Introduction This thesis describes two studies: The Auckland Heart Study Validation Project which validated the physical activity questionnaire from an earlier case-control study (known as the Auckland Heart Study); The Auckland Blood Pressure Control Study which was a factorial design randomised controlled trial of physical activity and salt restriction as a means of further lowering blood pressure in a community sample of patients treated with anti-hypertensive medication. This study used the physical activity questionnaire validated in the Auckland Heart Study Validation Project. Coronary heart disease is the leading cause of death and a major cause of morbidity in New Zealand. The Auckland Heart Study was a case-control study examining coronary heart disease and its risk factors and was conducted in Auckland from 1986 to 1988 (Jackson, 1989). This study incorporated a three month recall questionnaire on physical activity. The results showed that a high level of physical activity was associated with a low rate of coronary heart disease. For example the odds ratio for those with high levels of moderate leisure time physical activity was 0.78 for men and 0.39 for women. To assess the validity of the physical activity questionnaire, the Auckland Heart Study Validation Project was conducted in 1988. Both physical inactivity and hypertension are risk factors for coronary heart disease and physical activity is known to lower blood pressure. The Auckland Blood Pressure Control study was conducted during 1989-90 in order to assess the effectiveness of physical activity as a means of lowering blood pressure in a community setting. The physical activity questionnaire used in the Auckland Blood Pressure Control study was the same one validated in the Auckland Heart Study Validation Project. This thesis describes both the Auckland Heart Study Validation Project and the Auckland Blood Pressure Control study. The Auckland Heart Study Validation Project The 186 Participants for the Auckland Heart Study Validation Project were randomly selected from the control group of the Auckland Heart Study. Of those who could be contacted, 152 completed a seven day physical activity and food intake diary. The seven day diary was the gold standard for the three month physical activity recall questionnaire used in the Auckland Heart Study. The response rate for completing the seven day diary was 82%. The original control group had been randomly chosen from the community and hence the sub-sample of 152 participants represented a reasonable cross-section of the community. The correlations for the three month recall questionnaire compared with the seven day dairy, were 0.61, 0.49 and 0.86 for moderate, vigorous and total activity respectively. These findings were consistent with other validation studies in the literature. One of the strengths of the Auckland Heart Study Validation project was that it was undertaken in the community population for which it was intended. It was concluded that the three month physical activity recall measured physical activity in general and over the three recall period. Auckland Blood Pressure Control study Low levels of physical activity have been shown in observational studies to be associated with a high incidence of both coronary heart disease and hypertension. A concern with observational studies is that the findings may be due to confounding factors which are not able to be controlled, either in the design or the analysis. The best method of controlling for confounding is through the use of randomised controlled trials. The literature on physical activity as a means of lowering blood pressure contains many randomised trials and almost all have methodological weaknesses. Moreover, most of those studies have been conducted in laboratory settings; very few trials of physical activity and blood pressure have been conducted in community settings. The literature on salt restriction as a means of lowering blood pressure contains numerous well designed randomized controlled trials showing that salt restriction can lower blood pressure. While significant results have been achieved from salt restriction most of these studies have been involved intensive input from dietitians. None of the community based studies have demonstrated significant blood pressure reductions. The aim of the Auckland Blood Pressure Control study was to assess the effectiveness of physical activity and/or salt restriction as therapies to lower blood pressure in treated hypertensive patients in a community setting. The research design was a factorial design randomised controlled trial of physical activity and salt restriction as therapies for lowering blood pressure. Participants were recruited for the study from general practitioners and a variety of public advertisements. The study was conducted over six months and 181 of the baseline 208 participants completed the study. The two interventions were brisk walking for 40 minutes, three times a week and salt restriction advice. The main outcome measures were blinded blood pressures measured at three and six months. The average age of the participants was 55 years and there were approximately equal numbers of men and women. At the three month interview there was a statistically reduction in systolic blood pressure for salt restriction and physical activity as separate therapies, but not for the combination. There was no significant reduction in diastolic blood pressure at the three or six month assessment. Although the Auckland Heart Study three month recall questionnaire was valid for the case-control study there was concern that it was not sensitive enough for the randomised controlled trial. It was concluded that both physical activity and salt restriction lowered systolic blood pressure, at least in the short term, in persons with hypertension treated with medication in a community setting.

