In construction many problems exist that lead to poor quality of the built environment, for example, lack of integration between service and facility design and poor requirements management. Aiming to mitigate these problems, academics and practitioners have engaged in debating ways of improving the process of designing new facilities. One of the approaches that has been investigated is the use of scientific evidence to support decision makers within the design process. This process is called evidence-based design (EBD). In this respect, a range of studies developed in healthcare sectors encourages the application of EBD in order to add value to the design of these environments and to produce better building outcomes for patients and staff. In this respect, this study was designed to address this issue and is aimed at better understanding how evidence supports design. The achievement of the aim was based on (a) revisiting the philosophical debate about the definitions of evidence and knowledge formation to propose a conceptual framework that can be used to classify evidence within the design domain; (b) investigating the proposed use of evidence within prescriptive design methods of design; (c) understanding how evidence has been used in design practice (specifically in the design of healthcare facilities) and to propose a taxonomy for different categories of evidence that support building design and their advantages and disadvantages; and (d) exploring the existence of opportunities to improve design practice with a basis on a better understanding of evidence. The focus of the research was the design process of healthcare facilities and the unit of analysis was the role of evidence within design. The findings of this research enhance our understanding of design as a knowledge formation system. In this respect, the use of this approach opens opportunities for future studies related to the interpretation and the development of tools that assist design. This research also provides insights related to analysis and synthesis as the proto-theory of design as well as distributed intelligence in design.

Therapeutic footwear is provided to patients with the primary aims of reducing foot pain and improving foot health. Therefore, it is of concern that patients choose not to wear it. This choice has been attributed to its poor appearance. However, there may be other reasons for this choice and the reasons may be more complex than previously acknowledged. Therefore, the aim of this study was to investigate the users’ experiences of this footwear. In the context of this study the ‘users’ are women with rheumatoid arthritis. This study was based on an interpretive phenomenological approach (IPA) that employed conversational style interviews to gather data. Ten women with RA and experience of wearing the footwear were recruited and following ethical approval the interviews were carried out, transcribed, organised and analysed. Five organising themes emerged as findings. These were the participants: • feelings about themselves, • feelings about the footwear, • unmet needs and expectations, • behaviour with the footwear and • feelings about the consultation with the practitioner. The final, global theme was that the patient/practitioner consultation has a powerful influence on the women’s feelings about themselves, the footwear, their expectations of it and their behaviour with it. This study has provided insight into their experiences of this footwear in that, unlike any other intervention, it replaces something that is normally worn and is part of an individual’s perception of self and their perception of how others see them. The footwear impacts more on women’s emotions than previously acknowledged and in addition, it has been found that the consultation influences their emotions and behaviour with the footwear. As well as improvements in footwear design and the service that delivers it, the training of the practitioners in a more patient focussed consultation style could improve the women’s experience and engagement in the footwear as a health intervention, as well as something that is ‘worn’.

Occupational therapists believe that identity is shaped by engagement in occupations but this relationship has yet to be fully understood. This thesis is an account of a study which aimed to investigate how narratives told about occupations contribute to the construction of identity. Narratives, extracted from interviews with 17 leisure enthusiasts, were subject to systematic analysis of content, form and interactive elements. This was based on an understanding that identity is expressed in the meanings attributed to the events told in a narrative. The meanings were used to construct a framework which provides a basis for conceptualising the ‘occupied self’. The framework is organised around three dimensions. The dimension of the ‘active self’ enables people to present themselves in terms of morality, competence and agency. The ‘located self’ enables them to present a sense of location in time, place, society and the body. The ‘changing self’ enables the individual to present the self as changing in itself and in relation to occupation. These facets of the self are manifested and foregrounded differently by each individual. Based on a narrative perspective, the framework provides a unique and useful theoretical development, structuring and enhancing what is currently understood about the relationship between occupation and identity. The findings of the research contribute to the debate about how occupation is defined and how the meanings of occupations are understood. Other implications are also explored in the thesis. The framework offers practitioners a structured way of understanding the ways in which occupation can contribute therapeutically in the reconstruction of damaged identities. The method of analysing narratives used in this study has much to offer in understanding occupational engagement. Further research is needed to understand the various manifestations of the parts of the framework, and to explore its potential for use as a practice tool.

