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This study aimed to assess the effectiveness and suitability of social isolation and loneliness interventions for older people from minoritised ethnic groups living in the UK. It employed an iterative mixed-methods approach, conducted in four phases. Using data from Understanding Society: the UK Household Longitudinal Study, Phase 1 explored ethnic variations in the friendship networks of older people using logistic regression analyses. Compared to older white people, older minoritised people's friendship networks were found to be restricted in size and accessibility. These findings were explored further in Phase 2 using in-depth interviews with older people from minoritised ethnic groups. Community groups were identified as important for protecting against social isolation and loneliness. A mixed-methods systematic review was subsequently conducted to assess whether community-based group interventions reduced social isolation and loneliness in older people, and to uncover their underlying mechanisms. The evidence of effectiveness based on the meta-analyses was unclear, and qualitative comparative analysis was used to understand (non)effective interventions. The most effective interventions were found to adopt cognitive approaches to reducing loneliness, recruit participants with shared characteristics and provide participants with opportunities to connect. In Phase 4, the interviews conducted in Phase 2 were analysed using dialogic/performance analysis to gain an understanding of what older minoritised people consider their needs to be. The findings were used to assess the extent to which the interventions identified as most effective in Phase 3 matched what older people from minoritised ethnic groups view as their needs. The findings suggest that for community-based group interventions for social isolation and loneliness to be suitable and acceptable for older people from minoritised ethnic groups, they would need to be tailored to the aspects of their identities that they value and provide opportunities to connect based on these aspects of identity and activities that they find meaningful.

People with frailty are less likely to recover from illness and are at greater risk of falls, institutionalisation and death. Rates of frailty are increasing and expected to rise as the population ages putting great pressure on the NHS. Over the last 20 years frailty has been explored in terms of biomedical assessment and intervention however authors report that older people do not necessary value or want to take part in 'frailty' services. Focusing on identity and sense of self, this study set out to determine how a Day Hospital providing frailty services; which were highly regarded by older people, supported people to engage in services. This ethnographic study aims to contribute to this gap in knowledge through exploration of the socio-cultural experiences of older people undergoing treatment in an NHS Day Hospital. Through approximately 100 hours of participant observations and additional focus group discussions, the cultural practices and processes, interactions and experiences of care within the Day Hospital were documented and analysed. The findings of the study contribute knowledge in three main areas firstly; that sense of self-identity in people with frailty is constructed through numerous losses and social perceptions that shape their social roles. This can create a sense of ontological insecurity, or disruption to the order of their lives as they know them. Secondly humanising processes within the Day Hospital, supported people with frailty to feel more secure in their daily activities, social roles and identities. This was achieved through fostering a hospitable environment and building a culture of humanising relationships on embodied relational knowledge. These cultural processes contributed to older people with frailty engaging more fully in their rehabilitative journey. Finally, the study revealed that the construction of a nurturing and accepting work culture, is an essential foundation to support humanising and embodied practice for older people with frailty. Fostering a culture where positive sense of self for both patients and staff is supported is key to continued therapeutic engagement. Changes in personal identity in people with frailty and the responses needed to address them need to be considered by policy makers and healthcare providers to provide appropriate and effective care services.

