Background - One of the most significant changes within healthcare practice and research is a shift from ‘treating’ disability at the level of body function to an ecological approach that addresses the children’s involvement in everyday life, conceptualised as participation. Participation encompasses children’s involvement across home, school and community settings. A complex interaction of personal characteristics, performance skills and environmental factors influence children’s participation. Therefore, assessments that comprehensively and ecologically capture children’s participation and contributory factors are important. Gathering information from parents and teachers may enhance the accuracy of information. Of the currently available assessments, few include multiple informants and provide an overarching portrait of the child’s participation across all settings. The ACHIEVE Assessment is one that does and forms the focus of this work. Methods - Services from across Scotland agreed to participate in the research by implementing the ACHIEVE Assessment and inviting parents to consent to use of their child’s information. Rasch modelling was used to analyse the ACHIEVE Assessment. Parent and teacher questionnaires were also compared. Results – The study includes a large clinical sample ranging in age from 4-17 years old, with an average age of 8 years. The results from the study demonstrate that the ACHIEVE Assessment provides unidimensional measurement of children’s participation and contributory factors. The environment items measure a separate latent trait and are too easy for respondents to endorse. Parent and teacher questionnaires fit on the same dimension. However, self-care and social skills items differ in function between respondents. In addition, there is a low correlation between parent and teacher questionnaires. Overall, items relating to children’s participation in activities are easier than items about contributory factors. Process skills items are the hardest to endorse, despite the sample predominantly including children referred for reasons related to motor difficulties. Items about children’s school activities are relatively harder than items about community activities. Finally, item function differs for children in the youngest age group. Conclusion – Using Rasch analysis allowed exploration of the complexity of factors that interact to influence children’s participation as captured by the ACHIEVE Assessment. The study demonstrates the measurement qualities of the participation items on the ACHIEVE Assessment, however the environment items require further development as a separate measure. The item hierarchy emphasises the importance of further investigating the association between children’s process skills and their participation, in addition to research in the area of school participation. As there are only weak associations between parent and teacher reports, one is not substitutable for the other and multi-informant assessment will be an important strategy for gathering comprehensive information about children’s participation.

The thesis contextualises creative dance as art in a community setting. The participants were teenage members of a community-run creative dance company. The aim was to explore any links young people make between their creative dance experience in a community class and their feelings of social well-being. The literature gives a brief historical overview of dance as a performing art and of the nature of aesthetics and creativity. It considers the art of dance as a form of communication, and the conditions for creativity to flourish. It looks at Bourdieu‘s (2005) theory of ‗habitus‘ and ‗field‘ in understanding the social experience which the dancers derived through creative dance. Consideration is given to theories and accounts of adolescent development and how community interaction can affect the dancers‘ feelings of social wellbeing. The methodological approach is hermeneutic phenomenology, with influences from ethnomethodology and social constructionism. The ontological principle is that personal meaning is socially constructed. Epistemologically the study is informed by the belief that knowledge is generated through the creative dance experience. The main data collection method was semi-structured interviews with the dancers (n=10), supported by observation of dance classes (n=7; filmed: n=4), group discussions (n=3) and graffiti walls (n=8, completed by the dancers). The data were organised and analysed thematically using a method of presentation inspired by Bourdieu‘s concept of a ‗social trajectory‘ - a lifetime journey of social encounters – offering headings under which the data were loosely organised. Selected observations are presented on DVD. The responses suggested a dance ‗journey‘ from preparation to performance, which allowed further organisation of data. The emergent themes included the dancers‘ motivation for dancing, their feelings about the creative process, experiences of social interaction and of taking control of one‘s own identity, through all the stages of experimenting with movement, refining the dances and performing. The main findings are: the dancers attached importance to company membership because it offered a means to clarifying self-identity through physical and artistic endeavour; the creative dance context gave them freedom to explore their movement capabilities and to interact socially, and thus gave them a means of negotiating their ‗habitus‘, i.e. adopting and adjusting social norms and values on their own terms. Performing was a celebration of achievement and confirmation of identity as a dancer. The study contributes to the understanding of how adolescents make sense of their identity in their social context through their creative dance experience and how that influences their feelings of social wellbeing.

