• Understanding the diffusion of the idea of contact with nature to enhance health: An Eliasian case study

      Thurston, Miranda; Greening, Kim L. (University of Chester, 2015-12)
      In public health working in a less medical and more preventative way by focussing on the wider determinants of health, inter-sectoral collaboration, and evidence based practice have been advocated as ways to raise the health status of the population. In recent years, the idea of contact with nature to enhance health has come to the fore as one way to tackle current public health challenges: for example, diabetes, overweight and obesity, chronic liver disease, hypertension and mental health problems. Yet little is known about how this idea has diffused through the interdependent figurations of researchers, policy makers and into use through the actions of people in local organisations. The processes connecting these interdependent figurations are complex and, in the case of contact with nature, are not well understood. This is the research problem this thesis seeks to address, that is to say, the evidence into action process of an idea. The theoretical perspective of Norbert Elias is used throughout the thesis to analyse the diffusion process of the idea. Elias’s work is concerned with long term processes in human history; in adherence with his approach to sociological inquiry a historical context going back more than three generations provides the backdrop for the empirical work. An examination of the context illuminated the significance of the decade of the 1970s onwards to the present use of the idea of contact with nature in public health; notably the shift in discourse about hazards, risk and threats from nature to one of health enhancement. Norbert Elias’s own thinking and discourse about contact with nature to enhance health is used as a touchstone for the analysis. The empirical data in the thesis is generated through mixed methods, principally bibliometrics and content analysis, to reveal the diffusion and development of the idea over time and to show the way that the idea is framed when used by researchers, policy makers and by people within organisations. An Eliasian approach to case study methodology is utilised. Sub-study 1 revealed that empirical research literature about the idea emerged in the 1970s and that the number of publications per annum increased year on year until 2005. The empirical research was generated by researchers located across several continents and from different disciplines. Early researchers into the idea investigated the psychological benefits whilst latterly epidemiological studies have come to the fore. Sub-study 2 showed that the idea was taken up widely by policy makers in four government departments in England from 2000, with a peak in 2011. There were more references to the idea in the policy documents of the Department for Environment, Food and Rural Affairs than other government departments; the references of this department took an ecosystem services stance. Sub-study 3 showed that during July to October 2013 and within Greater Manchester, 36 organisations were providing and/or promoting activities which involved the idea of contact with nature on their websites. Of these 36 organisations, 16 (44%) were conservation/wildlife based agencies whose use of the idea included the pursuit of their own agendas and purposes. ix An analysis of the results, using the theoretical perspective of Norbert Elias, shows the involvement of many figurations of interdependent individuals, and the long term, largely unplanned, and non-linear character of the diffusion process. The empirical findings reflect the transdisciplinary nature of the research, inter-sectoral collaboration across government departments within policy, and the adoption of the idea outside of the traditional health service. People and thinking from the environment sector have greatly influenced the diffusion and development of the idea, and their involvement has widened the scope and form of public health action.
    • Understanding the Processes Involved in Implementing an Improving Access to Psychological Therapies Service: An Exploratory Study that Investigates Practitioner and Client Experience Regarding its Effect on Patient Pathways, Service Design and Overall Outcomes

      Pietroni, Patrick; Thomas, Mike; Steen, Scott (University of Chester, 2015-12-31)
      The English Improving Access to Psychological Therapies (IAPT) programme is a government-funded initiative that aims to provide timely and equitable access to evidence-based psychotherapeutic interventions, within a primary care setting. Despite the many achievements of the programme, there are several issues regarding research to clinical gaps, as well as a high rate of variation between sites concerning outcomes and attrition. This thesis explores the implementation process of the IAPT delivery model to understand which factors are influential in the successful uptake and integration of evidence-based psychotherapeutic interventions. The aims of this thesis are:  To explore, identify and analyse the implementation process involved in establishing and delivering an IAPT service.  To uncover the factors that either facilitate or impede its development to provide a more in-depth and detailed account of the implementation and operation of services.  To develop an understanding regarding the applicability of evidence-based practice and the IAPT delivery model in a clinical setting, for the provision of psychological therapies. I conducted a series of semi-structured interviews with practitioners delivering and implementing services, across seven sites, and clients, across three sites. The design and analysis followed an Interpretative Phenomenological Analysis, focusing on personal meaning and sense-making processes. The objective of the interview was to understand the implementation process regarding the IAPT delivery model, exploring how this influences personal experiences and client engagement. Additionally, participant narrative was set in context using open-access data collected and published by the programme. The analysis generated three master themes for practitioners delivering and implementing services including: ‘A Call to Action’ describing how participants regarded this process as a genuine opportunity to make a real impact in mental healthcare; ‘Contextual Influences on Service Operation’ which explores the activities in becoming a locally determined, adaptable and relevant service; and a ‘Focus on Relationships’ outlining the relational and collaborative work involved during implementation. For the client group, three master themes were generated including: ‘A Personal Journey: From Discovery to Advocacy’ illustrating the changing experiences involved during service access and engagement; ‘Perception of Self’ which portrays how individuals made sense of their engagement by judging what it meant to them; 5 and ‘Outside Factors’ which explores the role of others and the physical journey made in getting to services. The analysis suggested that both groups made sense of their experiences in complex and varied ways. Heavily influencing the implementation of the IAPT delivery model is the over-arching need to boost throughput and quantity, possibly at a cost of quality. Additionally, it is argued that the use of routine outcome monitoring in services is useful for reflecting on the implementation process and engaging clients. The key to successful implementation appears to be about achieving integration, requiring a whole-systems based approach that considers the mediating pathways into and out of services. In light of the findings and literature, the thesis proposes several recommendations for future practice and further research.
    • Using a feminist standpoint to explore women’s disclosure of domestic violence and their interaction with statutory agencies