This thesis presents the results from a mixed methods study examining the health and wellbeing of older women in the UK. In the context of an ageing population, understanding the determinants and nature of health and wellbeing in later life is important in improving health service provision. Women are more likely to live alone in later life in addition to experiencing different life course trajectories to men. Gender variations in the outcomes and experience of later life are well recognised. Living alone poses particular challenges in later life in terms of social and practical support and the existing evidence does not explore the implications for this for older women in the UK. The original research carried out for this thesis consists of two main phases in addition to a scoping review of existing literature. Quantitative analysis of data from the Understanding Society dataset was followed by qualitative analysis of transcripts gathered in 1:1 interviews with seven women between the ages of 65 and 80 who live alone in the UK. These interviews were undertaken during the summer of 2020, during the Covid-19 pandemic. One of the main findings is that women who live alone in the UK are older and in poorer health on average than their co-habiting counterparts. This highlights an important potential vulnerability in this population. Logistic and linear regression analyses indicate that household composition is not a predictor of poorer health and wellbeing once socioeconomic factors are included in the models. Another key finding from the regressions is the comparison of determinants of health between those who live alone and those who cohabit. The determinants of health and wellbeing differ between those two groups, suggesting different needs for support. Of particular interest is that although volunteering rates were comparable for the two groups, volunteering was a significant predictor of better health and wellbeing for those who live alone but not for those who live with others. This indicates that social factors influence the health and wellbeing of older women differently depending on their household composition: it also points to the importance of supporting older women who live alone to be able to engage in such civic activities if desired. The results of the qualitative analysis provide complementarity to the statistical analyses by providing a richer picture of the experience and life course trajectories of older women who live alone in the UK. The examination of the qualitative data was undertaken in two separate analyses. The first analysis used an Interpretative Phenomenological Analysis to examine the lived experience of living alone in later life. This was particularly important given the timing, during the Covid-19 pandemic. Three overarching themes were Productivity, Ownership, and Interconnectedness. The second round of analysis of the qualitative data used Critical Narrative Analysis. This enabled the use of a life course approach and a critical theoretical lens - in this case, critical feminist gerontology - to examine the data further. The three key themes from this analysis were Rootedness, Busyness and New Paths. Finally, the findings from each of the analyses were synthesised with the existing empirical and critical literature. This study contributes to the existing knowledge regarding the health and wellbeing of older women living alone in the UK in several ways. Firstly, it confirms that older women who live alone are a more vulnerable group, reporting poorer health and wellbeing overall. However, it also confirmed the importance of socioeconomic factors in mediating the effect of household composition in terms of health and wellbeing outcomes. The role of volunteering as a promoter of health and wellbeing in this population is demonstrated and this is added to by the results of the qualitative analysis which underscored the value of volunteering for older women living alone. Valuable insights are also gained regarding the experience of living alone as an older woman during the Covid-19 pandemic in the UK which posed additional challenges to issues around social connectivity and independence. Indications for future research and implications for policy and practice are given. For example, further research is needed on the effect of volunteering on health and wellbeing in addition to exploring ways in which to maximise health benefits in older women, especially those who live alone. Policy and public health practice should consider how volunteering and other time-use variables are related to health and wellbeing whilst also being mindful of the effect such a drive might have on those unable to participate.