Whilst hospitals are the dominant institutions through which Western biomedical treatment is delivered, it is also argued that these institutions do not reproduce a distinct notion of a biomedical model, but instead assume different configurations, reflecting and replicating wider socio-cultural processes. In South Africa, this includes a reflection and replication of challenges arising from an eclectic therapeutic landscape in which biomedicine is but one avenue. The challenge presented is that South Africa’s dominant therapeutic cultures of African traditional medicine, said to be used by an estimated 80% of the population, and Western biomedicine, reflect two distinct, and arguably conflicting, ontological and epistemological paradigms. A recognition of this is encompassed in many hospital ethnographies exploring how biomedical professionals confront and manage the collision of these therapeutic systems within the institutional space. Whilst such studies have been carried out in a number of African country-settings, this interface of therapeutic cultures in South African hospitals has received scant attention. Using a range of interpretive research methods that include narrative, informant, and respondent interviews, this project, carried out within two public hospitals in the town of Barberton, South Africa, explores the views, experiences, and perspectives of hospitalbased biomedical professionals, and hospital-bound tuberculosis patients, on the articulation of African traditional medicine and Western biomedicine. Barberton tuberculosis hospital Using a narrative approach, an exploration of TB patient’s stories of navigating the plural therapeutic landscape is undertaken. These examine the complex navigation of a plural medical ecology, the conflict arising as a result, as well as how personal accounts reflect broader meta-narrative illness archetypes. Alongside this, is an examination of the conflict between nurses and patients within the hospital-confines that arises as a result of the interface between African traditional medicine and Western biomedicine. This is examined in the context of a TB treatment facility that reflects strong Foucaultian characteristics of institutional control, and observation of patient bodies and behaviours. Barberton general hospital Using informant and respondent interviews, an exploration of the positioning, views, and sometimes allegiances of nurses and doctors towards African traditional medicine and Western biomedicine, is undertaken. This includes an examination of the described articulation between these therapeutic cultures within the biomedical space. A particular emphasis is placed on examining the role of nurses as brokers of culture, as they mediate and broker conflict arising as these therapeutic systems collide. This study presents a complex milieu of views and positions regarding the interface between African traditional medicine and Western biomedicine. Tuberculosis patients portray convoluted and meandering health seeking journey’s between healing systems, and both nurses and tuberculosis patients, describe an institution attempting to position itself as distinctly biomedical. Whilst African traditional medicine does emerge within this hospital space, this is largely clandestine, and is actively discouraged by biomedical staff through vigilant observation and oversight that is interpreted by patients as overt, and excessive biomedical control. In the general hospital, nurses and doctors described how African traditional medicine is encountered and confronted, where it is largely viewed as clouding and complicating biomedical healing and treatment endeavours. The range of views on these ontologically distinct systems, are broad, where health professionals who reject traditional medicine, and those, mainly nurses, who use traditional medicines, work side-by-side – sometimes leading to internal conflict. An exploration of the role of nurses as culture brokers is complex, where nurses describe encountering significant conflict in mediating between patients expectations, expectations demanded by professional roles, and their cultural allegiances. This is embedded within a complex political landscape, where biomedical practitioners who position themselves against African traditional medicine, feel reluctant to voice concerns in a post-apartheid institution that prioritises cultural pluralism, and respect for personal beliefs. This project uncovers the conflict and tensions arising from the plural medical landscape within, and without Barberton’s hospitals, as well as how the stance towards therapeutic pluralism by biomedical professionals differs between these institutions depending on context.

