A novel osteopathic treatment has been discovered during the clinical practice of the author which alleviates many of the symptoms of chronic fatigue syndrome (CFS) known in the UK as CFS/ME. The efficacy of this manual approach was tested using two separate clinical trials. The first examined the change in the symptoms following a year of treatment. The second repeated the first study and examined the possible mechanisms of the improvement. The studies were designed to develop a greater understanding of the disorder, for which there is much scientific uncertainty regarding the cause, diagnosis and treatment. Phase 1 of the research trials included self report questionnaires to examine overall symptom change. With post-exercise fatigue being a major symptom of CFS/ME, the treatment protocol was best evaluated by determining its effects on muscle function which was analysed utilising isometric testing of the knee extensor muscles measuring the impulse torque. The second trial, which included the same self report questionnaires assessing symptom relief as in the initial trial, was divided into two parallel phases. Phase 2 primarily took the form of brain analysis using magnetic resonance imaging (MRI) to confirm if brain abnormalities seen in previous research were found in sufferers of CFS/ME. No cerebral abnormality was detected in the patient group. Central lymph scans were also carried out showing a possible trend of enlargement in CFS/ME sufferers. In the other part, phase 3, isometric tests were repeated with more accurate equipment than in phase 1. Integrated EMG and median frequency of the power spectrum were measured using surface electromyography (sEMG). Overall this study has provided strong evidence that an important component of CFS/ME involves a disturbance of lymphatic drainage of the brain and muscles. The novel osteopathic treatment developed by the author has been statistically validated in both phases of the study, emphasising the need to focus future research on the biomechanical aspectso f this disorder.

The formal management of risk was an idea in its early stages of introduction into the National Health Service when this research started. In this thesis I document the development of my thinking as an acute hospital risk manager over the last five years as I developed the Trust's risk management system. Using Action Learning as the research approach, I explored theories and concepts and tested them in the fire of real world action and reflective questioning of experiences. The definition of risk is explored in relation to health care, as are the approaches used to manage these risks. A key finding is that risk management decision making does not generally fit into either programmed or non-programmed decision making models but neither do decision makers guess. Decision makers tend to use heuristics, which are simple rules of thumb, which generally help them make the right decision with minimum mental effort. However, heuristics also tend to be applied inappropriately and can result in an organisation being exposed to unacceptable levels of serious risk. A number of key heuristics are identified and they appear to fall into two general types, B-heuristics and E-heuristics. The B-heuristics are 'basic' in form and can be summarised as a simple sentence while, E-heuristics have an 'extended' form which can be summarised as a list of related simple sentences. Knowledge of heuristics helped in the design of the Trust's risk management which has been implemented and its effectiveness tested in the field. This field testing has demonstrated that the worst effects of heuristics can be mitigated by effective soft-system design.

The Iraqi women in this study have made Australia their ‘home’ in the years following the Gulf War in 1991, and are the first generation to move to a small rural town in Australia. The experiences documented in this thesis are based on 15 months of ethnographic research, between March 2003 and June 2004, with twenty-six Iraqi women, sixteen service providers and members of the communities of which they are a part. The focus of the study is on Iraqi women’s experiences of resettlement, their sense of emotional wellbeing and belonging. By and large, studies of refugee mental health attribute ‘refugee suffering’ to pre-migration experiences, rooted to the cultures of peoples’ home countries, principally through war, persecution and trauma, and how this legacy impacts upon women’s emotional wellbeing and ability to belong in resettlement. In many ways, it is convenient for host countries to ascribe refugee mental health problems to pre-migration experiences because the power dynamics of integration, the complex micro politics and the consequences of encounters with the Australian system are made indiscernible. The emergent discourse not only obscures the economic, historical and social conditions that lie at the heart of processes of displacement, but also ignores, silences and speaks on behalf of refugees. / This thesis demonstrates that Iraqi women’s articulations of their experiences of displacement and resettlement are anchored in and deeply affected by the material, legal and cultural circumstances of the local and national places they inhabit. Accordingly, their accounts of emotional suffering are in part framed within the experiences of war and persecution, both past and present, but they are also entangled and embedded in their contemporary realities resulting from multiple social barriers in resettlement, including cultural and religious racism, social invisibility, exclusion and being ‘othered’ in their daily lives, which impacts upon their wellbeing and sense of belonging in Australia. The experiences documented in this thesis not only privileges Iraqi women’s own understandings of displacement and resettlement and the ways in which they frame the reality of their lives, but also implicates the Australian system and structural axes of inequality in their resettlement experiences, in an attempt to move beyond western epistemological explanations that define the form and content of refugee lives as well as their illness and wellbeing.