Background: This thesis explored community-based responses to the alleviation of loneliness and social isolation among older people. Loneliness and social isolation have been largely identified as problems of old age and research evidence shows strong associations between loneliness and social isolation, and quality of life, mental ill-health and physical health. Hence, there has been increasing policy attention in the UK and implementation of a wide range of services that aim to prevent or alleviate the progression of loneliness. This thesis set out to identify how community-based responses to the alleviation of loneliness and social isolation are described by interrogating previous literature. It aims to evaluate the impact of befriending interventions, which are a predominant direct intervention delivered across NI (and the UK) to reduce loneliness and social isolation; to understand what works, under which circumstances, how and to what extent. This will help service providers to refine and tailor their interventions to fit the profile of the target individuals, as well as the different determinants of loneliness and social isolation. Methods: Three investigative activities make up the main body of the thesis. Firstly, a scoping review of international literature identified types of interventions that were implemented to alleviate loneliness and social isolation among older populations. Next, a study profiled existing interventions in NI implemented to alleviate loneliness and social isolation, by interviewing key stakeholders about the characteristics of relevant services using the TIDieR checklist. The loneliness framework by the Campaign to End Loneliness informed the sampling frame of the study and interventions were categorised as: (i) foundation services, (ii) direct interventions, (iii) gateway services, and (iv) structural enablers. Finally, a realist evaluation of befriending services (the predominant type of direct intervention in NI to reduce loneliness and social isolation) was conducted using a series of five case studies. The realist evaluation employed multiple methods including semi-structured realist interviews with different stakeholder groups of befriending interventions (e.g. service manager/coordinator, befriender, service user, and family member of service user), as well as reviews of service documentation. This was conducted in order to identify and subsequently refine programme theories explaining how befriending services work. Findings: Findings from the scoping review highlighted that loneliness and social isolation were often used interchangeably although they are distinct concepts. Review authors of existing literature often did not provide a rationale or theoretical underpinning for the categorisation of interventions designed to alleviate loneliness and/or social isolation. Lack of theoretical underpinning poses difficulties when ascertaining which context(s) a particular category of intervention would be most effective or appropriate, and also by which mechanisms these interventions work to alleviate loneliness and social isolation. The profile study of interventions in NI identified a broad range and diversity of interventions targeted at alleviating loneliness and social isolation among older people. These interventions did not appear to be based on empirical evidence that demonstrated the effectiveness of the service and how outcomes were achieved. Internal service evaluations were often conducted and comprised of satisfaction surveys completed by staff members and service users. However, this process lacks rigour and does not adhere to the principles of evidence-based practice. Direct interventions, specifically befriending, were identified as the most prevalent type of interventions delivered to alleviate loneliness and social isolation in NI, however, existing literature on befriending are predominantly outcome-focused with aims to answer questions on the effectiveness of these interventions, and whether they work (or not) to produce positive outcomes. However, this approach pays little attention to understanding the underlying mechanisms by which befriending interventions work to produce these outcomes, i.e. alleviation in loneliness and social isolation; and which contextual conditions influence this. In the realist evaluation of befriending services, eight programme theories describing the context-mechanism-outcome (CMO) configurations were rigorously developed, tested and refined over five case studies. Evidence is provided to demonstrate how befriending interventions work to alleviate loneliness and social isolation. The study's final findings are multifaceted and focus on the conditions of successful implementation which are presented under these demi-regularities: 1) reciprocity, 2) empathy, 3) autonomy and 4) privacy. Regarding reciprocity, consideration is given to how the matching process between befrienders and service users, face-to-face in-person service delivery, as well as monetisation of befrienders influences the translation from a professional relationship into a type of friendship. Under empathy, the contextual condition of shared experiences between the befriender and service user (i.e. illness) and the utilisation of face-to-face in-person service delivery is crucial to the development of a meaningful and trusting relationship between both parties. Autonomy is facilitated via open-ended befriending relationships with the same befriender whereas privacy is facilitated via one-to-one service delivery and was particularly important for service users with cognitive/sensory impairment due to reduced distractions. Conclusions: Overall, the findings of the PhD thesis contribute to our understanding about how befriending interventions work in alleviating loneliness and social isolation. Practical implications can be drawn from the theoretical propositions that were uncovered in this thesis, and this may be used to inform the design and implementation of these interventions in different settings. The theoretical propositions indicate some factors that could be used to support future befriending interventions and service providers can make informed decisions based on the findings about what is likely to work in their unique situation.

There is a growing demand for sustainable interventions to promote health and well-being in later life. One way to support older adults is to intervene during the retirement transition when individuals experience increased free time and a heightened need to develop new lifestyles (Moffatt & Heaven, 2017). However, to understand how retirement transition can serve as a 'gateway' for health interventions, exploring the mechanisms behind psychological adjustment to retirement is needed. t is posited that one approach to understanding retirement adjustment is to apply self-determination theory (SDT; Deci & Ryan, 1985, 2000). According to SDT, changes in well-being are predicted by satisfaction or frustration of basic needs for autonomy, competence, and relatedness. This PhD aimed to examine if SDT showed utility in understanding the complex process of retirement adjustment and to develop an intervention for supporting health and well-being in retirement. Four empirical studies used a combination of qualitative and quantitative methods to address the research aims. The first longitudinal study tracked changes in well-being and other psychological factors including need satisfaction/frustration over retirement transition. A vignette study examined the effects of personality on the perception and behaviour responses to need supportive and thwarting events in retirement. A qualitative study further explored the role of individual and contextual contributors to retirement adjustment. The final study followed the Intervention Mapping approach (IM; Bartholomew et al., 2006) to design a retirement lifestyle planning initiative. Results suggest that SDT can be used to understand retirement adjustment by 1) evidencing the link between need satisfaction and well-being in the target group; 2) suggesting an SDT-informed mechanism behind the effects of personality on retirement experiences; 3) explaining the role of psychological contributors (identity, social interaction, independence) and contextual factors in retirement adjustment through need satisfaction/frustration. The findings informed the development of a new 'Backcasting' intervention.