Drawing upon the biographical narratives of eight student physiotherapists and situated within an interpretive paradigm this thesis has explored the construction of professional identities within physiotherapy education. It has been predicated upon notions of identity as constructed through social interactions, therefore a relational concept requiring interaction, enactment and reciprocity. It took place within a contemporary professional context epitomised by increasing interprofessionalism challenging notions of what being a physiotherapist means. The main findings of this study suggest that student physiotherapists enter physiotherapy education (or very soon after, develop) with a well formed idea of what being a physiotherapist means, constructing an idealised professional self. This idealised professional self becomes the lens through which they subsequently experience and evaluate their professional education experiences. The process of constructing professional identities involves student physiotherapists in a continuous cycle of performance, mediation and impression management, through which they seek opportunities to confirm their idealised professional self. The findings of this thesis suggest that student physiotherapists exercise individual agency to construct socially and spatially situated professional identities in everyday professional interaction and supports contemporary notions of professional socialisation as interactive. This thesis contributes to the contemporary understanding of the process of identity construction. Theoretically, it emphasises the concept of role models and highlights the importance of anti-role models or disidentification. Practically, it offers physiotherapy educators the opportunity to reconsider the complexities of professional identity and its place within the learning context. Finally, for the students who took part in this study telling their stories has rendered their experiences with meaning and their stories have the capacity to become important cultural tools for future students.

Introduction: Gene therapy is currently being developed for people with cystic fibrosis (CF), a life-threatening condition for which there is no cure. The UK CF Gene Therapy Consortium are preparing for a multi-dose gene therapy trial of sufficient duration that clinical benefit may be seen. Aims: The current study aimed to explore the expectations and beliefs of cystic fibrosis (CF) patients involved in the preparatory phase of the gene therapy trial (the Run-in study), from which participants will be selected for the multi-dose actual gene therapy trial. Method: Twelve participants (six with mild and six with moderate CF) were interviewed using a semi-structured interview. Interviews were recorded, transcribed verbatim and then analysed using a Constructivist Grounded Theory approach. Results: Since entering the Run-in study, half of the patients had increased their expectations of gene therapy being an effective future treatment. Most of the participants hoped to derive clinical benefit from the trial itself though half were unsure of what to expect. Whilst half of the participants expressed the hope of a future cure for CF, the remainder saw gene therapy only in terms of an improved treatment. Participants used several strategies to manage their expectations including not thinking too far ahead and trusting the research team. Discussion: The findings indicate that participants in the Run-in trial are generally eager to be involved in the gene therapy trial and have developed a strong sense of trust in the research team conducting the trials. The levels of optimism expressed for personal benefit from trial were higher than those from earlier studies. Some of the positive expectations were unlikely to be met by the gene therapy trial and participants risk disappointment. However other patients participated with apparently realistic expectations and it seems likely that some patients would have participated even without prospect for personal benefit. Possible areas of psychological support are discussed e.g. a standard clinical interview for all those not accepted for the gene therapy trial; screening for anxiety pre-, during and post-participation.

Professional practice guidelines direct health care professionals to include patients in the decision-making process and to establish collaboration for therapeutic goal setting. Currently, little is known about the interaction between patients and professionals during this process. The aim of this study is to shed light on goal setting practices in physiotherapy. Twenty-eight consenting patients seeking physiotherapy for their musculoskeletal problems and their therapists were videotaped during three consecutive sessions. Sequences related to goal setting were selected, and Conversation Analysis was chosen to analyse patient-therapist interactions. The data comprise fifteen episodes in which therapists enquire explicitly about goals. Findings show that two assumptions underlie these enquiries: a) that patients have a goal in mind, and b) that they are able to articulate it. My data indicate that this is not straightforwardly the case in practice. Patients orient in their responses to epistemic dimensions related to issues of whether they have access to this knowledge, and whether they treat themselves as entitled to know about goals. When patients respond to therapists’ enquiries, they use a variety of interactional resources to convey their epistemic orientation. I further found that therapists use different strategies for following-up patients’ responses: these have different implications for patients’ continued talk. My analysis also shows that a goal can only be treated as acceptable by therapists when it is amenable to improvement by physiotherapy. My study indicates that the process of goal setting is not as straightforward as policy documents suggest. In actual practice it requires addressing and managing underlying assumptions and epistemic dimensions. A better comprehension of the interaction between physiotherapists and patients will contribute to better understand the limitations of current goal setting theory, and how and why current policies on goal setting may not have the desired effect.

