This article draws on data from a Stroke Association–funded longitudinal study in South East England (2003–2006) that explored the experiences and recovery of 43 stroke survivors under 60?years. Participants were invited to take part in four interviews over an 18-month period and to complete a diary for 1?week each month during this period. Here, we chart their shifting attitudes towards the process of their recovery. We bring a focus to how this transformed their views on the possible futures before them. We underline how hope was experienced as a deeply paradoxical and risk-laden notion. With energies concentrated upon the effort to live positively in the here and now, the very idea of hope for the future was met as an unwelcome distraction and in some cases even as a source of distress.

Active self-management of diabetes is essential for reducing the risk of serious complications. However, research indicates that many people with diabetes struggle to adhere to complex self-management regimens. Here, the authors describe the development of an intervention – a "concordance therapy" – to support diabetes self-management. The approach uses techniques from cognitive behavioural therapy and motivational interviewing to help people with diabetes and healthcare professionals work together to develop self-management regimens that are realistic and that work for the individual. Following development work, the intervention was piloted with a sample of older adults who had inadequately controlled type 2 diabetes. The authors' findings are presented, along with their considerations for future work in the area.

Trust is vital for quality healthcare outcomes, yet existing research neglects the 'embodiedness' of the interactions on which trust is based. This article draws on qualitative data from semi-structured interviews on cervical cancer patients. The significance of body work in winning or, on occasions, undermining trust emerged as a key theme within the responses interpretations of professionals' verbal and non-verbal presentations-of-self were often mutually reinforcing and intrinsically linked - forming a more general locus of meaning from which assumptions of competence and care were drawn. Yet it also became apparant that, whilst verbal communication was useful in establishing the agenda of the professional in relation to that of the patient, it was body work which was crucial in corroborating and validating beliefs pertaining to the ability and willingness of the professional to deliver this agenda in the future. The multi-temporal nature of trust makes apparent how certain seemingly distinct forms of body work - as presentation-of-self versus more hands-on modes - are inherently intertwined. Trust, and the affective relationship in which it is rooted, bridges the present with the future and thus makes apparent how seemingly 'detached' forms of body work are connected to the emotion-work of the caring role and the craftwork of body work as touch.

A lack of trust between clinicians and junior/middle managers is well documented in health care systems but under-theorized. Face-to-face interactions between clinicians and managers, through which trust is constructed, are vitally shaped by assumptions drawn from local organizational characteristics, which in turn are embedded within national policy structures. These latter conditions reform in order to enhance the quality and effectiveness of National Health Service management.

As Alan Johnson, the secretary of state for health, notes in his foreword to the End of Life Care Strategy, more than 500,000 people die each year in England, of whom more than two thirds are over 75. Surveys supporting the strategy indicate that most people would prefer to die at home (Higginson and Sen-Gupta 2000); however, only 18 per cent do so and older people are even less likely to die at home (Higginson et al 1999).

Dying now most typically occurs in later life. As such, the publication of the End of life Care Strategy should be welcome news for older people and those who work with them. In many ways it represents an acknowledgement by the Department of Health that most end-of-life care is not as good as it could be, and that some dying occurs in a manner that is not to be tolerated in 21st century Britain. Commitments to improve care through service development, workforce training and enhancing the evidence base for care provision have the potential to significantly improve the experiences of older people and their families at the end of life. This is very welcome. However, while the strategy begins by stating that two thirds of deaths in England occur among people aged over 75 years, I am not convinced that the real implications this has for care provision have been fully considered.

Effective communication by healthcare professionals is key to patients' understanding both the causes and prevention of ill health. Healthcare professionals need to be aware of the ways in which their audiences are likely to interpret information and the factors affecting their interpretations.