The thesis examines general medical practice with particular attention to patient outcomes. Sociological descriptions of healing are presented and compared with official views of medical institutions. A theoretical position is taken capable of interaction with the disciplines of both sociology and medicine. Definitions of health are reviewed and used to specify desirable outcomes to patient-practitioner encounters. The context of modern medical care is then discussed; the influence of the intellectual, social and economic environment on the development of medical care since 1800 are evaluated, and modern reformist pressure on medical practice is examined. From this discussion a list of qualities of interest in the sociological investigation of medical practice is developed. A research project, undertaken in New Zealand, is described which gathered information on a random sample of 9477 general practice patient-practitioner encounters. A survey methodology was used with data supplied by practitioners. In addition, a patient survey was carried out in a sub-sample of 763 visits. Data on practitioner, patient, problem presented, process of the encounter and outcome was recorded. Outcome was measured as empowerment at the visit and improvement after two weeks. The results of the project are presented and analyzed. It was found that most patients are satisfied with their consultation and that a majority have improved health state at two weeks. Much of the variation in improvement is explained by the severity of the problem and the age of the patient. Social variables make a small contribution to the prediction of good outcomes. In particular, empowerment at the consultation is related to improved subsequent health state. The influence of occupation, gender and ethnicity on problems presented to the practitioner and on outcome are discussed. A proportion of patients had delayed obtaining medical care for financial reasons. This was associated with more severe problems and poorer outcome. A psycho-social approach to problems was rare and patient counseling did not appear to contribute to a sense of empowerment. Practitioners reported highest rapport with simpler consultations and rapport was negatively related to empowerment. The significance of these findings is discussed. In a final section it is suggested that medical treatment and counseling may be antithetical skills and that both practitioner and patient may have vested interests in a materialistic view of the content of their interaction. The forms of social control implicit in the encounter are elaborated.

The main purpose of this study was to examine empirically the trends and reasons for rising acute adult medical admissions at two major public hospitals in Auckland from 1997 to 2004. According to recent national and international literature published on the topic, there has been unsustainable growth in the adult medical admissions both in NZ and most of the other developed countries. Overall, the causes of this increase have not been explored sufficiently in the literature reviewed. The NZ research has largely focused on the macro-analysis of hospital throughput data from health policy points of view. Methodology: A mixed methodology research design was applied to address the problem. Phase 1 quantitatively analysed adult medical hospital admission data (N = 277,416) obtained from the two hospitals (Middlemore and Auckland Public Hospitals), and phase 2 qualitatively explored the responses and views of the health professional expert panel (n = 16) in relation to the findings of phase 1 of the study. Findings: Overall, the crude number of admissions and age-standardised admission rates at both hospitals increased more rapidly than actual population increases. Approximately 1/3 of the patients accounted for 2/3 of the total admissions. Five major diagnostic categories accounted for 70%-80% of total acute admissions, with circulatory and respiratory system disorders being the leading causes of medical admissions. There was a strong relationship between age and increased admissions. MMH hospital overall, and its ethnic groups separately, had significantly higher admission rates than APH. Comparison of ethnic groups highlighted significant variations in the admission rates at the two hospitals despite adjusting for age, morbidity and deprivation. Conclusions: Overall the increase and variation in admission rates between the hospitals and ethnic groups was dependent on factors such as the characteristics of the population and patients, hospital admission and administration processes, availability of hospital beds, medical management at the hospital, and availability of primary and community care services. By making changes to those factors in the control of hospitals and District Health Boards, hospitals can potentially influence the trajectory of rising medical admissions. These factors include systems for managing patients with chronic illness, and pathways from community services to hospital. Finally, a number of future research areas, such as a large-scale study to explore the health service utilisation of the 55+ age groups, have been proposed.