There is a growing and more heterogeneous older urban population. Yet representations of older age are often overly simplistic and reductionist in western societies. Against this backdrop, I consider how older age is lived to complicate and enliven homogenising representations of older age. The rich ethnographic accounts shared were developed through a flexible combination of methods with 32 older people from the Greater Manchester town of Prestwich over 12 months. I foreground the more-than-representational aspects of experience to consider what representations of older age do in the lives of older individuals; how older people live and attach to places; how memory works and mediates lived experiences of the city; and how we might research-with (rather than on) older people. Specifically, this thesis responds to calls for the incorporation of relational and more-than-representational approaches into the geographic study of older age to strengthen research on ageing. I bring together life-course and more-than-representational theories to advance current debates surrounding age relationality. I illustrate how more-than-representational theories foreground how pasts, presents and futures emerge together as time is lived, demonstrating how memories are not locked in a past but are multiple and mobile. I show how using a flexible combination of different methods over time and attuning to the possibilities and potential of methods as they unfold produces detailed, non-linear biographical accounts. This thesis demonstrates how more-than-representational approaches can speak to policy in ways they are often deemed unable. I caution how impact does not have to be an end point: benefit can be found in the doing of research through capacity building. Geographical research on ageing must continue to foreground those more-than-representational dynamics which are often overlooked in favour of a simple narrative.

Sedentary behaviour involves low energy activities undertaken whilst sitting or lying down. Engagement in high levels of sedentary behaviour is a risk factor for obesity, diabetes, heart disease, and premature death, and these risks are largely independent of how much a person engages in moderate or vigorous physical activity. Older adults represent the age group in which sedentary behaviour is most common, therefore reducing sedentary behaviour is a particularly promising target for this population. This PhD aimed to investigate the acceptability of reducing sedentary behaviour for older adults, and to use this knowledge to develop an intervention in line with best practice. A further methodological objective involved investigating the how the Theoretical Domains Framework (TDF) has been used in qualitative research involving patient or public populations. A qualitative interview study (Study 1) was conducted with older adults from diverse socioeconomic areas, using the TDF to inform data collection. This study resulted in two papers, one relating to older adults' construal of sedentary behaviour and one identifying factors associated with older adults' engagement in sedentary behaviours and barriers and facilitators to reducing their sedentary behaviour. We used the TDF in Study 1 as it can facilitate comprehensive theoretical assessment of the determinants of a given behaviour. However, prescriptive use of the TDF may risk qualitative research becoming overly theory-driven, to the detriment of novel inductive insights. We conducted a rapid systematic review investigating specific ways the TDF has been used in data collection and analysis of qualitative studies and the impact of such methods on study findings (Study 2). The findings from Study 1 informed the development of an intervention to reduce sedentary behaviour in older adults, nested within a community physical activity programme for older adults in a deprived area of Manchester. A mixed methods evaluation of the feasibility and acceptability of the intervention, and feasibility of intervention methods and evaluation is provided (Study 3). Older adults appear to conflate reducing sedentary behaviour with increasing physical activity, and previous work has found increasing physical activity to be unacceptable to older adults. An intervention described as a sedentary behaviour reduction intervention may therefore be unappealing to many older adults. An education element within interventions may be useful in challenging the notion that reducing sedentary behaviour necessitates increasing moderate-vigorous physical activity. Providing examples of ways in which sedentary behaviour may be reduced, without involving moderate-vigorous physical activity, may also prove effective. Additionally, education could be provided on the independent effects of sedentary behaviour on health. Further, older adults desire social interaction, therefore community interventions should try to reduce sedentary behaviour by offering group-based, social activities, particularly in areas of high deprivation where current provision is limited. The TDF is often applied prescriptively within qualitative research involving behaviour change of patient or public populations. We suggest that qualitative work could use the TDF in conjunction with a less prescriptive and more inductive approach to research to ensure that the context and detail gained from an inductive approach to data collection and analysis is not lost. We have developed a sedentary behaviour change intervention based on information provision delivered within a community group setting, which has shown evidence of feasibility and acceptability to older adults. These studies provide a foundation for a future definitive trial to reduce sedentary behaviour in older adult populations.