The primary focus for this Thesis is an account of the degree to which nurses and other stakeholders in one National Health Service hospital Trust have responded to the ‘clinical governance’ initiative, the effects on quality improvement and professional regulation and the practical accomplishment of legitimacy. ‘Clinical governance’ involves demonstrating that quality assurance is routine practice within every healthcare organization. A case study was undertaken, using broadly ethnographic methods. The qualitative data were obtained by documentary analysis, non-participant observation of meetings and day-to-day ward activity and semi-structured interviews. In terms of the analysis of documents and observation of meetings, new institutionalism theory was found to be useful as a framework for understanding the political and ceremonial conformity that marked the clinical governance process. Errors and inconsistencies were found in formal documentation and the Trusts’ reporting systems were fraught with problems. Nevertheless, during the same period the Trust obtained national recognition for having appropriate structures and systems in place in relation to clinical governance. A grounded theory approach was adopted in the analysis of the semi-structured interviews. Emerging themes from interview data were identified under the main categories of: ‘Making Sense,’ ‘Knowledge Construction,’ ‘Somebody Else’s Job’ and ‘Real Work.’ It was concluded that at a practice level, clinical governance was poorly understood and that the corporate organizational goals were ambiguous and seen as unrealistic on a day-to-day basis. The study concludes that what is happening is not a ‘failure’ but an unintended consequence that has resulted from an inadequate understanding of how organizations work. It is suggested that the organization has conformed to the appropriate standards in order to survive legitimately, but the ultimate impact of clinical governance on the quality of care in practice is inconsistent.

Urban areas are hubs of creativity and innovation providing fertile ground for novel responses to modern environmental challenges. One such response is the community-led management of urban green spaces as a form of organised social-ecological innovation (OSEI). Previous studies have attempted to conceptualise the ecological, social and political potential of such informal approaches to urban green space management. However, little work has been carried out into their efficacy in the landscape, either by describing the social-ecological conditions influencing their occurrence or by quantifying the actual benefits in terms of ecosystem service provision. This research explores the emergence and impact of OSEI in a continuous urban landscape comprising the metropolitan areas of Manchester, Salford and Trafford (UK). The social-ecological context and content of OSEI were investigated using a cross-scale approach. At the landscape scale a snowball-sampling method mapped the occurrence of OSEIs using GIS and remote sensing technology. At the micro-scale, a case study quantified relative levels of provision across four key ecosystem services. The analysis presented OSEI as an adaptive response to environmental stressors, clustered around “hubs” of social-ecological innovation in the urban landscape. The distribution of OSEIs was influenced by historical context, degree of urbanisation and dependent on levels of, and dynamics between, social and ecological deprivation. Urban agriculture was instrumental as a catalyst for the emergence of OSEI and the associated production of a range of ecosystem services. Site productivity was also influenced by spatial and design considerations. This thesis has detailed the character of OSEI as a coherent phenomenon in the urban landscape which exhibits valuable response diversity according to social-ecological conditions. This, together with an evaluation of factors influencing ecosystem service provision at the local scale, has informed the validity of OSEI as an element of adaptive capacity which contributes to resilience in urban social-ecological systems.

Guidelines for the management of asthma in the UK have been published (BMJ, 1990, Thorax, 1993 and 1997) and embraced by many GP practices with improved outcome for patients. The study aims to observe and follow a cohort of adult asthma subjects from differing primary health care settings over a two-year period. Also to assess a newly devised patient focused morbidity index (Q score) by comparison to an established asthma specific quality of life questionnaire (AQLQ, Juniper et al, 1993). One hundred and fourteen subjects from four GP Practices, two inner city and two suburban were studied. Morbidity was assessed by AQLQ and Q score (Rimington et al, 2001), psychological status by the hospital anxiety and depression (HAD) scale (Zigmond and Snaith, 1983). Spirometry values (forced expiratory volume in one second, FEV1), peak expiratory flow (PEF) and details of current treatment as per BTS guidelines treatment step were recorded as markers of asthma severity. Subjects were assessed at baseline, twelve and twenty-four months. A random sub set of patients was asked to repeat certain elements of the study protocol at two weeks in order to assess the reliability of the Q score. The Q score correlated from baseline to two weeks (rs=0.61) as did AQLQ symptom score (rs=0.74) both p<0.01. At baseline AQLQ symptoms correlated with PEF (rs=0.40, p<0.001) and with BTS guidelines treatment step (rs=0.25, p=0.001) as did the Q score. Similar levels of correlation were reported for FEV1 with symptoms. HAD scores also correlated to AQLQ and Q score, but there was little correlation with lung function. At one and two year follow up no significant differences were observed in subjective or objective markers of asthma. There was a significant increase (p<0.001) in the number of subjects in the higher BTS guidelines treatment steps from baseline to twelve and twenty-four months while psychological symptoms remained high for inner city patients. In conclusion the Q score yields similar results to the AQLQ and is quick and easy to use in any busy clinic. The GP practice, at the forefront of asthma care should be offering appropriate therapy and regular review. The Q score used as a patient focused morbidity index can be a useful audit tool. Altering medication can give the impression of treating asthma but with out short-term reassessment the same levels of morbidity can persist.

