The history of psychiatry is littered with serious failures of governance, to the detriment of mentally disordered people, especially those resident in psychiatric hospitals. Current mental health providers, increasingly focussed on community care, have also struggled to develop effective internal governance systems. Nine peer-reviewed research papers, published by the author (mostly with others) and the wider literature, reveal deficits in mental health governance at a jurisdictional, professional, and corporate level. In this thesis new governance solutions are developed against this background, built on contemporary principles in mental health and healthcare management. A new model of mental health governance is presented, based on the key demands of the strategic and regulatory environment, articulated as rights, risks and recovery. This integrated healthcare governance approach, covering provider policy, staff training and service audit, can monitor and ensure the protection of patients’ rights, as well as those of others; it also promotes the management of clinical risks, and of patients’ recovery outcomes. Rights-based risk-reduction training is the core interventional element of the model, whilst the monitoring element can be formalised as part of a Balanced Scorecard reporting system. This thesis makes a contribution to research methodology, theory and practice in mental health, human rights, healthcare management and governance. The model generates specific propositions for testing in mental health governance, with the potential for application in wider settings of service provision.

Abstrakt Bakgrund: Flertalet av patienterna vilka söker akuten är inte i behov av akutsjukvård. Sjuksköterskor på akutmottagningarna kan idag hänvisa patienter till annan vårdnivå så som primärvård eller till hemmet med egenvårdsråd.   Syfte: Syftet var att belysa triagesjuksköterskans erfarenhet av hänvisning till annan vårdnivå än akutmottagning.   Metod: Studien var en kvalitativ intervjustudie genomförd med semistrukturerade intervjuer. I studien ingick intervjuer med 12 sjuksköterskor, både med och utan specialistutbildning, vilka arbetar på akutmottagning samt har erfarenhet av hänvisning av patienter till annan vårdnivå. Kvalitativ innehållsanalys har använts för att bearbeta insamlad data.   Resultat: Triagesjuksköterskans erfarenhet av att hänvisa patienter till annan vårdnivå tolkades utifrån följande teman för att belysa olika faktorer som påverkar sjuksköterskans handling på en akutmottagning; faktorer som påverkar hänvisning, professionella stöd och handläggningsstrategier vid hänvisning. Resultatet visade att respondenterna upplever hänvisning som komplext och stundtals svårt där sjuksköterskan känner sig osäker, samtliga respondenter uppgav att de hade erfarenhet av patienter som uppträder agiterat samt hotfullt vid hänvisning, flertalet uttryckte därför att de kände sig otrygga på sin arbetsplats, de uttryckte även att erfarenhet samt klinisk blick var av stor betydelse vid hänvisning av patienter.   Slutsats: Författarnas kliniska slutsats är att respondenterna anser att möjligheten till att kunna hänvisa patienterna till en annan vårdnivå är av stor patientnytta. Detta då patienten får adekvat och rätt vård från början relaterat till deras sjukdomstillstånd vilket även kan leda till att väntetiden på akutmottagningen minskar. Mer utbildning liksom beslutstöd behövs för att göra sjuk sjuksköterskor tryggare med sin hänvisning. Författarna anser även att studien ger viktiga infallsvinklar inom problemområdet som kan vara användbara i en kommande yrkesroll. / Abstract Background: The majority of patients who seek emergency care, are not in need of it. Nurses at emergency departments can refer patients to other type of care, such as primary care or to the home with self-care advices. Referral are often carried out independent and therefore the nurses requires a high level of expertise as well as good communication skills.   Purpose: The aim of the study is to highlight the triage nurse's experience of referral of patients from the emergency department to other care givers such as primary healthcare and self-care.   Method: The study was a qualitative interview study, conducted with semi-structured interviews. The study included interviews with 12 nurses, both with and without specialisteducation, who works in the emergency department and has experience of referring patients to other level of care. Content analysis has been used to process the collected data   Result: The triagenurse experience of referring patients to other care was interpreted based on the following themes to highlight the various factors affecting the nurse's action in an emergency; factors affecting reference, professional support and management strategies by reference. The results showed that respondents perceive reference as complex and sometimes difficult where the nurse feels insecure, all respondents stated that they had the experience of patients who appear agitated and threatening at time of referral, the majority of the respondents therefore expressed they felt insecure in their workplace, they also expressed that the experience and clinical gaze was of great importance in referring patients.   Conclusion: The authors' clinical conclusion is that the respondents believe that the ability to be able to refer patients to other level of care is of significant patient benefit. This resulting in the patient receiving adequate care from the start related to their disease severity which also can lead to that the waiting time at the emergency room is reduced. More education and decision support is needed to make nurses more secure whilst performing referrals. The authors also believe that the study provides important insights in the problem area that may be useful in a future profession.