A study of cleft lip and cleft palate was carried out in order to determine whether or not any differences in incidence between Europeans and Polynesians were accompanied by differences in recurrence risks, and to test the genetic hypotheses currently favoured as explanations of familial agggregation of these disorders. An incidence study vas undertaken on all live births in the Auckland urban area for the years 1960 to 1976.Family information was obtained from these probands and from other affected persons or their close relatives, by interview at the cleft palate clinic at Middlemore Hospital. The ascertainment probability for cleft 1ip and cleft palate probands was about 95% and was not correlated with any of the demographic characteristics measured on the probands. After correction for ascertainment, the incidence of cleft palate in Maoris was estimated to be 1.867/1000 1lve births. For Europeans the estimate was 0.643/1000. The corresponding figures for cleft lip with or without cleft palate were 0.397/1000 and 1.195/1000. The sex ratio for cleft palate was 0.485 with heterogeneity between the races. For cleft lip the sax ratio was 0.649 overall. There were no secular or seasonal trends in the incidence of facial clefts and no significant effects of maternal age, or paternal age. The mean birth rank for probands with cleft lip with or without cleft palate was higher than expected. For probands with cleft palate, mean birth rank was not significantly elevated. The pattern of additional malformations in these probands was similar to those reported in similar studies from other centres. The recurrence risk for cleft palate was 1.8% overall. Although it was s1ightly higher in polynesian families than in European families, the difference was nowhere near statistical significance. For cleft lip the recurrence risk was 2.6% overall, with the risk being slightly higher in Polynesian families, but again not significantly higher than in European families. Using current analytical techniques, no discrimination was possible between a generalized single autosomal locus model and a multifactoriar threshold model. A consideration of the parameter estimates for both models suggests that the multifactorial threshold model is the more appropriate one to use for the calculation of recurrence risks in complicated family situations. It is concluded that further family studies of this nature would no longer be warranted unless hypotheses can realistically be tested on the samples available. However, incidence studies in special populations will remain important for hypothesis testing. Following on the work using animal models, a study of face shape within and among races in New Zealand may provide clues to the aetiology of facial clefts, particularly isoleted cleft palate. It will be important to follow changes in incidence over time and discover what effects intermarriage and cultural changes might have on the incidence of facial clefts.

Whole document restricted, see Access Instructions file below for details of how to access the print copy. / Background: Giardia is a leading cause of human gastrointestinal illnesses globally and is the most commonly notified waterborne disease in New Zealand. The national incidence rate of 46.6 per 100,000 is thought to be one of the highest among developed countries, peaking in the 1-4 and the 25-44 age groups. Risk factors for infection among vulnerable groups have not been explored systematically in New Zealand, although environmental factors and person-to-person transmission have been suspected. The true burden of Giardia infecion in the community has been difficult to estimate due to suspected under-notification of the disease. An important component of disease surveillance and the validation of disease incidence rates is an estimation of the degree of undercount. AIMS: To describe the epidemiological patterns of Giardia infection in the Auckland region and in New Zealand, compare them with local and international patterns of infection, and explore environmental links. To estimate the level of completeness of giardiasis notification in the Auckland adult population by using a simple capture-recapture method. To identify risk factors for giardiasis among Auckland children under 5 years of age. Methods: Analysis of Auckland data: Anonymised giardiasis notification data from Auckland Regional Public Health Services (ARPHS) for the period of July 1996 to June 2000 were analysed by person, place and time. Infection rates and relative risks were calculated and compared with national and international information. Analysis of New Zealand data: A study of national surveillance data utilised anonymised information for 7818 notified cases throughout New Zealand between July 1996 and June 2000. A weighted average of drinking water grades was estimated using the Community Drinking Register. Pearson's coefficient was used to measure the correlation between average drinking water grades and notified cases. Daily climate data were plotted against daily case notifications and modelled, using Poisson's regression, to predict any influence of climate on infection. Data were presented by age, gender, ethnicity and area using statistical and spatial methods. Estimation of under-notification: The capture-recapture technique is now being used in many countries to evaluate the completeness of disease ascertainment. Comparison of disease