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The majority of deaths worldwide can now be attributed to so called, diseases of lifestyle, also known as non-communicable diseases (NCDs). These diseases are generally attributed to lifestyle behaviours, such as low fruit and vegetable consumption and lack of physical activity. Whilst historically NCDs have been known as diseases of the rich, current evidence shows that they are most prevalent in individuals with low socio-economic status. This thesis sets out to specifically address this issue by recruiting participants from a low SES population, in order to develop and test a web-based intervention addressing lifestyle behaviours. Initially the research identifies, and explores the barriers experienced by low SES individuals to leading healthy lifestyles, through interview data and further Q-sort analysis. The findings from these studies are used to tailor a health message, making it more pertinent to the target audience; the resulting message is incorporated into a website. The website is developed by understanding what constitutes a credible health related site in the eyes of the target audience. Initially the research identifies, and explores the barriers experienced by low SES individuals to leading healthy lifestyles, through interview data and further Q-sort analysis. The findings from these studies are used to tailor a health message, making it more pertinent to the target audience; the resulting message is incorporated into a website. The website is developed by understanding what constitutes a credible health related site in the eyes of the target audience. Self-affirmation theory (Steele, 1988) posits that reflecting on one’s positive attributes, reduces defensiveness to a potentially threatening health message. A recent study (Epton and Harris, 2008) suggests self-affirmation can lead to an actual change in the behaviour of individuals. This thesis replicates the work of Epton and Harris (2008) in an online environment, by demonstrating self-affirmed participants consumed more fruit and vegetable in the 7 days following exposure to the tailored website. These findings highlight the barriers experienced by low SES parents to adopting healthy lifestyles, and present a novel technique suitable for web-based interventions that has implications for a range of health related behaviours.

Background: There has been little research into the area of future disorientation in adults living with and beyond a cancer diagnosis. Research conducted in this area tends to focus on women who have been treated for gynaecological cancer and to be cross-sectional. Therefore, little is known about the impact of future disorientation on other groups of people living with and beyond cancer, including men, and little is known about how the experience may change over time. Aims: This thesis aims to develop a conceptual framework illustrating the experience of future disorientation. This was achieved by exploring what the consequence of future disorientation are, what factors cause participants to experience future disorientation and what factors prevent/reduce the impact of future disorientation. Methods: This study utilised an interpretative phenomenological analysis approach (IPA) which informed all aspects of the data collection and analysis process. Eight patients attending follow up clinics in the North East of England were recruited and were interviewed on two occasions six months apart. The interviews were semi-structured and analysed using an IPA approach. Results: The results of this study have shown that future disorientation can be experienced by men and women living with and beyond cancer, that it can persist over time, and have a number of consequences. A number of factors have been identified which may contribute to the experience of future disorientation such as cancer related fears, and anxiety. Furthermore a number of factors emerged which may protect patients from experiencing future disorientation, such as support networks and making lifestyle adjustments. This thesis constitutes an original contribution to knowledge as no work has previously sought to map out the conceptual framework of future disorientation or how it changes over time.

Background: Finding effective ways to care for people with palliative care needs is a national priority. A primary care locality has developed and implemented an Integrated Care Pathway (ICP) for those with life limiting illnesses. It focuses on identifying patients early, regardless of disease type, and uses proactive and patient centred interventions to plan for a good death. Although palliative care pathways present a promising practice framework, the literature does not allow for an assessment of how and when they work best. This thesis aimed to explain which parts of the ICP worked best, for whom and in what circumstances. Design: Realist evaluation was used to guide the analysis of multiple data strands: quantitative data from the GP practices; interviews with palliative care patients and bereaved relatives; bereaved relatives and matched health care professional questionnaires; focus groups with health care professionals; consultation recordings with palliative care patients and their GPs. Results: The results of this study are multifaceted, and focus on the conditions of successful implementation, such as the presence of a champion; palliative care registration decisions for all diagnoses and the importance of leadership and peer support; advance care planning, including the roles of mental capacity and time constraints; communication in consultations and the role of patient and GP traits; and using open multicomponent communication strategies to facilitate home deaths. Discussion: A realist approach has exposed how the ICP implementation has led to positive practice and patient level outcomes. The ICP can be construed as a translational tool, which enables the operationalisation of policy directives on shared decision making, proactivity and patient centeredness in primary care. In the context of palliative care, this study allows important reconceptualisations of shared decision making and advance care planning to be presented.