Large resources are invested in healthcare research, but despite this there is a wide gap between research knowledge and healthcare practice. Implementation researchers have addressed this gap, focusing mostly on the role of healthcare practitioners. However, a narrow focus on implementation does not take into consideration the preceding stages and the roles of different actors during the whole innovation process, which starts from research and ends with implementation. The aim of this thesis is to examine the behaviors of three key actors during an innovation process and to explore the influence of selected contextual factors on their behavior. Study I (n=10 funders) identifies several facilitative roles for funders and suggests that implementation risks becoming no one’s responsibility as the funders identify six different actors responsible for implementation, the majority of whom embody a collective or an organization. Study II finds that the implementation knowledge of Swedish funding managers (n=18) is mostly based on experience-based knowledge. The majority of the funding managers define implementation as a process and express limited knowledge of implementation. The findings of Study III (n=4 innovation cases) show that the roles and involvement of academic inventors and ISAs (innovation-supporting actors) are more connected to intellectual property (IP) nature than to intellectual property rights (IPR) ownership. Study IV (n=4 innovation cases) identifies three different logics that influence the behavior of academic inventors: market, academic and care logics. A pattern emerges where the behavior of academic inventors is guided by a unique logic and there is no interaction between logics, despite the existence of multiple logics. The individual strategies to handle multiple logics coincide with the influence of logics. In addition, IP nature, distinguishing between high-tech and low-tech innovations, is connected to the influence of institutional logics: low-tech connected to the care logic and high-tech connected to the market logic. This thesis has three main theoretical and practical implications relevant for practitioners, policymakers and researchers. First, implementation responsibility is an important issue to study and discuss, because without clearly defined responsibilities and management of responsibilities, responsibility might become no one’s responsibility. Second, the finding that experience-based implementation knowledge contributes heavily to policymakers’ knowledge encourages further studies and discussions regarding this relatively neglected issue. Third, the importance of IP nature in shaping innovation processes should be considered and further examined, not only as a factor influencing inventors and ISAs’ roles and involvement, but also as influencing the prevalence of different institutional logics. Further, the relevance of a distinction between low-tech and high-tech IP should be reflected on.