East Asian familialist welfare regimes have experienced major elder-care reforms over the last two decades under socio-economic and political pressures. This raises questions regarding the policy continuity and change of the familialist trajectories and its explanations. Adopting too narrow a focus on policy change, and viewing it as an automatic response to functional and political pressures, or as a static trajectory of the existing cultural and institutional legacies, the existing East Asian welfare state literature has found it difficult to understand the dynamics and outcomes of these rapid policy reforms. This thesis addresses these questions by undertaking a case study of Taiwan’s elder-care reform between 2004 and 2016, based on an analysis of documents from governmental and non-governmental sources and in-depth interviews with high-profile government officials, legislators, and representatives of advocacy groups. By developing a comprehensive framework based on the concept of defamilialisation, which covers the major policy domains of elder care, including legal caring obligations, care services and provision, cash benefits, and care leave, this thesis demonstrates that Taiwan’s elder-care reform involves a high degree of policy continuity with the familialist trajectory. This policy continuity results from the interaction between policy ideas and political agency operated differently in two distinct periods of reform. Calling for stronger public responsibility for elder care, policy actors promote diverging reform ideas, which involves different treatments of the defamilialisation of care responsibility and the formalisation of informal care labour. Strategic policy actors are not only able to bring forward new policy ideas through power imbalance among actors (policy ideas of powerful political actors), but, in a different setting, they can also resist policy change through the exercise of the ideational ambiguity of ‘care going public’ (policy ideas empowering political actors). Examining the interplay between ideas and politics in Taiwan’s elder-care reform, this thesis furthers the understanding of East Asian social policy development by moving beyond the conventional functionalist, democratisation, and cultural theses, and also enriches general analyses of the transformation of social care and policy change.

This research was undertaken as part of a Doctoral degree undertaken at the Queen’s University Belfast. This research explored the health and wellbeing needs of older men held in custody in Northern Ireland. The study also explored how these needs were met in prison and the older men’s experiences and perceptions of health improvement in prison. The study included both older prisoners as participants as well as a sample of staff from key stakeholder organisations. The research found that older men in prison experience similar incidence of poor health than those living in the community and in some instances worse health. Furthermore older people in prison experience distinct pains whilst being in prison relating to both the immediate custodial environment and through virtue of their healthcare usage. These findings suggest the need for policy makers to consider how care is delivered to an increasing population of older people held in prison.

This largely qualitative research used thematic analysis and some contextual quantitative data to supplement qualitative findings. It explored the decisions, experience and efficacy of 39 female homeowners, living alone in or near London, around downsizing to retirement housing. The focus was on wellbeing and chronic stress for participants who moved or did not. The timespan was: (1) ‘decision-making’ five months before the move, (2) just after moving, (3) ‘settling-in’ five months later. ‘Mover’ and ‘Non Mover’ cohorts were in two age groups 60-75; 76 and over. Structured interviews explored person-environment fit, quality of life, support networks and personal views and characteristics at Times (2) and (3) together with hair samples, for hair cortisol concentration (HCC) analysis of chronic stress. Depression, anxiety and stress measures were also taken retrospectively for Time (1). Two from each cohort had semi-structured interviews at Time (3). There were three ‘Overarching Themes’ and thirteen sub themes. Impediments and motivators to move were reported as either functional (practical) matters or ‘meaningful’ (emotional) matters, which had more influence for those disinclined to move. The inclination to move was dependent upon lifetime characteristics, beliefs, experience and self–efficacy, not age per se. Older Movers struggled with cognitive aspects and pressure to move from family, which was uncomfortably high in the research. Role diminishment within the community or family, and levels of autonomy, affected desire to move, the acceptance of help and time taken to settle-in. HCC results for chronic stress were interpreted using contextualised biographical material. This qualitative approach was essential in revealing individual delayed reactivity and different lengths/levels of response, depending on perception of ‘stressors’. Future research, policy and practice have been recommended, using richer than previous relocation research, for this growing social group.