ascertainment involves two or more datasets. Two independent datasets of giardiasis cases aged 15 years or over were generated. Of them one was generated from the demographic information of cases recruited during the Auckland Giardiasis Study in 1998-99 and the other from giardiasis cases notified to the ARPHS for the same period of time. The area of residence of cases was geo-coded, mapped and overlaid by water distribution zones. Cases were matched and under-notification was estimated using a two-sample capture-recapture method. Case-control study: A case-control methodology was used to analyse the exposure history of 69 cases and 98 controls under 5 years of age in Auckland. Significant risks of infection were estimated and their attributable risks. Results: Giardiasis in Auckland: Auckland had a significantly higher rate of Giardia notification (58/100,000) than New Zealand (46/100,000) as a whole. Notification rates, which peaked during February-May, were significantly higher in Pakeha/Europeans and Asian/others, compared with Maori/Pacificans. Adjusted notification rates were higher for residents of North Shore and Auckland cities than for other areas of Auckland. The crude regional and national notification rates were almost 6 times the rate of laboratory identification of positive isolates in the UK and 4 times US reported rates. Giardiasis in New Zealand: At the national level, most cases occurred in the 1-4 year age group followed by the 25-44 year age group, and most cases were Pakeha/European. Ethnicity was not known for 18% of cases, affecting demographic calculations. Infection rates were high for a number of Health Districts (West Coast, Wanganui, Waikato and Tauranga) compared to the national average. Over 50% of the population received Aa-graded drinking water. No correlation between infection and the weighted average grades for water treatment plants (r = -0.12) or the reticulation systems (r = -0.11)) was found. A significant correlation with the mean daily maximum (r = 0.05) and minimum (r = 0.06) temperature was observed. Poisson's regression modelled minimum-temperature (chi2 = 5.40, p<0.05) and relative humidity (chi2 = 5.37, p<0.05) as predictors of a significant number of Giardia infections on a given day. Under-notification of giardiasis: The estimation of under-notification during the 12 month period, compared 413 cases who were notified to the ARPHS with 199 cases who had participated in a case-control study over the same period of time. North Auckland had slightly higher notification rates and also study participation rates. The giardiasis notification rate was higher in un-reticulated water zones (72.4/100,000 population). The capture-recapture calculation indicated that only 49% of cases were notified. Risk of giardiasis in children: In the case-control study, 95% of cases and 86% of controls used water from the Auckland Metropolitan Mains (AMM) supply for domestic purposes, 44 cases and 42 controls swam, and 59 cases and 54 controls wore nappies. Children wearing nappies were at significantly increased risk of the disease (OR=3.0, 95%CI 1.01-8.9), as were those from households which had more than one child wearing a nappy (OR=6.5, 1.8-23.4). The AMM water supply was associated with a reduced giardiasis risk compared to other drinking water sources. Significantly increased risks were associated with drinking water consumed away from home (OR=4.7, 2.2-10.1), swimming at least once a week (OR=2.4, 1.1-5.3) and travelling in side New Zealand (OR=2.5, 1.03-6.0). Conclusions: The higher rates of giardiasis observed in Auckland and New Zealand, in comparison with other developed countries, may be related to environmental or social factors. Missing ethnicity information precludes clear interpretation of variations in notification rate by ethnic group and suggests a need for improvement in data collection. There are opportunities to investigate the influence of risk factors on seasonal changes in notification rates both locally and nationally. Reported improvements in some areas could be due to local health measures or to random variation. Time-trend analysis suggests a seasonal pattern. The weighted average drinking water grading is a novel and readily available measure, and may not be truly representative of local supplies. Modelling of climate data showed an association with giardiasis but was inconclusive. Giardia notifications in Auckland are under-notified by half. This has obscured the true burden of Giardia infection. This has implications for estimates of the burden of disease in New Zealand. Notification rates vary inversely with socio-economic conditions and the presence of a reticulated water system. The case-control study identified vulnerable groups and modifiable risk factors for Giardia infection. Nappy-wearing was an independent risk factor for infection. Further study is advocated to ensure better protection of public health, especially for children. These studies identified vulnerable groups and major data-gaps. The risk of infection in children needs further attention for effective infection control measures to be developed for this disease. Recommendations for improvements in disease surveillance and data quality are discussed. GIS (Geographical Information System) is a useful tool for disease monitoring. Capture-recapture techniques are useful tools in evaluating the completeness of disease surveillance.