A large number of emerging infectious diseases (including influenza epidemics) has been identified during the last century. The emergence and re-emergence of infectious diseases have a negative impact on global health. Influenza epidemics alone cause between 3 and 5 million cases of severe illness annually, and between 250,000 and 500,000 deaths. In addition to the human suffering, influenza epidemics also impose heavy demands on the health care system. For example, hospitals and intensive care units have limited excess capacity during infectious diseases epidemics. Therefore, it is important that increased influenza activity is noticed early at local levels to allow time to adjust primary care and hospital resources that are already under pressure. Algorithms for the detection and prediction of influenza epidemics are essential components to achieve this. Although a large number of studies have reported algorithms for detection or prediction of influenza epidemics, outputs that fulfil standard criteria for operational readiness are seldom produced. Furthermore, in the light of the rapidly growing availability of “Big Data” from both diagnostic and prediagnostic (syndromic) data sources in health care and public health settings, a new generation of epidemiologic and statistical methods, using several data sources, is desired for reliable analyses and modeling. The rationale for this thesis was to inform the planning of local response measures and adjustments to health care capacity during influenza epidemics. The overall aim was to develop a method for detection and prediction of influenza epidemics. Before developing the method, three preparatory studies were performed. In the first of these studies, the associations (in terms of correlation) between diagnostic and pre-diagnostic data sources were examined, with the aim of investigating the potential of these sources for use in influenza surveillance systems. In the second study, a literature study of detection and prediction algorithms used in the field of influenza surveillance was performed. In the third study, the algorithms found in the previous study were compared in a prospective evaluation study. In the fourth study, a method for nowcasting of influenza activity was developed using electronically available data for real-time surveillance in local settings followed by retrospective application on the same data. This method includes three functions: detection of the start of the epidemic at the local level and predictions of the peak timing and the peak intensity. In the fifth and final study, the nowcasting method was evaluated by prospective application on authentic data from Östergötland County, Sweden. In the first study, correlations with large effect sizes between diagnostic and pre-diagnostic data were found, indicating that pre-diagnostic data sources have potential for use in influenza surveillance systems. However, it was concluded that further longitudinal research incorporating prospective evaluations is required before these sources can be used for this purpose. In the second study, a meta-narrative review approach was used in which two narratives for reporting prospective evaluation of influenza detection and prediction algorithms were identified: the biodefence informatics narrative and the health policy research narrative. As a result of the promising performances of one detection algorithm and one prediction algorithm in the third study, it was concluded that both further evaluation research and research on methods for nowcasting of influenza activity were warranted. In the fourth study, the performance of the nowcasting method was promising when applied on retrospective data but it was concluded that thorough prospective evaluations are necessary before recommending the method for broader use. In the fifth study, the performance of the nowcasting method was promising when prospectively applied on authentic data, implying that the method has potential for routine use. In future studies, the validity of the nowcasting method must be investigated by application and further evaluation in multiple local settings, including large urbanizations.

Introdução: A atual mudança do perfil etário da população brasileira tem afetado a dinâmica dos sistemas de saúde, sociais, econômicos e políticos existentes, indicando a necessidade da articulação entre esses setores e o fortalecimento de políticas que proporcionem situação de independência aos idosos. Assim, a atenção primária vem sendo considerada uma importante estratégia, devendo apresentar acessibilidade e adaptação às necessidades dos idosos. Objetivos: Compreender a percepção de idosos atendidos em uma Unidade de Estratégia de Saúde da Família, do Município de São Paulo, acerca do processo de envelhecimento e conhecer as necessidades de saúde autorreferidas por esse grupo social. Percurso metodológico: Estudo qualitativo de abordagem etnográfica, cujo cenário cultural foi uma Unidade de Estratégia de Saúde da Família (ESF). Os participantes foram dez idosos atendidos na referida ESF. Os dados foram coletados por meio de entrevistas e da observação participante, no período de junho de 2015 a janeiro de 2016. Os achados foram apresentados na forma de narrativa e analisados segundo Minayo e à luz do referencial teórico da Resiliência e do Envelhecimento Ativo. Resultados: Das narrativas emergiram cinco categorias culturais, a saber: a percepção do envelhecimento e da velhice; a violência ao idoso; o ostracismo social; o acesso aos serviços de saúde e social: fatores dificultadores; a avaliação da ESF. A percepção do envelhecimento esteve associada à diminuição da capacidade funcional e às limitações físicas e cognitivas. Esse processo remeteu aos idosos a consciência da finitude e do luto antecipado, que afetou a perspectiva de vida