This editorial provides an overview of the articles included in the Special Issue of Health, Risk Society on living with risk and uncertainty. The papers were originally given at the 2006 BSA Risk and Society Study group and the authors were invited to revise them from this Special Issue. In this Editorial, we identify several important themes within the papers. While it has become a commonplace that modern society is a 'risk society,' in which individuals have become responsible for managing an increasing range of potentially life threatening risks, it is not clear how and in what circumstances individuals frame their situation in terms of risk. Henwood and colleagues draw on evidence from three interrelated studies which form part of the Economic and Social Research Council funded network on the Social Contexts and Responses to Risk (SCARR). These authors concluded that 'risk' is not ubiquitous within respondents' accounts but is rather one frame amongst many that can be used. The articles in the Special Issue indicate that a situation is framed as a risk if individuals are aware of the presence of danger which if not correctly or skilfully managed could result in harm, even death. Harries' article on flood risk emphasises the shock and trauma of being flooded and relates how some flood victims experience long term insecurity and anxiety. Gjernes' account of Sami reindeer herders describes the ways in which a combination of external forces threaten the continued existence of Sami culture and their social relations, and Tulloch documents the impact of being directly affected by a bomb attack as well as his resistance to the media accounts and construction of risks. As Zinn indicates, when individuals frame a situation in terms of risk, it does not follow that they will rely upon experts with their cognitive rational approaches to risk management, and they may instead use approaches which are neither rational nor irrational but have elements of both, such as trust. Indeed, in this issue, only Tulloch describes using experts to manage the personal consequences of his post-bomb trauma. There is generally more evidence in these papers of resistance to expert definitions of risk and to expert prescriptions for managing it, whether this is the explicit resistance which Lee describes amongst her bottle-feeding mothers or the transformation of public health messages to fit with lay beliefs which Gjernes describes amongst women reindeer herders in Northern Norway. As Zinn notes, individuals use a variety of approaches to managing risk including those which are apparently irrational such as the denial described by Harries or the 'enduring' described by Honkasalo in her study of women in Northern Karelia in their response to the perceived certainty of a negative outcome; in this case, death from heart disease.

Purpose. This paper examines respondents' relationship with work following a stroke and explores their experiences including the perceived barriers to and facilitators of a return to employment. Method. Our qualitative study explored the experiences and recovery of 43 individuals under 60 years who had survived a stroke. Participants, who had experienced a first stroke less than three months before and who could engage in in-depth interviews, were recruited through three stroke services in South East England. Each participant was invited to take part in four interviews over an 18-month period and to complete a diary for one week each month during this period. Results. At the time of their stroke a minority of our sample ( 12, 28% of the original sample) were not actively involved in the labour market and did not return to the work during the period that they were involved in the study. Of the 31 participants working at the time of the stroke, 13 had not returned to work during the period that they were involved in the study, six returned to work after three months and nine returned in under three months and in some cases virtually immediately after their stroke. The participants in our study all valued work and felt that working, especially in paid employment, was more desirable than not working. The participants who were not working at the time of their stroke or who had not returned to work during the period of the study also endorsed these views. However they felt that there were a variety of barriers and practical problems that prevented them working and in some cases had adjusted to a life without paid employment. Participants' relationship with work was influenced by barriers and facilitators. The positive valuations of work were modified by the specific context of stroke, for some participants work was a cause of stress and therefore potentially risky, for others it was a way of demonstrating recovery from stroke. The value and meaning varied between participants and this variation was related to past experience and biography. Participants who wanted to work indicated that their ability to work was influenced by the nature and extent of their residual disabilities. A small group of participants had such severe residual disabilities that managing everyday life was a challenge and that working was not a realistic prospect unless their situation changed radically. The remaining participants all reported residual disabilities. The extent to which these disabilities formed a barrier to work depended on an additional range of factors that acted as either barriers or facilitator to return to work. A flexible working environment and supportive social networks were cited as facilitators of return to paid employment. Conclusion. Participants in our study viewed return to work as an important indicator of recovery following a stroke. Individuals who had not returned to work felt that paid employment was desirable but they could not overcome the barriers. Individuals who returned to work recognized the barriers but had found ways of managing them.

While the development of modem medicine is associated with both increases in scientific knowledge and. improved outcomes in health care it is also associated with increased uncertainty as expert and lay knowledge bases have diverged and separated. The development of a principal-agent relationship in the late nineteenth and early twentieth century in which medical practitioners used their specialist knowledge to make decisions for and on behalf of their patients provided one way of managing this uncertainty. However the development of a less deferential and more consumerist culture associated with medical scandals in which trust has been betrayed have led to increased regulation of medical practice, especially the development of national standards based on encoded knowledge. Even if governments can overcome the practical problems of using such systems to structure decision-making, because these systems fail to address the personal and emotional components of trust they are likely to create a 'trust deficit,' a system that may work better, but is trusted less.

Over time, a number of alternative approaches to risk have developed and, while these co-exist, they structure time in different ways and are grounded in different combinations of cognitive rationality and affect. The initial conceptualization of risk, which remains prominent, was based on the use of knowledge from past events to provide the context for choices which minimize harm in the future. It underpins structured approaches to decision making based on use of statistics as a means of calculating the probability of future outcomes. This approach has been challenged by the development of a more forensic approach in which the emphasis is on identifying the specific causes of disasters using hindsight and from the analysis of specific cases making recommendations to prevent future disasters. While this approach has a rational basis, it also addresses the collective emotional responses to disaster and provides a cathartic function. In the late twentieth century a more precautionary approach has emerged, in which the fear of future is given precedence over evidence or lack of evidence of past harm. The precautionary approach is future oriented and casts the future principally in negative, potentially catastrophic terms.