Background Road traffic injury is projected to rank as the third largest contributor to the global burden of disease by 2020. Disability is a significant component of the burden of disease ranking. Most published data on traffic crash outcomes, however, focus primarily on deaths and hospitalisations. Reliable estimates of post-crash disability and information on factors that modify the disabling process are essential to prioritise and allocate appropriate resources for road traffic injury prevention and interventions that reduce the risk of secondary disability. Aims To quantify the risk of disability associated with serious injury crashes in car drivers in a defined population; to explore the extent to which this risk is modified by chronic alcohol abuse; and to critically review methodological approaches that can redress the inadequate epidemiological attention to injury-related disability. Methods Systematic reviews were conducted to examine the available epidemiological evidence quantifying the association of car crashes with disability and the effect of alcohol on the risk of post-injury disability. Studies published or presented between January 1980 and April 2003 were reviewed. No language restriction was imposed. A population-based prospective cohort study conducted in the Auckland region of New Zealand recruited drivers exposed to serious injury crashes (identified through a surveillance system monitoring hospital admissions of injured car occupants). A representative sample of car drivers in the region was identified through roadside surveys (controls). The participants were interviewed at recruitment (to obtain pre-crash information from crash drivers and baseline data from controls) and re-interviewed at five and eighteen-months follow-up. Structured interviews on all three occasions included the Short Form-36, a global health change indicator, and the Alcohol Use Disorders Identification Test. Information on a range of potential confounders was sought at baseline through the interview, alcohol measurements and clinical records. Results Studies identified in the systematic reviews revealed that published estimates of the risk of post-crash disability ranged from 2% to 57%. The evidence regarding the effect of alcohol on post-injury disability is inconclusive largely because none examined this association directly. Most studies identified in the reviews were limited by several methodological problems including the absence of appropriate comparison groups, inadequate or no adjustment for confounding, significant potential for selection bias due to the study setting, high levels of loss to follow-up, and missing data. In the prospective cohort study, 215 crash drivers (75% follow-up) and 254 controls (69%) completed the 18-month interview. Overall, 40% of the drivers who were hospitalised, 20% of the crash drivers not hospitalised, and 7% of the controls reported deteriorated health at 18 months relative to their baseline health. This represents a tenfold excess risk of disability among hospitalised drivers and a three-fold excess risk among non-hospitalised crash drivers, relative to drivers in the general population. Among crash drivers reporting an overall decline in health, clinically important reductions in general and mental health were apparent over the follow-up period despite improving physical health and function. This trend was more evident among non-hospitalised than hospitalised crash drivers. Compared with drivers who were neither involved in a crash nor defined as hazardous drinkers, crash drivers who were hazardous drinkers had a seven-fold excess risk of a clinically significant (≥ 10%) decline in the SF-36 general health score (OR 6.85; 95% CI: 1.84-25.43). Crash drivers who were not hazardous drinkers had a three-fold risk (OR: 3.00; 95% CI: 1.14-7.89). The results indicated an important interaction between crash involvement and chronic alcohol abuse in potentiating the risk of disability. Conclusion Serious traffic crashes are associated with significant longer-term disability in a substantial proportion of survivors with an apparent worsening of mental health over time. Definitions of disability and estimates of the burden of disability following traffic injury remain highly variable in the published literature and it is timely for the international research community to develop a more systematic and consistent approach to this major and increasing component of the global burden of disease. By addressing the main methodological limitations of previous studies, this study revealed that chronic alcohol abuse potentiates the risk of post-crash disability. The findings suggest that measures for preventing road traffic crashes as well as efforts to identify problem drinkers among crash survivors should be intensified. The thesis highlights the need for robust indicators of non-fatal injury to monitor the impact of road safety programs and large-scale epidemiological studies to investigate the spectrum and determinants of post-injury disability.