desestimulando a realização de ações que proporcionassem bem-estar. Os discursos apresentaram, ainda, a problemática da violência por meio de abuso financeiro e abandono de familiares e dos setores formais, favorecendo o sentimento de solidão e de improdutividade. Esses componentes destacaram os fatores de riscos que interferiram no processo de resiliência, como a falta de acesso aos recursos necessários para o suprimento das necessidades sociais e de saúde, impossibilitando a continuidade de cuidado e a piora do quadro clínico. Considerações finais: O estudo permitiu identificar a percepção e as necessidades sociais e de saúde dos idosos. A falta de acesso aos serviços afetou a dinâmica social e familiar, a saúde e o bem-estar dos participantes. Assim, os serviços de atenção aos idosos precisam atuar diretamente sobre os determinantes que favorecem o Envelhecimento Ativo, por meio de ações que potencializem o bem-estar físico, social e mental ao longo de toda a vida. / Introduction: The change of population age profile in Brazil influences the dynamics of existing systems such as health, social, economic and political, suggesting the need for articulation between services and strengthening of policies that provide independence of the elderly. The primary health care is an important resource and must present accessibility and adaptation to the elder`s needs. Objective: Understanding the perception of aging process, of elderly treated in Family Health Strategy Service of São Paulo city and to know the health needs self-reported by this social group. Methods: Qualitative study using an ethnographic approach, focusing on the cultural scenario of the Family Health Strategy Unit (FHS). The participants in this study were ten elders treated in FHS. The data collection were done from June 2015 to January 2016. Was taken from narratives and analyzed according to Minayo, resilience theory and Active Aging. Findings: The following five cultural categories emerged from the narratives: perception about aging and oldness; the health and social services accessibility: difficulty factors; the elder abuse; the social ostracism; health and social services accessibility; FHS assessment. The perception of aging was associated with decreased functional capacity and physical and cognitive limitations. This process referred the elderly to awareness of finitude and anticipated mourning, which affected the prospect of life discouraging the realization of actions that provided welfare. The narrative presented the problem of violence through financial abuse, family neglect and formal sectors, favoring the feeling of abandonment, of loneliness and lack of productivity. These components highlighted the risk factors that interfere with the resilience process, such as lack of accessibility to the resources needed for the supply of social and health needs, preventing the continuity of care and the worsening of clinical symptoms. Final considerations: This study provided the perception, the social and health needs of the elderly. Lack of accessibility to services affected the social and family dynamics, health and welfare of participants. Care services for the elderly needs to act directly on the determinants that promote Active Aging, through actions that enhance the physical, social and mental well-being throughout life.

Marine and coastal ecosystems are subject to diverse and increasingly intensive anthropogenic activities, making understanding cumulative effects critically important. However, accurately accounting for the cumulative effects of human impacts can be difficult, with the possibility of multiple stressors interacting and having greater impacts than expected, compounding direct and indirect effects on individuals, populations, communities and ecosystems. Assessment of multiple stressors therefore requires extensive scientific research that directly tests how single or multiple ecological components are affected by stressors, both singly and when combined, and as a consequence, cumulative effects assessments are now increasingly included in environmental assessments. Currently, there is a need to assess these at larger spatial scales, with additional research also urgently needed on the responses of ecological components, processes and functions to single and cumulative stressors. As cumulative environmental impacts could be better addressed by regional stressor effects assessments that combine methods for predicting multiple pressures on ecosystem recovery alongside degradation, this study used several separate approaches that can be used in parallel to give support for local management measures. I tested four completely different methods - a range of multi-metric indices, a food web model (Ecopath), a predictive model (Ecosim) and a Bayesian Belief Network model. Each approach was tested and compared in two shallow water estuarine systems, in Scotland and England, initially concerning the impact of nutrient enrichment and subsequent recovery and was followed by an investigation of how the addition of multiple stressors (nutrient levels, temperature and river-flow rates) would impact the future state of each system. The response to stressors was highly context dependent, varying between and within geographic locations. Overall, each of the four different approaches complemented each other and gave strong support for the need to make big reductions in the pressures and to consider trade-offs between impacting pressures. The models and tools also indicate that in order to reach an improved overall environmental state of each ecosystem, a focus on nutrient reductions are likely to be the most effective of the controls on stressors explored and that cumulative effects of the management of nutrient inputs and increased water temperatures and river-flow are likely to exist.