This thesis is about people with mental health problems who happen to be older, rather than older people with mental health problems. Health policy that has focused on older people as a category has maintained a narrow focus on recognising depression and dementia, with older people being excluded from mental health policy aimed at adults of working age. This has resulted in age discriminatory practices, but in addition, the unique needs of people who have lived long term with mental ill health into later life have been ignored. Older people have been often conceptualised as consumers of care rather than citizens with aspirations and research about long term experience of mental ill health and recovery commonly excludes older people. This study aimed to redress this marginalisation and lack of knowledge by exploring the experience of long term mental ill health to older age from a strengths perspective congruent with recovery principles. The study is based on a social constructionist epistemology and narrative inquiry methodology. The research questions were: 1) How does living with long term mental ill health affect achievement and 2) How does long term mental ill health affect life in the present? People who were aged over 50 and who had at least 20 years duration of mental ill health that started before the age of 45 were included. Seven people were recruited though posters placed in GP surgeries, leisure centres and libraries and contacts through mental health services. Four women and three men between the ages of 52 and 76 participated. The study develops the curriculum vitae as a research tool, a method unique in mental health research, in order to root the enquiry within participant relevancies and perspectives to ensure that this previously unheard voice is captured. This tool is congruent with a biographical method that informs the development of two personalised interviews and enables the implementation of this method within a recovery (strengths) frame of reference. The resulting individual narratives were interpreted with reference to the principles of over reading and life course theory. A collective text was also developed which discusses the key findings. The novel approach taken in this research study resulted in an original contribution to current knowledge which provides evidence that can be used to challenge beliefs about people who have lived a lifetime with mental ill health. The study revealed a lifelong process where participants returned to their early life in making sense of their experiences. Long term mental ill health appeared to create an environment whereby participants maximised their chances of success by avoiding stress which has a myriad of personally relevant causes. This appeared to be achieved by keeping silent, which, whilst self-protective, nevertheless potentially exacerbated their stress further and resulted in further stressful consequences. In later life the changed sociocultural and personal environment became part of an autobiographical reasoning that sustained self-theory. This created a situation whereby the participants felt better but also worse at the same time, where personal growth co-existed alongside stress burnout but was coupled with a renewed sense of hope in later life. The implications for health and social care are discussed in relation to policy, practice, research and education in the context of age equality, recovery and long term conditions. Recommendations include: to focus on extensive durations of mental ill health as a special characteristic, to review the of use stress assessments and trauma histories in practice and research, for practitioners to establish the hopes and aspirations of older people who come into contact with services and for researchers to examine the presence of hope in older people with long term mental health problems.

Entitlement to drive is now viewed by many people as an essential component in the maintenance of independence (Box et al, 2010). Private motor vehicles are considered a key component in many aspects of contemporary life and are particularly important for people with a limitation in personal mobility. The driving task involves the smooth integration and coordination of a number of cognitive, perceptual and physical elements (Hoffman and Snyder, 2005). Testing tools designed to evaluate the effect of cognitive impairment upon driving are available but many perform poorly when evaluating both older individuals and people with a diagnosis of dementia (Molnar et al, 2006). This research project aimed to give voice to the experience of people with dementia, carers and health professionals in the construction of an effective and clinically useful prototype screening tool, specifically for use in predicting the safety of drivers with a diagnosis of dementia. A participatory action research approach was taken with two separate groups formed from a dementia volunteer support group and a health professional dementia special interest group. The key findings of the research identified characteristic driving behaviours associated with a decline in driving safety and these were used to develop a dementia and driving screening tool. Additionally, a comprehensive information guide for the monitoring and management of driving with dementia was constructed through the action of group meetings. The experiences of both research groups strongly suggested that early consideration and planning is essential in the successful management of driving and eventual driving cessation for people with dementia.