The primary aim of the study was to validate the short and long form of the recently-created NZ physical activity questionnaires (NZPAQ-SF and NZPAQ-LF, respectively) in a multi-ethnic sample in Auckland. An international physical activity questionnaire (IPAQ-long) was also validated and compared to the NZ instruments. Objective PA measures were used to create a NZ compendium of PA intensities, providing baseline data for culturally-specific PAs. Secondary aims included an examination of the relationship between PA and CRF, and their associations with cross-sectional measures of cardiovascular (CV) risk factors. The study sample consisted of 186 apparently healthy males (n=90) and females (n=96) aged 19-86 yrs, classified as European/Other (n=60), Māori (n=61), and Pacific (n=65). Heart rate monitoring (HRM) with individual calibration was used to objectively measure the duration, frequency, and intensity of at least moderate-intensity PAs performed over 3 consecutive days. Type of PA and the context in which it was performed was simultaneously recorded by participants on daily PA logs. Correlations between HRM and self-reported levels of brisk walking, moderate-intensity, vigorousintensity, were poor for each questionnaire, and correlations were lower for Māori and Pacific ethnic groups than for European/Other. The NZPAQ-SF (r=0.3, p<0.001) and NZPAQ-LF (r=0.3, p<0.001) performed better than the IPAQ-long (r=0.1, p=0.37). The culturally-specific list of PA intensities showed strong correlation (R2=0.68) to an internationally-accepted compendium of PA intensities, and provided baseline energy cost data for 13 PAs performed by Māori and Pacific people in NZ. CRF levels were primarily influenced by gender, ethnicity, obesity, and performing at least 15 min/day of vigorous-intensity PA, and showed stronger associations with fasting blood lipids and glucose, while PA was more strongly related to SBP and DBP. The validated NZPAQs are acceptable for measuring population level PA prevalence in NZ adults, although accuracy is lower for Māori and Pacific people. However, the availability of a culturallyspecific list of PA intensities could potentially increase the accuracy of self-reported PA by Māori and Pacific people. Results from this study highlight the importance of vigorous-intensity PA for CV health, and identifies NZ Pacific people as high risk in terms of PA, obesity, and CRF.

The risk of developing type 2 diabetes is four fold higher in New Zealand(NZ) Polynesians compared to Caucasians. Hence diabetes is more prevalent in Maori (16.5% of the general population) and Pacific Island people (10.1%) compared to NZ Caucasians (9.3%). It is generally accepted that type 2 diabetes has major genetic determinants and heterozygous mutations in a number of genes have previously been identified in some subsets of type 2 diabetes and certain ethnic groups. The high prevalence of diabetes in NZ Polynesians, when compared with NZ Caucasians, after controlling for age, income and body mass index (BMI), suggest that genes may be important in this population. Therefore, the prevalence of allelic variations in the genes encoding amylin and insulin promoter factor-1 (IPF-1), and exon 2 of the hepatocyte nuclear factor-1α (HNF-1α) gene in NZ Polynesians with type 2 diabetes was determined. These genes are known to produce type 2 diabetes in other populations. The genes investigated were screened for mutations by PCR amplification and direct sequencing of promoter regions, exons and adjacent intronic sequences from genomic DNA. DNA was obtained from 146 NZ Polynesians (131 Maori and 15 Pacific Island) with type 2 diabetes and 387 NZ Polynesian non-diabetic control subjects (258 Maori and 129 Pacific Island). Sequences were compared to previously published sequences in the National Centre for Biotechnology Information database. Allelic variations in IPF-1 and exon 2 of the HNF-1α gene were not associated with type 2 diabetes in NZ Polynesians. However, in the amylin gene, two new and one previously described allele was identified in the Maori population including: two alleles in the promoter region (-132G>A and -215T>G), and a missense mutation in exon 3 (QlOR). The -215T>G allele was observed in 5.4% and l% of type 2 diabetic and non-diabetic Maori respectively, and predisposed the carrier to diabetes with a relative risk of 7.23. The -215T>G allele was inherited with a previously described amylin promoter polymorphism(-230A>C) in 3% of Maori with type 2 diabetes, which suggests linkage equilibrium exists between these two alleles. Both Q10R and -132G>A were observed in 0.76% of type 2 diabetic patients and were absent in non-diabetic subjects. Together these allelic variations may account for approximately 7% of type 2 diabetes in Maori. These results suggest that the amylin gene maybe an important candidate marker gene for type 2 diabetes in Maori.