The overarching purpose of this research was to find out about life with Parkinson's disease and to use that knowledge to inform physiotherapy management. The project aimed to explore current and alternative ways in which professionals could seek to understand the experience of life with Parkinson's disease; to explore the implications of resultant new knowledge; and to investigate how physiotherapy relationships should take account of new ways of understanding and new knowledge. A spiral of research activity was undertaken comprising three successive cycles. The first two cycles were undertaken using case study methodology, focusing on the experience of life with Parkinson's disease from a group and an individual perspective. A wide range of qualitative and quantitative methods for both data collection (including interviews, disability and quality of life scales and activity monitoring) and data analysis were employed. The level and complexity of personal work undertaken by individuals to manage their condition was the principal theme to emerge from initial cycles. This insight led to the development of a tool — strategy mapping — to enable professionals to capture and use information about self- management in their interactions with individuals. The third cycle employed action research methodology to develop and evaluate the strategy mapping framework - centred on identifying strategies related to Self, Routines, Support and Involvement - in physiotherapy practice. A number of perspectives were developed in relation to the project's aims. The methodological perspective highlighted the need for commitment to listening to the experiential narrative and hearing the story of self-management. The ontological perspective offered the potential for practice and research to build on existing self- management solutions. The epistemological perspective pointed to addressing power differentials between knowledge bases to promote collaborative therapy relationships. The full potential of a paradigm shift which attempts to increase the degree of alignment between the everyday lives of individuals with Parkinson's disease and physiotherapy practice, education and research remains to be uncovered.

In total knee replacement (TKR) surgery, mobile bearing (MB) total knee prostheses were designed to more closely mimic the function of the normal knee than traditional fixed bearing (FB) designs by allowing axial mobility between the polyethylene insert and tibial tray. Despite the hypothetical benefits of the MB design, few studies have objectively analysed knee biomechanics during activities of daily living (ADLs) in the laboratory compared to FB designs. This thesis aimed to substantiate the theoretical advantages of MB implantation during ADLs in the laboratory as well as during free living conditions, in addition to investigating previous claims of instability in MB knees. Sixteen patients undergoing primary unilateral total knee replacement (TKR) surgery were randomised to receive either a FB (n=8) or MB (n=8) total knee prosthesis and were tested at pre-surgery, three months post-surgery, and nine months post-surgery using three dimensional motion analysis in the laboratory and electrogoniometry and accelerometry during free living conditions. No differences were found between FB and MB groups during walking at post-surgery that could not be explained by differences at pre-surgery. There were also no differences between FB and MB groups during the more biomechanically demanding activities of stair negotiation and sit to stand and stand to sit activities, as well as no differences during free living conditions away from the laboratory. There appears to be no evidence based rationale for the widespread use of MBs with regards to optimising knee function during ADLs. This thesis was the first to compare FB and MB designs using the same implant range, posterior cruciate ligament (PCL) scenario, posterior stabilising strategy, and patella strategy over a range of ADLs, as well as being the first to combine testing in the laboratory with testing during free living conditions away from the laboratory.

The Chinese group is the fastest growing ethnic group in the UK; this group is ageing fast, with the number of older Chinese doubling in 8 years. The majority of older Chinese immigrants in the UK have low education levels and limited English proficiency, and were reported to have low service use rate, lack of social support, and poor emotional status. This suggests that they may have difficult ageing experiences. This research set out to understand the UK older Chinese immigrants’ ageing experiences and coping strategies with the challenges of ageing, with a focus on the formal service use in their later life. The research adopted grounded theory as methodology, and used semi-structured interviews for data collection. The research had two phases. The first phase was exploratory using, mainly, focus groups to investigate perceptions of ageing, and for orientation to the field. Based on the contextual data provided by the phase one study, the phase two study was more focused on the support network and its influences on services use. Here individual interviews with follow-ups were used to gain in-depth understanding. Together, 58 participants, including older Chinese immigrants (n=44), family members of older Chinese (n=9), staff from organizations that work with Chinese people (n=3), and acquaintance who provided support for older Chinese (n=2), were interviewed. During phase two of the study, a group of key support providers who facilitated access to formal services for older Chinese were identified, and named as Bridge People. The outcomes of this research revealed that older Chinese immigrants used Bridge People, consisting of people from family, public sectors, Chinese community, and personal social network, to communicate with formal service providers. Older Chinese immigrants also rely on Bridge People to bridge other gaps in service delivery, such as lack of transportation, informational support, emotional support, and other cultural issues. In return, Bridge People gained trust and incurred power with older Chinese immigrants. Properties of Bridge People were identified as bilingual, bicultural, accessible, costless, and no social debt. Within the concept of Bridge People, each category provides a different combination of support, and older Chinese immigrants used this range of support in different combinations. In this study new theory and knowledge were generated about older Chinese and their key support providers. The Bridge People network model highlights the importance of interactions between Bridge People and older Chinese immigrants in accessing and using formal services. As many factors, including limited information resources, availability, role, emotional attachment, confined the performance of Bridge People, there are implications for policy makers; namely the role and importance of Bridge People should be recognized across health, social care and housing provision for older people. To promote engagement and optimise service use by older Chinese, relevant support should also be provided to Bridge People.