In this article, the ways in which diaries can be used as narratives of risk are explored. It is noted that unsolicited diaries appear to be an especially valuable resource for researchers who wish to explore the nature of suffering. They also provide a way of avoiding some of the moral dilemmas created when researchers solicit narratives of suffering and represent accounts which contextualize suffering within a personal biography. Such texts provide a mechanism for accessing not only contemporary accounts of suffering but also accounts from previous generations thus allowing researchers to explore the ways in which narratives of suffering have developed over time. These points are illustrated via an analysis of stroke survivors' accounts of their stroke and the traumatic experience of knowing themselves to be under threat and at risk of dying.

This paper examines the ways in which stroke survivors identify and manage the risks and uncertainties of their situation. It draws on interview data from a UK study in East Kent of 31 stroke survivors (aged between 38 and 89 years). The interviews created accounts based on the experience of stroke and post stroke recovery. Stroke survivors experienced their stroke as an unanticipated event in which there was a failure of foresight. The stroke undermined their ontological security and increased their awareness of and anxiety about everyday activities both in and outside the home, created awareness of a new danger, that of having another potentially fatal stroke, and could damage their social standing. Survivors used a variety of strategies to manage such uncertainties. They shortened their time horizons, either abandoning longer-term plans or discussing them in very vague and general terms. They concentrated either on the present, "taking each day as it comes" or developed goals to structure the short-term future. These short-term goals involved challenges and there was in some cases the possibility of a harmful outcome. Such voluntary risk-taking provided an opportunity for "centre work" which could re-establish the stroke survivors social standing.

Diary researchers use pre-existing or solicited diaries, documents made up of regular dated entries. Such documents are particularly useful for researchers who would like to observe specific phenomena but are unable to do so because they took place before the research started or are intrinsically difficult to observe. Diaries can also provide ways of accessing voices that are often silenced in public discourses such as those of gay men, members of countercultures, or women. Diaries can be used as a source of data in a variety of research designs, including experimental and survey research that use structured diaries to collect specific data from selected groups as well as interpretive, ethnographic research that examines the ways in which diarists narrate their life and experiences. While the entries in diaries may appear to be accurate records of diarists' observations and reflections, they are shaped by diarists' interests and by social, cultural, and literary conventions. Furthermore, dated entries may not be written at the specified time and may be subsequently edited by the diarist and others. Researchers can respond to such issues by maximising their control over the ways diaries are used and entries made, for example, by carefully selecting diarists and providing them with detailed instructions on how to complete their diaries. An alternative approach is to focus on the underlying structure of diaries and explore why diarists have chosen to keep diaries as well as how they used existing conventions to narrate their stories.

Time is a key element of social life. Yet it has been relatively neglected in social theory and in the study of health and risk. In this chapter we show how interrogating understandings of time provides insights into how uncertainty and risk shape the ways in which organisations and individuals respond to illness. While individuals have their own personal 'my' time, if they want to engage with others they need to recognize and align their personal time with others and this alignment involves implicit agreements about and standardisation of time between members of a community. In premodern societies such standardisation was localised however in modern society this standardisation has become abstracted from specific social setting and universalised and globalised. The development of abstract times has implication for the ways in which individuals think about and organise their personal time and the ways in which time is used to organise activities in modern bureaucratic organisations. The development of abstract time has created the possibility for individuals to view their own lives through the lens of risk. The accumulation of epidemiological knowledge about the ways in which adverse events are distributed across the life course creates a generalised life timetable in which there are designated time-periods for particular life activities or events and individuals are considered to be at-risk, or exposed to harm, if they do not undertake normal activities in these periods. In modern society, bureaucratic organisations play a key role in the creation and management of uncertainty, for example hospitals claim to provide a safe environment which individuals can rely on during fateful moments, when their very existence is under threat. Such organisation use abstract time embedded in institutional routines to manage uncertainty. While such routines may appear to be rational and technically neutral, they do in practice contain irrational elements and are used as a form of social control. There is tension between the abstract time imposed by organisations and institutions and personal timings which form an important locus of power relations. Personal time is often colonised by those in more powerful positions and by organisations, while resistance to such colonisation requires both determination and subterfuge.