This thesis examines the impacts of human-elephant conflict on human wellbeing and the implications for elephant conservation and management in Trans Mara District, Kenya. The District comprises communal lands bordering the world-famous Masai Mara National Reserve in southwestern Kenya. Trans Mara supports a range of land use types and provides refuge to one of Kenya’s large elephant population comprised of over 3,000 transient and 500 resident animals. This study used interdisciplinary methods to gain insights into the nature and consequences of conflict on the wellbeing of communities living with elephants. In particular, I used a combination of existing wellbeing indices and a set of indicators developed through consultations with local communities in TM to measure impacts of HEC on specific wellbeing domains. The results show that elephants still use the communal lands in Trans Mara but are increasingly restricted to the riverine forest remnants in central Trans Mara. However, there was no evidence of a further decline in the elephant range. Instead, this study points to a shift in elephant range against a background of increasing human settlement, land sub-division and agricultural expansion. The wellbeing of Trans Mara residents comprised eight indicators. Human-elephant conflict negatively affected peoples’ wellbeing, but the impacts were limited to certain dimensions. Elephants affected school-going children within elephant range. Attitudes towards elephants and its conservation in TM were influenced by the location of human residence relative to elephant refuge, diversity of income sources, and age and gender. Finally, conflict mitigation in Trans Mara is still elusive and challenging, but opportunities exist to develop simple and dynamic mitigation tools. The findings of this study have important implications for the future of elephant conservation in the face of competing human needs, both in Trans Mara District and elsewhere in Africa.

This thesis explores the implementation of an area-based health improvement initiative in the north west of England called Target Wellbeing. In the decades before Target Wellbeing was commissioned in 2007, health inequalities between people living in different areas of the UK had been widening. ABIs were identified by the Labour Government as a key tool for improving the health and wellbeing of residents in areas of socio-economic disadvantage and addressing inequalities in health. ABIs such as this have been well evaluated but there remains no firm evidence about the ability of such initiatives to improve health or to reduce health inequalities. In addition to the problems associated with evaluation, the processes through which ABIs might be used to influence change are not well understood and the value of using area-based services to improve health has been taken for granted. There is little understanding about the processes through which service provider partnerships might develop and limited knowledge about the processes through which residents might develop relations with providers. The key aim of this research was to examine the social processes through which ABIs develop over time. Using a case study approach, the research examined one Target Wellbeing programme as a social figuration of interdependent people. Ethnographic methods, including documentary analysis, non-participant observation and interviews, were used to explore the processes and networks that mediated the planned public health development. The study also drew on relevant quantitative data to describe changes over time. Ideas from figurational sociology were used as sensitising concepts in the development of a substantive theory about the processes through which ABIs develop. The study developed theoretical insight into processes of joint working that helps to explain why, in the context in which services are commissioned and performance managed, provider co-ordination is unlikely to be implemented as planned. It also provided a more sociologically adequate account of the ways in which relations between residents and providers were influenced by the history of relations in the town. Changes to residents’ relations with other residents and providers in the town influenced a greater sense of control over their circumstances. These findings demonstrate that, in relation to public health policy and practice, ABIs might more usefully be conceptualised as a series of interrelated processes that might be used to establish the preconditions for influencing change among residents. However, the study showed that interventions targeted at a small part of much wider networks of interconnected people are unlikely to influence sustained changes for residents in deprived areas.

