their healthcare encounters in mainstream and specialist services. The study can be seen as adding to the growing literature about the lived experiences of people with learning difficulties, to narratives about their everyday lives, to a questioning of tacit assumptions by staff about capacity and best interest, and to the power struggles people with learning difficulties continue to face in their everyday lives. The findings also demonstrate how situational and contextual factors mediate experiences, re-emphasising the importance of the social model of disability.

This thesis explores how women with oral cancer in Pakistan make sense of their experiences. The social context of Pakistan is seen as integral to people's meanings and experiences because it is intimately connected. Oral history interviews were conducted with fifteen women diagnosed with oral cancer receiving treatment at the Foundation University College of Dentistry, Pakistan. The findings suggested that the pathways to diagnosis with oral cancer could be direct or circuitous. These variations reflected the interplay of the social determinants of health, which included socioeconomic status, gender, beliefs in alternative medicine and religious influences. Socioeconomic status mediated access to diagnosis with some participants reporting extensive consultations with spiritual healers before accessing medical services. This contributed to late presentation for diagnosis. The diagnosis often left participants feeling that God had decided they would develop cancer. Cancer was interpreted as a death sentence and in some cases as a personal punishment. Participants also tended to resort to home remedies and alternative medicines before accessing dental professionals. Gender acted as a determinant by promoting the isolation of women from social participation in education and health. Participants interpreted the use of naswar, areca nut, chillum, bleeding gums, boils/ulcers and past sins as the main causes of oral cancer. Some women reported having to go through their husbands and complex private networks in order to secure diagnosis. This meant that they would often present late, which has implications for disease progression. The social position of women also affected how they made sense of their disease through their faith and talking more about its impact on their family. The findings of this thesis suggest that oral cancer diagnosis in the context of Pakistan develops within complex individual cosmologies and pathways, determined by the perplex interplay of the social determinants of health.

Background: Children with disabilities experience poorer oral health and have higher oral health needs than their non-disabled peers. The poor oral health status of children with disabilities has been attributed to a variety of factors; from chronic diseases and conditions, to the varying knowledge and negative attitudes of oral health providers. Other barriers include accessibility and availability of oral health services, the skills of oral health professionals, and family support to maintain oral health. Access to oral health services would also appear to be an issue, but it has not explored in depth. This thesis employed a city in the Kingdom of Saudi Arabia as a case study to explore the ways that fathers of children with disabilities access oral health services. Methods: Ethnography was used as the methodology and this involved observation of 4 dental settings, interviews with 25 participants and 2 focus groups with 13 participants in total. All interviews were carried out in Arabic, recorded and transcribed where possible and then translated from Arabic to English. Thematic analysis was used to identify themes. Results: Parents, mainly fathers, of children with disabilities acted as gate-keepers for accessing oral health care services. Saudi culture played an active role in accessing oral health services because wasta (is a form of connection, contact, network and nepotism) and social networks were identified as means to ease the process. Affordability, availability, accessibility and geographical location of services were an issue within Al-Madinah and related to an inequitable distribution of services and resources. Conclusion: Overall, the findings of this thesis suggest that access to oral health care services for children with disabilities in Saudi Arabia exhibits some similarities to the evidence base, but there are also differences to access compared to those described in western countries. The differences could be attributed to lack of oral health policy and guidance for children with disabilities, cultural perspectives around oral health and service provision within the Saudi community and structural contrasts in commissioning and oral health service provision in the Kingdom of Saudi Arabia.