Documents, especially personal documents such as diaries and letters, provide a relatively neglected resource for health service researchers. They can be used to access data that are difficult to obtain in other ways. For example, such documents can tell us about individuals who died several centuries ago; people from marginalized and stigmatized groups who are often reluctant to participate in research; or activities, such as gay sex, that are otherwise concealed. In this respect, the overall aim of this chapter is to examine the ways in which documents have been and can be used for health research. This includes describing documentary research, identifying the type of resources it requires, and examining the research issues for which it is appropriate. The chapter will also, amongst other things, outline the strengths and weaknesses of documentary research and consider how documentary data can be coded, analyzed and presented.

In this chapter, I review current research on health and health care. In the opening section I consider the importance of risk in the development of health care, especially the ways in which the medical profession has used it to establish a dominant role, and the development of epidemiology as the main method of health risk analysis. The in second section I examine the current health risk agenda. In the third section I review four areas of health risk research: patient safety, medical knowledge, risk communications, the media. In the final section I identify two emerging areas of risk research, trust, and health futures.

The development of modern nursing practice was closely linked to the development of health care institutions such as hospitals and asylums in the nineteenth century and its development outside such settings occurred more recently, mainly in the second half of the twentieth century. Since these two settings differ both in the type of risk which nurses are likely to experience and in the ways in which nurses assess and manage risk, I will compare and contrast these two settings before considering in more detail risk in community nursing practice.

The purpose of this research is to help patients to control their diabetes more effectively, by allowing them to develop a greater understanding of their condition and increase their confidence to keep to necessary behaviour changes such as appropriate diet and regular exercise. The method used here is based on an 'adherence therapy' manual originally developed to help older people comply with their antidepressant medication. We think that this approach can be adapted to improve the extent to which people with diabetes stick to their treatment plans. We have selected this group of patients because diabetes presents a significant challenge, both to the patient and healthcare system. Diabetes is also increasingly common in the ageing population and can increase the risk of other serious conditions such as heart disease and stroke. If people can control their diabetes effectively, the risk of complications and further health problems can be reduced. In this study we compare patients' ability to control their diabetes before and after therapy by looking at blood test results and rating-scale scores. If the treatment is effective, we plan to conduct a larger study in which patients receiving adherence therapy will be compared with patients having usual treatment only. The larger study would also allow us to see if any changes are maintained over the long-term.

This study explored current approaches to communicating information to stroke survivors and their relatives. The project's aim was to gain better understanding of information provision about stroke from health professionals. It explored the perspectives of stroke survivors, their carers and professionals. The study aimed to explore, through qualitative interviews, how information is provided, what works well in information giving, what the barriers to good information provision are and how these arise. The study helped develop an information toolkit for service providers, stroke survivors and relatives to engage in effective person-centred communication. The study is based on interviews conducted with health professionals in acute, community and primary care settings in East Kent and with a small sample of stroke survivors and carers. We interviewed 19 stroke survivors, 6 relatives and 23 health professionals (11 individually and 12 in 2 focus groups) involved in their care and support.

This study explored current approaches to communicating information to stroke survivors and their relatives. The aim of this pilot project was to gain better understanding of information provision about stroke from health professionals by exploring the perspectives of the stroke survivors, their carers and professionals themselves. The study aimed to explore, through qualitative interviews, how such information is provided, what works well in information giving, what the barriers to good information provision are and how these arise. The research provided a step towards developing an information toolkit for service providers, stroke survivors and relatives to engage in effective person-centred communication. The study is based on interviews conducted with health professionals in acute, community and primary care settings in East Kent and with a small sample of stroke survivors and carers. We interviewed 19 stroke survivors, 6 relatives and 23 health professionals (11 individually and 12 in 2 focus groups) involved in their care and support. To protect individual identities, we have changed all names in our report.

It starts with a short discussion of the nature of multimedia profiling, then discusses the development of multimedia profiling within Kingsgate Resource Centre and with KOVE and considers why Acting Up successfully developed in these contexts and not in others. It concludes with a discussion of the outputs of profiling and their impacts.

This report describes a project funded by KCC. The Centre for Health Services Studies at the University of Kent monitored and reviewed the development of three pilot Telecare projects in Kent on behalf of Kent Social Services. Specifically the project aimed to: Examine how the service developed and the factors which shaped its development; Analyse the nature, application and impact of the technology on users, carers and providers especially in terms of the experiences of service users and the outcomes of specific interventions; Indentify the type of infrastructure that was needed to support Telecare and make recommendations for the development of a full service from the pilot.