Phenylketonuria is a rare genetic disorder that causes cognitive impairment unless treated with a strict, protein-restricted diet. Due to the challenges of treatment adherence, caring for a child with PKU may affect parental wellbeing, and many children and adolescents have poor metabolic control. The overall aim of the thesis was to examine influences on parental wellbeing and treatment adherence. Paper 1 is a systematic literature review of the demographic and psychosocial influences on blood phenylalanine concentration for children and adolescents with PKU. The aim was to identify factors that were robustly linked with metabolic control and could potentially be used to inform clinical practice. Findings from 29 identified studies indicated that whilst a number of demographic and psychosocial factors were related to metabolic control, the most reproducible association was with child age. Quality assessment of the studies indicated some methodological limitations, and a paucity of research in some areas highlighted the need for further research. The limitations of the evidence-base, clinical implications, and directions for future research are discussed. Paper 2 presents an investigation of the psychological impact of parenting a child with PKU, the determinants of parental wellbeing, and the association between parental wellbeing and treatment adherence. Forty-six caregivers of children with PKU completed questionnaires examining psychological distress, parenting stress related to caring for a child with an illness, resilience, perceived social support, and child dependency. The proportion of blood phenylalanine concentrations within target range in the preceding year was used a measure of treatment adherence. Results showed that more than half of caregivers had clinical levels of psychological distress, which was predicted by their parenting stress and resilience. Whilst treatment adherence was not associated with parental distress, it was predicted by child age and caregiver perceived support from family. The limitations of the study, implications for clinical practice, and future research directions are discussed. Paper 3 provides a critical evaluation of Papers 1 and 2 and a personal reflection of the research process.

British Muslims make up the second largest, and fastest growing, non- Christian religious community in Britain. Because of this, their integration into society has become a focus of interest for academic study and in broader social and political debates. Despite this, the question of how Muslims make sense of their own religious identity remains relatively unexplored in previous research. The same is true for the question of how they construct understandings of what integration means to them and of how this relates to what they say about their own wellbeing. This thesis aims to fill these gaps in extant research and to provide a platform for the voices of this minority group to be heard. Semi-structured interviews were carried out with 20 first generation and 20 second generation Muslim immigrants and a further four focus groups were also conducted. Gender was balanced across all of these. Data were analysed using discourse analysis focusing on participants’ discursive constructions of religion, identity, integration, wellbeing, and the problems that impacted on wellbeing. Analysis showed that British Muslims adopt a variety of forms of categorization in constructing their religious and ethnic identity. Some first generation Muslims focus on presenting their identities as flexible phenomena that depend upon the culture they are living in; others display a rigid religious identity. Second generation Muslims use hyphenated identities for defining the multiplicity of their belongings to Britain and their ethnic home country. Integration in Britain is usually welcomed by both generations but is described as being restricted and guided by religious boundaries. British Muslims construct happiness and unhappiness in relation to life in Britain in a complex manner. The most prevalent reasons they give for happiness are the religious freedom and security found in Britain. But these are described by comparing Britain with their home countries, where such freedoms and security are often said to be lacking. In a sense, this allows participants to legitimize their status as immigrants into Britain. Unhappiness is also associated with life in Britain, with references made to moral decline and to discrimination and racism. Participants also construct a sense of their wellbeing, or lack of it, in relation to other problems. They present Muslims’ selfs-egregation, and a lack of proper leadership among Muslims in Britain, as further major problems associated with living in Britain. However, while talking about these problems, participants seek to distance themselves from them by making vague attributions of agency and by indicating that such problems were faced by others rather than by themselves. When participants talk of ways in which Muslims’ wellbeing could be enhanced, they focus on Muslims’ own need for personal improvement but also on the need for responsible media coverage of Muslims and Islam. The thesis concludes by discussing these findings in relation to previous literature and by reviewing their implications for future policy, practice and research.

