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.

The aim of this study was to determine if there is a relationship between children's physical activity and wellbeing, and if that relationship is enhanced by physical activity in nature. This study was a non-experimental retrospective multi-informant data review conducted at an outpatient pediatric psychiatric clinic in the Northeast. The theoretical framework used to guide this study was the Health Promotion Model, suggesting Advanced Practice Nursing investigate the relationship between health promoting behaviors and personal factors that support mental wellness in children and protect against mental illness. Data collected included age, sex, and exercise and wellbeing subsections of the Vermont Child Health and Behavior Questionnaire (VHBQ): Parent Reports and Self-reports for 11-21 year olds. Data from three sample groups were analyzed: parent participants (n=178, 61% male, 38% female), child participants (n=78, 51% male, 49% female), and parent-child pairs with sex determined by child (n-25, 60% male, 40% female). Physical activity was calculated using a metric for participation in sports. Two sample t tests were used to analyze children's response to the question "do you participate in sports regularly?" in relation to wellbeing scores. Pearson's correlation coefficient was used to investigate correlations between 1) parent reports of their children's physical activity and wellbeing, 2) children's self-reports of physical activity and wellbeing, 3) parent reports of their children's physical and children's self-reports of physical activity, and 4) parent reports of their children's wellbeing and children's self-reports of wellbeing. Statistically significant results included positive correlations between parent reports of their children's physical activity and wellbeing item, "his/her living conditions are excellent" (r=.34, p=<0.001 for overall, r=.25, p=.002 for indoor, and r=.28, p=<0.001 for outdoor). Positive weak correlations were found between parent reports of their children's physical activity and scores on the VHBQ 10-point Worst Life/Best Life bar (r=.19, p=0.02 for overall and r=.17, p=.04 outdoor). Additionally, results showed significant strong positive correlations for all physical activities between parent reports of children's participation and children's self-report of participation (r=0.83, p=<0.001 for overall, r=0.85, p=<0.001 for indoor, and r=.67, p=0.02 for outdoor). However, only a single wellbeing item, "Compared with...most peer, [child] is less happy than they are", demonstrated statistically significant positive correlation (r=.48, p=0.03) when parent reports and self-reports of wellbeing were compared. These results underscore the need for further research. Among professions, Advanced Practice Nurses may be best equipped to fully understand the lifestyle factors that promote children's mental health. Moreover, because of their background, training and employment settings, Advanced Practice Nurses could play an important role not only in initiating well-being research studies, but also in using the resultant information to develop educational resources and policy.

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.

Neighborhood design affects lifestyle physical activity, and ultimately human wellbeing. There are, however, a limited number of studies that examine neighborhood design types. In this research, we examine four types of neighborhood designs: traditional development, suburban development, enclosed community, and cluster housing development, and assess their level of walkability and their effects on physical activity and wellbeing. We examine significant associations through a questionnaire (n = 486) distributed in Tucson, Arizona using the Walkability Model. Among the tested neighborhood design types, traditional development showed significant associations and the highest value for walkability, as well as for each of the two types of walking (recreation and transportation) representing physical activity. Suburban development showed significant associations and the highest mean values for mental health and wellbeing. Cluster housing showed significant associations and the highest mean value for social interactions with neighbors and for perceived safety from crime. Enclosed community did not obtain the highest means for any wellbeing benefit. The Walkability Model proved useful in identifying the walkability categories associated with physical activity and perceived crime. For example, the experience category was strongly and inversely associated with perceived crime. This study provides empirical evidence of the importance of including vegetation, particularly trees, throughout neighborhoods in order to increase physical activity and wellbeing. Likewise, the results suggest that regular maintenance is an important strategy to improve mental health and overall wellbeing in cities.

This thesis is an exploration of values-consistent behaviour from a contextual behavioural science perspective. The first chapter is a systematic review of the effectiveness of acceptance and commitment therapy in enhancing values-consistent behaviour. The results from this review were inconclusive, mainly due to a lack of psychometrically robust outcome measures, and inconsistent use of available measures. Recommendations were made to improve the utility of measures of values-consistent behaviour. The second chapter reports a cross-sectional survey of adolescents, aimed at testing the psychometric properties of values measures, and assessing the relationship between values-consistent behaviour and wellbeing. The measures used in this study were the Valued Living Questionnaire 2 (VLQ-2), Portrait Values Questionnaire – Second Revision, Child and Adolescent Mindfulness Measure, Avoidance and Fusion Questionnaire for Youth – Short Form, and the Warwick-Edinburgh Mental Well-being Scale. Using the VLQ-2 in its current form, values-consistent behaviour was found to account for an additional 13% of variance in wellbeing, above the contributions of demographics, mindfulness and experiential avoidance. However, a recommendation was made for adaptions to be made to the VLQ-2 to make it more suitable for adolescents.

In this thesis, I offer a complex exploration of positive motivation and life evaluation in two adjacent villages in the Buganda kingdom of Central Uganda. Focusing primarily on the lives of five individuals, I examine the tensions and inconsistencies that arise in the day-to-day pursuit of a good life in these villages and argue that, while individual lives may differ, people everywhere face similar concerns in their desire to live well. Through these individuals, but drawing also on wider ethnographic insights, I explore five core themes, with a trajectory broadly moving from more material to more transcendental concerns. These are: making a living, aspiration, gratification deferral, the source of good things, and the importance of connectedness. Running through the thesis is the assertion that wellbeing is a relational and moral project as people’s efforts to live well are inextricably intertwined. A key underlying question is ‘How can we live well in a socially acceptable way?’ This research contributes to the fledgling field of the anthropology of happiness and wellbeing as well as regional scholarship on, for example, development, livelihoods, aspirations, and ‘modernity’. In addition, it speaks to interdisciplinary wellbeing research and I argue that the nuance and contextualisation offered by anthropological and ethnographic study can both augment and challenge the primarily quantitative research from other disciplines. Furthermore, I make a particular claim for the value of biographical approaches to the study of wellbeing.