The benefits that humans receive from nature are not fully understood. The ecosystem service framework has been developed to improve understanding of the benefits, or ecosystem services, that humans receive from the natural environment. Although the ecosystem service framework is designed to provide insights into the state of ecosystem services, it has been criticised for its neglect of spatial analysis. This thesis contains a critical discussion on the spatial relationships between ecosystem services and the urban landscape in Salford, Greater Manchester. An innovative approach has been devised for creating a landscape mosaic, which uses remotely-sensed spectral indices and land cover measurements. Five ecosystem services are considered: carbon storage, water flow mitigation, climate stress mitigation, aesthetics, and recreation. Analysis of ecosystem service generation uses the landscape mosaic, hotspot identification and measurements of spatial association. Ecosystem service consumption is evaluated via original perspectives of physical accessibility through a transport network, and greenspace visibility over a 3D surface. Results suggest that the landscape mosaic accuracy compares favourably to a map created using traditional classification methods. Ecosystem service patterns are unevenly distributed across Salford. The regulating services draw from similar natural resource locations, while cultural services have more diverse sources. The accessibility and visibility analysis provides evidence for the importance of urban trees as mitigators of ‘grey’ views, and urban parks as accessible producers of multiple services. Comprehensive ecosystem service analysis requires integration of quantitative and qualitative approaches. Evaluation of spatial relationships between ecosystem services and the physical landscapes in this thesis provides a practical method for improved measurement and management of the natural environment in urban areas. These findings can be used by urban planners and decision makers to integrate ecological considerations into proposed development schemes.

With proposed increases in both freight and passenger railway in the United Kingdom and the European Union and the building of new high speed lines, there has been an increase in interest in recent years in the human response to vibration in residential environments. As with exposure to environmental noise, exposure to environmental vibration can result in adverse effects such as annoyance and sleep disturbance. However, unlike exposure to environmental noise, well established relationships to evaluate annoyance caused by vibration in residential environments do not exist. In order to predict and control annoyance caused by vibration from environmental sources, a better understanding is needed of how humans perceive vibration and how their perception relates to measureable, quantifiable features of the vibration exposure. In the work presented in this thesis, the human response to vibration is considered on both a community and individual level. The first major aim of this work is to develop statistically robust exposure-response relationships for the human response to railway and construction induced vibration in residential environments. This is achieved via a large scale field survey in which 1431 questionnaires were conducted with residents in their own homes along with extensive vibration measurements at internal and external positions. Analysis of the data collected through this field survey shows that all of the vibration exposure descriptors advocated in national and international standards are equally well correlated with annoyance due to railway induced vibration. Using a grouped regression model, exposure-response relationships describing the proportion of respondents expected to express annoyance above a given threshold are derived for railway and construction induced vibration in terms of a variety of vibration exposure descriptors. The second major aim of this work is to investigate the perception of railway induced vibration on an individual level by investigating the salient dimensions of the perception of whole body vibration. This is achieved via a subjective laboratory test in which paired comparisons of similarity and annoyance are conducted using fourteen measured railway vibration stimuli. Through multidimensional scaling analysis, it is shown that the perception of railway induced vibration is dependent on up to four perceptual dimensions. These dimensions relate to energy in the 16 Hz 1/3 octave band, energy in the 32 Hz 1/3 octave band, the duration of the train passage, and the modulation frequency of the envelope of the signal. These perceptual dimensions are related to single figure Perceived Annoyance Ratings (A) by the following relationship: $A=-0.40+4.57{{\ddot{X}}_{RMS,16Hz}}+3.18{{\ddot{X}}_{RMS,32Hz}}+0.02{{T}_{10dB}}+0.02f{}_{\bmod }$. Finally, the single figure Perceived Annoyance Ratings are related to categorical ratings of annoyance via a logistic regression model.