Esse estudo teve por objetivo analisar as dinâmicas de mudanças organizacionais transcorridas em um estabelecimento de saúde. Conduzido através metodologia de estudo de caso descritivo, teve como campo de pesquisa o Instituto de Hematologia do Estado do Rio de Janeiro. Buscando conhecer o papel da preparação para acreditação na dinâmica da mudança em uma organização de saúde essa pesquisa foi assim estruturada: abordagem dos problemas encontrados nas mudanças organizacionais em estabelecimentos de saúde; quadro teórico estruturado com uma revisão de literatura; embasamento da metodologia aplicada, com definição de instrumentos de coletas de dados, de material e atores implicados no levantamento para realização da análise qualitativa. O estudo analisou as seguintes variáveis: a natureza da mudança focalizando a extensão, ritmo e trajetória; as estratégias de ação, contemplando as situações de adesões e resistência e a concepção, verificando se as mudanças foram indutivas ou dedutivas. O resultado demonstrou que a preparação para acreditação naquele hospital, proporcionou mudanças com movimentos lentos, mas com continuidade em todos os setores do estabelecimento. Foi identificada participação mais ativa de um grupo de profissionais identificados como facilitadores, funcionando como multiplicadores. A abrangência das estratégias aplicadas foram desde as reuniões em assembléias gerais, á formação de grupos de estudo por setores para entendimento do manual de padrões de acreditação. Foram realizados processos internos de auto-avaliação com base no manual de acreditação. Em relação á concepção, o processo de mudança foi motivado pela determinação da direção do hospital para obtenção do certificado de acreditação internacional. Quanto á resistência e adesão, o estudo demonstrou que a participação de uma grande maioria dos profissionais foi motivada pelo desejo de aprender e desenvolver novas práticas que proporcionasse a melhoria da qualidade da assistência. A análise de dados aponta certa resistência da categoria médica no início do processo. Do ponto de vista organizacional, foram criadas novas estruturas. A conclusão do estudo: O processo de preparação para acreditação na unidade de saúde estudada demonstrou ser um instrumento capaz de promover mudanças em organizações de saúde. / This study it had objective to analyze the dynamic ones of which elapsed organizational changes in a health establishment. Lead through methodology study of descriptive case, the Institute of Hematology of the State of Rio de Janeiro had as research field. Searching this research to know the paper of the preparation for accreditation in the dynamics of the change in a health organization thus was structured: boarding of the problems found in the organizational changes in health establishments; structured theoretical picture with a literature revision; basement of the applied methodology, with definition of instruments of collections of data, material and actors implied in the survey for accomplishment of the qualitative analysis. The study it analyzed the changeable following: the nature of the change focusing the extension, rhythm and trajectory; the action strategies, contemplating the situations of adhesions and resistance and the conception, verifying if the changes were inductive or deductive. The result demonstrated that the preparation for accreditation in that hospital, provided changes with slow movements, but with continuity in all the sectors of the establishment. It was identified to more active participation of a group of identified professionals as providers, functioning as multiplying. They comprehensives, was applied strategies was since the meetings in general meetings, the training of groups of study for sectors for agreement of the manual of accreditation standards. Internal processes of autoevaluation on the basis of the accreditation manual were accomplished. In respect to conception, the change process was motivated by the determination of the direction of the hospital for attainment of the certificate of international accreditation. How much the resistance and adhesion, the study demonstrated that the participation of a great majority of the professionals was motivated by the desire to learn and to develop new practices that the improvement of the quality of the assistance provided. The analysis of data points certain at the beginning resistance of the medical category of the process. Of the point of view organizational, structures were new servants. The conclusion of the study: The process of preparation for accreditation in the unit of studied health demonstrated to be an instrument capable to promote changes in health organizations.