Unmet psychosocial needs indicate a desire for additional support in cancer patients, having a direct clinical utility in directing the provision of supportive care. There is evidence in wider cancer groups that unmet needs relate to psychological wellbeing but this relationship has yet to be fully explored and factors that may explain or moderate this relationship yet to be examined. There has been little investigation of type or prevalence of unmet need in haematological cancer patients, however, haematological cancers are noteworthy for their high levels of associated distress. Understanding causality of distress is key to the effective implementation of supportive care services. This thesis aimed to highlight the unmet needs most relevant to haematological cancer patients and to explore their impact upon psychological wellbeing. This thesis comprises four interconnected research studies: a systematic review exploring existing knowledge of unmet needs; a qualitative exploration of patient experiences of unmet needs and their impact; a quantitative questionnaire study of unmet need and psychological wellbeing in newly diagnosed haematological cancer patients, placing a special emphasis on the difference between active treatment and watch and wait regimes; and, a second quantitative questionnaire study that explores unmet need, psychological wellbeing, and psychological flexibility as a potential moderator in their relationship in a sample of haematological cancer survivors. This thesis demonstrates a relationship between unmet need and psychological wellbeing in haematological cancer patients. Fear of recurrence, concerns about loved ones, being able to do the things you used to, and a need for information were all found to be of relevance. The qualitative study highlighted that patients feel that, as haematology patients, they are distinct from other cancer patients which impacts upon the perceived acceptability of support services and specific barriers to the accessing of support services are presented. Significant correlations between unmet need and key psychological outcomes such as anxiety, depression and quality of life were observed in both quantitative studies. In addition, the concept of psychological flexibility was found to moderate the relationship between unmet need and psychological wellbeing in haematological cancer survivors. This work has clear implications for both future research and clinical practice. Unmet needs assessment has the potential to be used as a screening tool for overall psychological wellbeing, a way to stratify and understand the specific causes of distress and poor quality of life for this patient group. In the UK, on-going support for cancer patients diminishes at the end of treatment, these findings suggest that further support is needed in order to meet the psychological needs of cancer survivors. Further research is needed to further explore the role of psychological flexibility in cancer-related distress: interventions that target psychological flexibility have the potential to improve both unmet need and distress.

Health centres, like hospitals and clinics, tend to be unwelcome, sterile environments. This dissertation is about the making of a conventional and complementary health centre that aims to be a place-making building. This intervantion will give a sense of place and give identity, which the Modern Movement has so cleary disrupted. The intention would be to emphasise place through sensory experiences. By this the user will be connecting (orientate and identify) to a sense of place and then ultimately to him or herself through the various therapies. / Dissertation (MArch(Prof))--University of Pretoria, 2009. / Architecture / unrestricted

This research endeavour with Moose Cree First Nation provides insights into how emerging Indigenous methodologies are fundamentally grounded in an Indigenous epistemology that, for the purpose of this project, was found to be integral to youth and community wellbeing. More specifically, this project highlights an Indigenous perspective of health and wellbeing, milo pimatisiwin, that yields individual, collective and relational strengths with its focus on reconnecting youth to the land. This thesis offers methodological contributions in an effort to discuss research with Indigenous peoples beyond the participatory paradigm; it also develops on coming to know through the “visiting way” and elaborates further on Indigenous methods such as learning by doing concepts and conversational method. Discussing approaches of coloniality and settler-colonialism highlighted territoriality and land dispute issues, but most importantly here, these approaches established how the land is at the very core of the Omushkego people’s epistemology. Two land-based initiatives with Moose Cree First Nation were examined in this study. The initiatives provide insights into Indigenous resurgence as they relate to the land, to spirit, and to life stage teachings. The community experiences suggest how vital it is to center Indigenous knowledge in research and land-based initiatives for youth wellbeing as they contribute to developing, integrating and applying Indigenous methodologies, given this process is inter-related to fostering milo pimatisiwin. The Omushkegowuk people’s conceptions of health and wellbeing challenges colonial ideas and actions, and just as important, it allows for the production of knowledge within the context of Indigenous methods, experiences and wisdom.