This social-cultural history explores the changing context, culture, and identity of psychiatric nurses working in New Zealand public mental hospitals between 1939 and 1972. Primary documentary sources and oral history interviews provided the data for analysis. The thesis is divided into two periods: 1939 to 1959 when asylum-type conditions shaped the culture of the institutional workforce, and 1960 to 1972 when mental health reform and nursing professionalisation challenged the isolation and distinct identity of mental hospital nurses. Between 1939 and 1959 the introduction of somatic treatments did not substantially change nursing practice in mental hospitals. Overcrowding, understaffing and poor resources necessitated the continuance of custodial care. The asylum-type institutions were dependent on a male attendant workforce to ensure the safety of disturbed male patients, and the maintenance of hospital farms, gardens, and buildings. Although female nurses provided all the care and domestic work on the female side, the belief that psychiatric nursing was physically demanding, potentially dangerous, and morally questionable, characterised the work as generally unsuitable for women. Introduction of psychiatric nursing registration which was a move toward professionalisation did little to change the dominance of a male, working-class culture. From 1960 to 1972 psychiatric nurses’ identity was contested. New therapeutic roles created the possibility of the nurses becoming health professionals. Their economic security and occupational power, however, was tied to an identity as unionised, male workers. As psychiatric nurses were drawn closer to the female-dominated nursing profession through health service changes and nursing education reform, both men and women acted to protect both their working conditions and their patients’ welfare. To achieve these ends, they employed working-class means of industrial action. By accepting the notion that psychiatric nurses’ identity was socially constructed, this thesis provides an interpretation that goes beyond the assumption that nursing is a woman’s profession. Instead, it presents psychiatric nursing as a changing phenomenon shaped by contested discourses of gender, class and professionalisation. Nursing in public mental hospitals attracted ordinary men and uncommon women whose collective identity was forged from the experience of working in a stigmatised role.

This research began a journey towards improved maturity around data quality management in New Zealand health care, where total data quality management is 'business as usual" institutionalised into the daily practices of all those who work in health care. The increasingly information intensive nature of health care demands a proactive and strategic approach to data quality to ensure the right information is available to the right person at the right time in the right format, all in consideration of the rights of the patient to have his/her health data protected and used in an ethical way. The work extends and tests principles to establish good practice and overcome practical barriers. This thesis explores the issues that define and control data quality in the national health data collections and the mechanisms and frameworks that can be developed to achieve and sustain good data quality. The research is interpretive, studying meaning within a social setting. The research provides the structure for learning and potential change through the utilisation of action research. Grounded theory provides the structure for the analysis of qualitative data through inductive coding and constant comparison in the analysis phase of the action research iterative cycle. Participatory observation provided considerable rich data as the researcher was a member of staff within the organisation. Data were also collected at workshops, focus groups, structured meetings and interviews. The development of a Data Quality Evaluation Framework and a national Data quality Improvement Strategy provides clear direction for a holistic and 'whole of health sector' way of viewing data quality, with the ability for organisations to develop and implement local innovations through locally developed strategies and data quality improvement programmes. The researcher utilised the theory of appreciative enquiry (Fry, 2002) to positively encourage change, and to encourage the utilisation of existing organisational knowledge. Simple rules, such as the TDQM process and the data quality dimensions guided the change, leaving room for innovation. The theory of 'complex systems of adjustment' (Champagne, 2002; Stacey, 1993) can be instilled in the organisation to encourage change through the constant interaction of people throughout the organisation.