The rarity of a disease can give rise to challenges that differ from conventional diseases. For example, rarity hampers research and development of new drugs, and patients with severe, rare diseases have limited access to qualified treatments. When drugs are available, clinical evidence has higher uncertainty and the drugs can be very expensive. When setting priorities in the healthcare sector, treatments aimed at patients with rare diseases, so called orphan drugs, have become a source of concern. Orphan drugs seldom show solid evidence of effectiveness or cost-effectiveness. Still, treatments for rare disease patients, available on the European market, has increased rapidly since the adoption of a regulation offering incentives for research and development of orphan drugs. The question arises as to whether the publicly funded health care system should provide such expensive treatments, and if so, to what extent. This doctoral thesis aims to investigate healthcare priority setting and rare diseases in the context of orphan drug reimbursement. Priority setting for orphan drugs is located at the intersection of economic, ethical and psychological perspectives. This intersection is explored by studying the public’s view on the relevance of rarity when setting priorities for orphan drugs, and by examining how orphan drugs are managed when making reimbursement decisions in practice. Papers I and II in this thesis employ quantitative, experimental methods in order to investigate preferences for prioritising rare diseases, and the extent to which psychological factors influence such preferences. Papers III and IV employ qualitative methods to further explore what factors (apart from rarity) influence priority-setting decisions for orphan drugs, as well as how decisions regarding orphan drugs are made in practice in England, France, the Netherlands, Norway and Sweden. Combining quantitative and qualitative methods has provided a more comprehensive understanding of the topic explored in the thesis, and the methods have complemented each other. Paper I shows that there is no general preference for giving higher priority to rare disease patients when allocating resources between rare and common disease patients. However, results show that preferences for treating the rare patients are malleable to a set of psychological factors, in particular “proportion dominance”. Paper II shows that the identifiability of an individual has no, or a negative, influence on the share of respondents choosing to allocate resources to him/her (compared to a nonidentified individual). Paper III confirms that rarity per se is not seen as a factor that should influence priority-setting decisions (i.e. accept a greater willingness to pay for orphan drugs), however, other factors such as disease severity, treatment effect and whether there are treatment alternatives were seen as relevant for consideration. Paper IV explores the challenges with and solutions for orphan drug reimbursement, as perceived by different actors in five European countries. Perceived challenges are related to the components involved when making reimbursement decisions, to the reimbursement system, and to the acceptance of the final decision. Solutions are either specific for orphan drugs, or general measures that can be used for orphan drugs as well as for other drugs. In conclusion, priority setting for orphan drugs is complex and requires particular attention from decision makers. There are many factors to consider when making reimbursement decisions for orphan drugs. The consequences of a decision are potentially severe (both for rare disease patients and for common disease patients, depending on the decision) and psychological factors can potentially influence decisions.