      Mason, Tom; Keeling, June J. (University of ChesterUniversity of Chester, 2011-11)
      This thesis explores women’s disclosure of domestic violence, and is based on the findings of two research studies. The first study explored prevalence rates of domestic violence reported by women following childbirth. The subsequent narrative study explored women’s experiences of disclosure and their interactions with statutory agencies. The research was influenced by a feminist epistemology, recognizing the marginalisation of the women’s experiences from a subjugated relationship, addressing the power relationship between the researcher and participants and because of the significant disparity between gendered lives. The study was conducted in two parts. A survey of five hundred women in the immediate postnatal period within a large NHS Hospital participated in the first part of the study. The second study involved narrative interviews with fifteen women living within their own community who talked about their experiences of domestic violence and issues surrounding disclosure. Women’s stories about disclosure including the responses they received were influenced by cultural narratives. The theories of social power have been utilized as an explanatory framework and provide the theoretical basis of the analysis. The study found low levels of disclosure at two specific points along the pregnancy/childbirth continuum; during booking in clinic and in the immediate postnatal period. Furthermore, the findings revealed three specific tactics used by perpetrators to engage women in the early relational stage with the intentionality of exerting control and subjugation. These have been termed feeling special, feeling vulnerable and commitment. Whilst women talked of coercion and subjugation by their partners, they also talked of how their interactions with statutory agencies limited their agency. The significance of this study is that the thesis was able to challenge contemporary policies developed by statutory agencies in the provision of support to women who experience domestic violence. The thesis develops some understanding of the nature and role of cultural narratives and patterns of disclosure before suggesting new directions to further advance the findings presented. Finally, the thesis proposes recommendations to improve training for statutory agencies in providing a response to women disclosing domestic violence, suggesting a new direction in thinking about the facilitation of this training.
    • Visual perceptions of ageing: A multi method and longitudinal study exploring attitudes of undergraduate nurses towards older people

      Mason-Whitehead, Elizabeth; McIntosh-Scott, Annette; Ridgway, Victoria (University of Chester, 2015-12)
      Ageism and negative attitudes are reported to be institutionally embedded in healthcare. The unprecedented increase in the older population together with social perceptions of later life presents all those involved in the delivery of healthcare with considerable challenges. It was therefore timely to examine attitudes and perceptions of healthcare professionals towards older people. This study presents a critical visual exploration of the perceptions of ageing of undergraduate nursing students at a University in the North of England, based on the findings of a three year longitudinal study. The research employed a pragmatic standpoint where mixed methodology was adopted to explore perceptions and included the use of an attitude towards older people scale (KOP) (Kogan, 1961), visual methods (participants were asked to draw a person aged 75), a Thurstone scale and photo elicitation. The research design and construct was influenced by the epistemology of constructionism and discourse analysis. The research was conducted alongside an undergraduate nursing programme, and followed the natural journey of 310 students from one intake and involved three waves of data collection. The study established that the majority of participants had moderately positive attitudes towards older people the beginning of the programme and that these had improved for a significant number by the end of the study programme. From the quantitative data it was determined that age, gender, educational qualifications, practice learning, branch of nursing and contact with older people influenced the participants’ overall attitude score. The use of visual methods provided a narrative of the participants’ perceptions of later life and appearance dominated the imagery via the physical depiction of ageing and the ascetics of clothing and grooming. The influence of role models was seen to impact upon the production of the image via the depiction of grandparents and people they knew and the drawings identified some older people being active. The visual findings established that the undergraduate nurses in the study viewed older people from a socially constructed phenomenon and used symbols (hairstyle, clothing, mobility aids) to depict old age. The nursing programme was found to positively alter perceptions. The research findings have led to recommendations based on three prominent themes; 1) implications for nurse education and practice, 2) gerontology education and research and 3) future use of the research methods.