Objectives: Depression is often unrecognised or sub-optimally treated in primary care. This has led to research exploring the barriers and enablers to effective recognition but little is known about health care professionals’ (HCPs) beliefs or personal illness models about depression in patients with long term conditions (LTCs), the presence of which may affect recognition and management. Using Leventhal’s Common Sense or Self-regulatory Model this thesis aimed to: explore HCPs’ illness representations and management in people with LTCs and depression; to understand the role of personal models and perceived barriers to depression recognition and management; and to address them in a theory-based online training intervention. Methods: This thesis was undertaken in three stages; a scoping review with narrative synthesis was conducted to explore the role of HCPs’ personal illness models of depression, a qualitative study using semi-structured interviews with 16 HCPs to investigate their illness beliefs about depression in patients with LTCs and finally, the development and feasibility assessment of a theory-based online training intervention to target HCPs’ attitudes, beliefs and self-efficacy. During this stage a new measure of HCPs’ beliefs and attitudes towards depression in patients with LTCs was developed as no appropriate measures were currently available to capture HCPs’ personal illness models of depression as a comorbid condition. Results: Twenty-seven papers were included in a mixed method scoping review. The review concluded that HCPs mainly normalised depression but lacked a complete conceptualisation of depression in primary care. HCPs reported time constraints and lack of skills as important barriers to recognising of depression in primary care. Negative attitudes towards depression and lack of confidence to recognise and manage depression were also commonly reported. In the qualitative study, the main themes were; 1) Recognition of depression in people with LTCs is complex (unclear illness identity) 2) Attitudes towards recognition and management of depression in people with LTCs act as either barriers and enablers to depression management 3) The necessary level of condition-related knowledge and understanding of depression in the context of a LTC 4) Controllability of depression in people with LTCs. The findings suggested that HCPs’ illness beliefs about depression in people with LTC varied in crucial ways with some participants prioritising the management of the LTC or expecting patients with diabetes or CHD to diagnose depression themselves due to time constraints. Some HCPs also reported simplistic views of causation which appeared to impact on their decisions whether or not to detect depression in people with LTCs. The findings of the qualitative study were used to inform the content of a novel online training intervention using illustrations to facilitate engagement. Thirty one HCPs were recruited and 15 completed the evaluation. The results of the feasibility study suggested that the method, context and mode of intervention was feasible but the lack of validated measures and the small sample size hinder conclusions about changes in participants’ illness beliefs, intentions, self-efficacy and perceived barriers towards depression. Comments: The scoping review study provided new insights into why HCPs may not engage with detection of depression but only a limited amount of research has explored HCPs’ beliefs about depression in patients with LTCs. The qualitative study addressed this and contributes new knowledge about the way HCPs conceptualise depression in patients with LTC and was used to design an online intervention to improve the management and recognition of depression in these patients. Further research to develop this intervention and evaluate it on a larger scale is needed.

The need for Registered Nurses (RNs) in the long-term care of older people is being questioned, particularly in the context of nursing shortages, while suggestions for 'professionalising' Care Assistant (CA) roles are emerging. Despite ongoing debates about the importance of their work, research has so far been unable to provide an evidence-base for the outcomes of the work of either RNs or CAs in UK care homes. Using a multi-method interpretive approach, adopting a structure-process-outcome framework and grounded in the philosophical hermeneutics of Hans-Georg Gadamer, this qualitative research sought to illuminate the distinct contributions made by RNs and CAs to outcomes for older people in care homes. RNs and CAs from around the UK contributed 'significant' examples of their work for Phase 1 of the study and Phase 2 comprised researcher fieldwork (observation, interviews and documentary analysis) in three care homes around England. Participants included RNs, CAs, older residents, relatives, home managers and professionals working in the homes. The findings offer a rich and detailed analysis of the realities of the work, much of which takes place 'behind closed doors' and has been described to a limited extent in the literature. They suggest that the CAs' daily support helps residents to function and to feel valued, and that close, reciprocal, family-type relationships develop. The health knowledge and clinical expertise of good RNs is critical in determining residents' health outcomes, particularly in the long-term, and RNs' 24-hour 'perceptual presence' can make life or death differences in acute or emergency situations. RNs also influence the environment, atmosphere and quality of care in the home. In the context of the literature, the findings offer new insights into the role and contribution of RNs and CAs, the outcomes of their work and the priorities of residents. The study produced new models of RN and CA roles in care homes, encompassing dimensions not previously acknowledged in the literature or their job descriptions, and a new framework within which the outcomes of care for older people could be evaluated. The research offers a positive image of work with older people in independent sector care homes.

This thesis seeks to contribute to the knowledge base about social policy in the United States, using long-term care (LTC) financing policy reform as an illustrative example. Specifically, this thesis explores LTC financing reform efforts during three U.S. Presidential administrations: Bill Clinton (1993-2001), George W. Bush (2001-2009), and Barack Obama (2009-2010). Within this historical framework, the LTC provisions of the Health Security Act of 1993, the development of the Community Living Assistant Services and Supports or 'CLASS' Act during the Bush Administration, and the legislative success of the CLASS Act as a part of the Patient Protection and Affordable Care Act of 2010 provide comparable cases to compare the drivers of social policy. Drawing on the explanatory frameworks of the welfare state such as ideology, historical institutionalism, and an actor-centered approach to policy analysis, this thesis argues that successful path-departing legislation is difficult to achieve due, in part, to the presumed high costs of social programs and the complex institutional framework of the American political system. Policy outcomes result from the interaction between the complex processes and dynamics of the political system through which policy change (or the failure to change) actually occurs. The fact that the CLASS Act was politically successful, yet administratively inoperable as designed, reinforces the argument that social policy outcomes in the United States are reflective of a complex, enduring struggle of competing ideologies. This continual struggle, coupled with a heightened concern over cost control and fiscal austerity, helps to ensure that policies which are legislatively successful within the institutional architecture of the American political system are unlikely to produce major expansions of the welfare state. Social change is therefore highly difficult to achieve, even in the face of significant unmet social needs. Comprehensive reform of U.S. LTC financing arrangements will remain an elusive goal for the foreseeable future. Instead, incremental, highly pro-market solutions are likely to be the types of policies promoted in the years of ahead.

Across Scotland, there is a lack of research in care homes. This thesis explores this topic by examining links between inclusion, participation in general and participation in research and whether those who work and live in the care home environment experience social citizenship. Using a national survey and interviews with residents, staff, relatives and experts in care home research, this thesis investigated whether participation generally was linked to participation in research for residents, staff and visitors in a care home setting. The thesis further explored how social citizenship functions in a care home environment and whether there is a link between participation and citizenship. The findings suggest there is a lack of general participation which is connected with the leadership style and management within the care homes. There is misunderstanding about research and legislation amongst the care home staff, residents, visitors, as well as the junior research staff which inhibited staff and resident participation. Furthermore, citizenship is not experienced universally by residents or staff due to disempowerment, and exclusion occurs amongst residents due to age, frailty and dementia. By facilitating good leadership, communication and relationship-building such issues may be overcome. In addition, the analysis suggests a link is evident between inclusion, participation and citizenship. Where choice is provided and residents have their social position maintained, as well as have a degree of responsibility for shaping events, this leads to participation and inclusivity as described in Bartlett and O’Connor’s (2010) definition of social citizenship. Furthermore, if inclusion is adapted for cognition and frailty, then participation leads to the experience of social citizenship, encouraging a culture which can welcome research. The explicit emphasis on inclusion and participation in research has enabled this under-researched area of participation and experience of social citizenship in care homes to be more fully explored.