Bakgrund: Ljumskbråck är den vanligaste operationen inom allmänkirurgin, varje år utförs nästan 20 000 operationer i Sverige. I Östergötland utförs ljumskbråcksoperationer på tre ställen inom ramen för dagkirurgi; vid Aleris Specialistvård i Motala (ASM), Närsjukvården i Finspång (NiF) samt Medicinskt Centrum i Linköping (MCL). Det finns en teori om att privata vårdgivare är mer tidseffektiva än offentliga vårdgivare. De privata anses kunna utföra fler operationer under en given tid, men ingen studie har gjorts på tidseffektiviteten kring operationerna hos respektive vårdgivare. Denna studie har genomförts för att detektera om det finns en skillnad i hur lång tid olika moment tar att utföra och vad denna skillnad i sådana fall beror på, samt om patientunderlaget skiljer sig mellan klinikerna. Metod: Studien omfattade 70 patienter fördelade på tre kliniker; ASM, MCL och NiF. Ljumskbråcksoperationerna delades upp i flertalet moment som mättes med digital klocka. Dessutom samlades uppgifter in om patientens ålder, ASA-klass, BMI samt information om vilka som närvarade i operationssalen. Statistisk analys gjordes enligt Kruskal-Wallis. Programvaran som användes var SPSS version 22. Resultat: Studien fann ingen signifikant skillnad i BMI, ASA-klass eller ålder mellan klinikernas patienter (p > 0,05 för samtliga). Däremot fanns stora skillnader vad gäller hur lång tid ett flertal av momenten under ljumskbråcksoperationen tog. Slutsats: Studien påvisar att det finns stora skillnader i olika moment vid ljumskbråcksoperationer. De privata klinikerna var alltid snabbare än den offentliga kliniken. Då det saknas studier inom området vore det intressant att se om det finns liknande skillnader vid andra ingrepp som utförs av olika aktörer. / Background: Inguinal hernia surgery is one of the most common surgeries within general surgery, with approximately 20 000 surgeries per year in Sweden. There are three places in Östergötland County where inguinal hernias are executed within outpatient surgery; at Aleris Specialistvård in Motala (ASM), Närsjukvården in Finspång (NiF) and at Medicinskt Centrum in Linköping (MCL). There is a theory that private health care providers are more time-efficient than public health care providers. The private health care providers are considered to perform more operations over a given time though no studies has been done on time efficiency. This study was performed to detect if there is a difference in time in the various steps during the surgery between the clinics, what causes these differences and if the patients differ. Methods: The study includes 70 patients distributed on three outpatient surgery clinics; ASM, MCL and NiF. The inguinal hernia operations were divided into shorter steps measured with a digital watch.  Furthermore, data were noted about the patients’ age, ASA-score, BMI and who were present in the operating room. Statistical analyses were performed with the Kruskal-Wallis one-way analysis of variance. The software used was SPSS version 22. Results: The study found no significant difference in BMI, ASA-score and age between the health care providers (p > 0,05). However, regarding the time efficiency, there were significant differences between the clinics. Conclusions: The study concludes that there are big differences in time, within the various steps in the inguinal hernia surgeries, between the clinics. The private health care providers were always faster than the public health care provider. Since no earlier studies have been made in this area, it would be interesting to see if there are similar differences in other types of surgeries.

Community participation is a key feature of major global health declarations and a fundamental principle of health strategies in Aotearoa New Zealand. However, the frequency with which it is espoused belies the complexities associated with its practical application. Engaging communities in primary health care programmes designed to improve their health has been identified as a major challenge. This study’s objective was to explore community members’ perspectives of participation within a health development programme. The programme chosen aimed to increase the fruit and vegetable intake of targeted population groups, including M ori, Pacific peoples, and low income earners. A qualitative instrumental case study approach was adopted to examine the programme and investigate what influenced, constrained, and sustained community participation. Data collection included fieldwork over an eighteen-month period. Two programme projects were selected as the study foci: a communityled project involving distributions of thousands of free heritage variety plants; and, instigated by health services, a project establishing community gardens. These projects provided markedly different pictures of participation occurring within the same programme. The plant distributions had widespread appeal, while the community garden faltered. Community participation fitted within a description of ‘focused social action’. Participation was motivated by needs, values, and interests. While some were personal and family based, the programme also became an imagined vehicle for addressing wider health, social justice, and environmental sustainability goals. Ongoing challenges related to defining targeted communities and groups, varying degrees and types of participation, and different perspectives of participation, especially as health sector staff worked from an equity mandate and community members spoke of equality. Programme groups established as mechanisms to foster community participation had contradictory effects, engaging some as advisors, while failing to reach communities targeted for the programme. The complexities of health sector bureaucracy both enabled and constrained the programme and community participation. This thesis provides an in-depth examination of the complexities of community participation in action, the contradictory effects of contexts enveloping programmes, and the resolve of community members. It increases our understandings of how community members perceive health programmes and community participation, which are critical factors in improving population health.