Background: Despite a call for participatory child-centred approaches in oral health there remains a lack of research regarding children's participation in oral health promotion. The aim of this study is to explore the meaning and dynamics of children's participation within an oral health promotion programme. Method: This study involved an ethnographic-case study approach. Data collection involved participant observation of children and Early Years Professionals (EYP's) within 2 toothbrushing clubs set in 2 nurseries over a period of 9 months. In addition, 6 semi-structured interviews were conducted with EYP's and oral health promotion professionals. Purposive sampling was used to select the nurseries. Data were analysed using inductive thematic analysis. Results: The model of children's participation provided by educational pedagogy in early years education provides a better understanding for facilitating and enabling child participation within a nursery setting. Children's participation in the toothbrushing club was significantly shaped by the setting, the practitioners' capacity and their views of children's participation and childhood. Discussion and conclusions: Children's participation in toothbrushing clubs may be better understood from a relational perspective which values interactions and places emphasis on the adult as the enabler of participation. This perspective has implication for health promotion and has yet to be fully appreciated in oral health promotion. There appears to be a discrepancy between policy and practice resulting in the mouth still being separated from the body and oral health viewed in isolation to general health by policy makers. The nurseries in this study each took on a different approach to their toothbrushing club. The capacity of each nursery may influence the approaches that EYPs adopt in promoting oral health. This highlights the importance of the need for capacity building through continuous professional development of staff-human resources.

Objectives: Head and neck (H&N) cancer is commonly cited as the most emotionally traumatic of all tumours with potentially severe impacts on quality of life (QoL). Social support is increasingly recognised as playing an important role in helping people cope with the diagnosis, progression, and outcomes of cancer, including H&N cancer. Using online support groups (OSGs) has been found to be associated with a range of positive psychosocial outcomes in relation to several health conditions. The aim of this thesis was three-fold; firstly, to assess the types of social support, sought and offered, within OSGs for H&N cancer. Secondly, to explore the relationship between using OSGs and QoL and examine the psychosocial factors that may influence this relationship and, thirdly, to explore, in depth, the OSGs experiences of people with H&N cancer. Methods: Two studies are reported in this thesis: Study 1 was a content analysis of posted messages within H&N cancer-OSGs. A total of 312 support-offering messages and 87 support-seeking messages (in a one year period) were randomly selected from 18 H&N cancer OSGs. The content of the support-offering messages were analysed using a modified version of Social Support Behaviour Code and the content of the support-seeking messages were analysed using a modified version of the Coursaris and Liu coding scheme. Study 2 was a cross-sectional study consisting of two parts; the first was an online questionnaire using six pre-validated measures for social network, self-efficacy, anxiety and depression, adjustment, empowerment and quality of life. In addition, socio-demographic as well as illness-related and OSGs-related information were collected. This questionnaire was completed by 199 persons with H&N cancer using four OSGs within a 6 month period. The second part of Study 2 was an unstructured online interview in which, 30 people from the previous 199 were interviewed synchronously online using Facebook, Email, Skype, Yahoo messenger and MSN, and a narrative thematic experience analysis was conducted on the data. Results: The content analysis of Study 1 showed that the most frequently offered types of social support by members of OSGs were informational (43.4%) and emotional (32.4%), followed by esteem (15.65%) and network support (6.04%), whereas little tangible assistance was offered (2.47%). The content of messages seeking support included OSGs members sharing personal experience (31.52 %), with the most frequently sought support being informational support (25.54 %). In the quantitative part of Study 2 a series of multiple linear regression analyses indicated that longer use of OSGs was related to better QoL (p= 0.02), and lower levels of depression and anxiety, lower endorsement of negative adjustment behaviour (p = 0.00 for each), greater self-efficacy (p = 0.02) and higher levels of empowerment (p = 0.01). Additional analysis of mediation effects suggested that depression and adjustment were direct mediators of the relationship between OSGs and QoL, whilst anxiety, self-efficacy and empowerment were indirect mediators. The narrative thematic analysis of the qualitative part of Study 2 showed that one main theme emerged (Trust) which included four subthemes: (1) distrust, (2) institutional trust, (3) identification based and relational trust (4) power relationships and normalisation. Conclusion: The advantages of cancer related-OSGs appear to be inclusive; regardless of location, access, availability or user characteristics. The results of the studies tentatively suggest that OSGs could benefit H&N cancer patients by providing support and information related to their condition, enhance empowerment processes and patient’s beliefs in their control over their H&N cancer, as well as reduce anxiety, depression, and negative adjustment behaviours and subsequently improve quality of life. Moreover, these results support previous research on other types of cancer in importance of trust in managing online relationships and further emphasises the complexity of online social relationships.