As the population of people in the UK, over 65, increases and the welfare system moves from a collectivist, towards a consumerist system, involving older people in their rehabilitation and care becomes more important. It is recognised that the effectiveness of practices to increase involvement varies. The reasons for this include the lack of clarity about the meaning of involvement in health care. The aims of this research were to develop a substantive theory, which explains the meaning of involvement for older people in their rehabilitation after acute illness and facilitates recommendations for health care practice development. Grounded theory was employed to collect longitudinal data from four older people, their practitioners and support staff, during the participants’ rehabilitation stay of around six weeks in an Intermediate Care unit in the UK and at home. Data were collected using recorded, semi-structured interviews and conversations, from December 2008 to November 2009 and were analysed qualitatively. The findings suggest that involvement in rehabilitation operates through an Involvement Attribute set consisting of two interdependent groups of Involvement Attributes (the psychologically-based and the action-based). Collectively, the Involvement Attributes are: the possession of a Vision, Incentive and Goals, a positive Disposition; a propensity for Cognitive Development; Goal planning, setting and achievement; and Risk Management. To be maximally involved the Involvement Attribute set has to be strong, balanced and with alignment between the two groups. Involvement in rehabilitation is also related to the type of relationships developed with the health care staff and relatives. Improvements in Involvement Attribute sets require a move away from paternalistic relationships towards the collaborative, partnerships suggested within relationship-centred care. In this way, involvement of older people in rehabilitation is: “A joint commitment within therapeutic relationships to determine and be determined in the pursuit of an Involvement Attribute set that is strong, balanced and aligned”.

Collaboration is central in the transformation and sustainability of future healthcare with a clear place in integrated models of care, but the operationalisation of collaborative working presents challenges in practice. There is a lack of evidence about how collaboration is sustained in the delivery of healthcare, and a deficiency of studies which include patients as part of collaboration. This thesis investigates the meaning and manifestation of collaboration, including the experience of patients and professionals in practice. A social constructionist approach to grounded theory is used to investigate collaboration in an Outpatient Parenteral Antimicrobial Therapy (OPAT) service. The sample consists of staff and patients who have experience of OPAT. Interviews and focus groups are used to generate data, and grounded theory methods are used to progress the study through constant comparative analysis and theoretical sampling to a point of data saturation. Coding, categorising and techniques of situational analysis are used to analyse data and develop theory. The theory of Interactive Navigation conceptualises collaboration as a device used to navigate complex care situations and to direct collaboration with differing consequences for patients and professionals. The factors which influence collaboration are found to be a range of Situational Co-ordinates (Certainty, Uncertainty, Limits, Goals and Power) and interaction takes place through Interactive Mechanisms (Rehearsing, Coordination, Communication and Trust). The Collaboration Compass model is presented as a tool to inform understanding of Developing, Maintaining, Limiting and Disrupting collaboration. Collaboration is differentiated into four distinct areas and is revealed as a social device integral to the situation in which it takes place. This complexity requires recognition if collaborative health and social care developments are to succeed. The theory of Interactive Navigation presents a new way to view collaboration, and the Collaboration Compass offers a tool to navigate situations and map collaboration in practice.

Background: The connections between music and wellbeing are well recognised. In the current climate of economic austerity, there is a growing demand for more robust evidence of the benefits of music-based interventions to make the best use of limited arts and health resources. Aims: To explore the connections between participatory music activity and self-defined wellbeing concepts. In particular, this study seeks to identify mechanisms that connect specific types of group music activity with specific wellbeing outcomes for people with mental health issues and/or learning disabilities. Research question: What are the mechanisms that connect music and wellbeing for people in challenging circumstances? What works, for whom and in what circumstances? Design: A Realist Evaluation approach was used to identify and explore generative mechanisms in social music programmes that give rise to specific wellbeing outcomes. Two music programmes were investigated and a focus group was carried out with a third programme for validation purposes. Participant-observation and semi-structured interviews were used to identify programme theories (theories that explain outcomes), which were further developed and refined through iterative data accrual. Findings: Six programme theories were identified. Song writing and recording projects that involved both technical and artistic choices had an engaging effect, leading to outcomes of praise, hope and self-advocacy (with a corresponding sense of empowerment). Forms of musical improvisation tended to affect energy levels and consequently mood and perception, yielding both immediate effects (expressed as a sense of ‘balance’) and subsequent effects (described here as resilience). Activities involving pre-existing songs or styles (e.g. cover versions) engaged notions of identity and memory, which affected mood and increased wellbeing. Conclusion: The programme theories identified here have the potential to inform and improve music for health programmes in other contexts. Useful similarities and significant differences between service user groups were identified, enabling more specific questions to be asked of music programmes and indicating directions for future inquiry. These findings may enable similar interventions to be better tailored to their client base, making them more effective and more cost-effective.