Background There is growing interest in the idea that arts and singing have effects on health, wellbeing and quality of life in older individuals. This study assesses the effectiveness and transferability to Italy of an English model of health promotion which promotes wellbeing and quality of life in older people through participation in singing groups (Silver Song Clubs). The model developed in the South East of England has proved to be successful. A recently completed randomized controlled trial (Coulton, et al. in press) demonstrated a significant improvement in mental health with a reduction in measured anxiety and depression for older people living independently. The current study adopted the same measures. Method A mixed method approach was adopted with research divided into two parts; Part A was focused on exploring the status of older people living in Rome, their interest in music and singing today and in the past and in taking part in a singing experience. It also explored how local politicians and social workers see the status of older people. Part B was focused on setting up and evaluating singing groups and gathering information from participants on their experiences of singing. The primary outcome measure was an Italian version of the York SF-12 which provides scores for physical and mental wellbeing. The Italian version of the EQ-5D-3L questionnaire was also employed. Results Results from Part A revealed a highly fragmented Italian family, with widespread poverty and social isolation and a need for emotional support and leisure activities among older people. In Part B, three singing groups were established in different areas of Rome with weekly sessions over a period of three months. Participants completed the standardized measures of health and wellbeing at baseline (n=62), after the singing experience (n=45) and three months later (n=41). After the singing experience, older people showed a statistically significant decrease in their levels of anxiety and depression, but this was not maintained over the three month follow up period. However, a significant improvement was found from baseline to follow up in reported performance of „usual activities‟. Conclusions Silver Song Clubs provide a health promotion model which was successfully transferred from England to the different cultural setting of Italy. Singing can be widely used because it is grounded in a fundamental human ability to engage with music. The present study had a number of limitations, primarily a lack of a control group and small sample size. However it provides a good foundation for the development of further research on singing and the wellbeing of older people in Italy.

This research explores professional identity formation amongst occupational therapy students. Professional identity is examined within an occupational science framework. Much has been written, in recent years, about the professional identity development of occupational therapists during the first stages of their career focusing on preceptorship (Morley, 2006, Tryssenaar, 1999) but the concept of initial professional identity formation remains under examined. This thesis addresses that gap by following one student’s journey of becoming an occupational therapist from enrolment to graduating on an undergraduate occupational therapy course. Five in-depth interviews were carried out over three years. This was situated against a series of focus groups drawn from the same cohort. The Kawa model (Iwama, 2006) was used as a data collection and analytical tool. Three overarching themes which highlight the processes involved in professional identity formation, were identified • Establishing occupational coherence; the participants needed to make sense of their occupational history. It was important for participants to explain and present themselves as having developed occupational coherence over time. • Managing occupational adaptation; the participants dealt with many challenges as they coped with transitions and a changing sense of self. It was important that they developed agency and feelings of competence on their professional journey. •Developing a new identity; the participants explored how they adapted to new possibilities as they experienced the doing of occupational therapy. Their new occupational identity was congruent their own personal values. This interpretative phenomenological analysis makes a significant contribution to the small body of knowledge around professional identity formation in occupational therapy. The longitudinal approach created a nuanced narrative which expounds the complex ongoing process. It highlighted the importance of paying attention to the processes of doing, being, belonging and becoming. The fundamental importance of enabling students to develop an occupational perspective to understand their developing professional identity is identified.

Bone remodelling, the process by which the skeleton adapts to environmental changes, is dependent on the actions of osteoclasts that resorb bone and osteoblasts which make new bone matrix. Aberrant remodelling underpins bone loss in several debilitating skeletal diseases such as osteoporosis, metastatic breast cancer and multiple myeloma. Changes in remodelling activity can also arise as a consequence of therapeutic intervention for instance intravenous bisphosphonate treatment is associated with osteochemonecrosis of the jaw and localised osteoradionecrosis is a common side effect of radiotherapy. Hyperbaric oxygen is often used as an adjunctive therapy in the treatment of these disorders. HBO involves the administration of 100% oxygen at atmospheric pressures greater than one in sealed chambers. The following studies aimed to evaluate the effect of HBO, hyperoxia, and pressure on RANKL-induced osteoclast differentiation and bone resorption from RAW264.7 and human peripheral blood mononuclear cells (PBMC), and osteoblast differentiation in vitro. The study also aimed to further examine the effect of HBO on ex vivo osteoclast formation from peripheral blood monocytes obtained from patients undergoing HBO. Daily exposure to HBO for ninety minutes significantly suppressed osteoclast differentiation and bone resorption in mouse and human monocytes in normoxic and hypoxic conditions in vitro. The suppressive action of HBO on osteoclast formation was associated with a significant reduction in HIF-1α and RANK mRNA expression and HBO also caused a significant reduction in NFATc1 and DC-STAMP expression. This study has for the first time shown that HBO is able to reduce the ability of precursors to form bone resorbing osteoclast. HBO also suppressed the ability of peripheral blood monocytes to develop into RANKL-induced resorptive osteoclasts. In an ex vivo culture system the suppressive effect of HBO was meditated by an action prior to activation of osteoclast differentiation by RANKL and must therefore be an inhibitory effect on the ability of precursors to differentiate along the osteoclastic lineage. HBO also accelerates the rate of osteoblast differentiation and augments early stages of mineralization and has a more pronounced effect than hyperoxia or pressure alone. HBO enhanced bone nodule formation and ALP activity in human osteoblasts. Furthermore HBO promoted the expression of type I collagen and Runx-2 in both normoxic and hypoxic conditions. HBO had a greater effect on these key markers of osteoblast differentiation than hyperoxia or pressure alone. This study suggests that HBO suppresses osteoclast activity and promotes osteoblastic bone formation, which may at least in part mediate its beneficial effects on necrotic bone. This provides evidence supporting the use of HBO as an adjunctive therapy to prevent osteoclast formation in a range of skeletal disorders associated with low oxygen partial pressure. The study also provides further support for the use of HBO in the treatment of skeletal disorders associated with excessive resorption such as osteomyelitis, and also provides a potential mechanism through which short term HBO may help fracture healing.

It is estimated that more than 60% of cancer patients will receive radiotherapy (RT). Medical images acquired from different imaging modalities are used to guide the entire RT process from the initial treatment plan to fractionated radiation delivery. Accurate identification of the gross tumor volume (GTV) on computed tomography (CT), acquired at different time points, is crucial for the success of RT. In addition, complementary information from magnetic resonance imaging (MRI), positron emission tomography (PET), cone-beam computed tomography (CBCT) and electronic portal imaging device (EPID) is often used to obtain better definition of the target, track disease progression and update the radiotherapy plan. However, identifying tumor volumes on medical image data requires significant clinical experience and is extremely time consuming. Computer-based methods have the potential to assist with this task and improve radiotherapy. In this thesis a method was developed for automatically identifying the tumor volume on medical images. The method consists of three main parts: (1) a novel rigid image registration method based on scale invariant feature transform (SIFT) and mutual information (MI); (2) a non-rigid registration (deformable registration) method based on the cubic B-spline and a novel similarity function; (3) a gradient-based level set method that used the registered information as prior knowledge for further segmentation to detect changes in the patient from disease progression or regression and to account for the time difference between image acquisition. Validation was carried out by a clinician and by using objective methods that measure the similarity between the anatomy defined by a clinician and by the method proposed. With this automatic approach it was possible to identify the tumor volume on different images acquired at different time points in the radiotherapy workflow. Specifically, for lung cancer a mean error of 3.9% was found; clinically acceptable results were found for 12 of the 14 prostate cancer cases; and a similarity of 84.44% was achieved for the nasal cancer data. This framework has the potential ability to track the shape variation of tumor volumes over time, and in response to radiotherapy, and could therefore, with more validation, be used for adaptive radiotherapy.