In the social gerontology literature, there is a wide agreement on the importance of affective bonds with places for a positive experience of ‘ageing-in-place’. This includes a sense of attachment to and identification with places, also defined as a ‘sense of home’. However, the ways in which these affective bonds with places are negotiated by ageing migrants is yet a fairly neglected area of research. Nevertheless, with increasing numbers of older migrants adopting a transnational lifestyle or returning to the country of origin after retirement, there is a pertinent need to explore ageing migrants’ meanings of the affective bonds with places. Through an ethnographic approach, this project aims to gain a better understanding of the sense of attachment to and identification with places by members of an older Italian migrant population in Newcastle upon Tyne, UK. The main argument of this work is that a ‘sense of home’ – or a lack of it –shapes the conditions for ageing-in-place in the context of migration. Firstly, I explore how the negotiation of belonging, which relates to social and political aspects of the environment, contributes to a ‘sense of home’ in the context of migration. Secondly, I illustrate how the attachment to places left pre-migration, through transnationality and ‘home-making’ practices, elucidates the expectation of ageing. Thirdly, I address how the facilitators to a ‘sense of home’ in the context of migration mark a new status in later life. Finally, I focus on the barriers to a sense of identification with the places inhabited, that co-exist with a sense of attachment, but that undermine the sense of belonging to these. Ultimately, challenging the assumption of older Italian migrants as a homogeneous population, this work highlights how the diversity within the group is shaped by the relationship established with places in later life.

Objective: This thesis reports on the design, development and implementation of a feasibility study to investigate if a tailored exergame could be implemented to improve postural control outcomes for community-dwelling older adult fallers living in the North East of England, UK. Design: This feasibility study was carried out in several phases according to the Medical Research Council (MRC) framework guidance for complex interventions. Phase 1 consisted of two systematic reviews to identify characteristics to aid in the design, development and implementation of the intervention and subsequent pilot study and also to identify potential outcome measures. This also included a qualitative study of participants' perspectives using focus groups. Phase 2 consisted of a non-randomised controlled study where participants, recruited from 2 sites, Northumbria University and Gateshead Older Peoples Association (GOPA), were allocated to either one of two intervention groups (exergaming or traditional balance training) or a no exercise control group. The intervention lasted for 6 weeks and outcomes were assessed prior to the start of the intervention and following the final training session. Follow up interviews were conducted with participants and analysed using deductive thematic analysis. Findings: After reviewing the existing evidence, the literature indicated that exergaming interventions were as beneficial as traditional balance interventions, although the evidence for each outcome was of low quality, assessed using the GRADE approach. No intervention had implemented an outcome measure that assessed reactive postural control, verticality or the cognitive influences on postural control, such as the Mini-Balance Evaluation Systems Test (Mini-BESTest) and not all components of postural control were trained. Thematically analysed data from 3 focus groups totalling 13 participants, deduced four main themes: 1) attitudes toward technology, 2) consideration of balance and movement, 3) ease of use, and 4) social influence and exergaming. Adults of all ages perceived exergames to be enjoyable, yet, there were perceived barriers in using commercial exergames for older adults and individuals with balance impairments. The nonrandomised pilot intervention took place in Newcastle and Gateshead, UK. Thirty-five participants (10 exergaming, 10 traditional balance training and 10 controls) were included in the study. All four of the progression criteria were met in that 69% of eligible participants were screened and allocated to the intervention with a retention rate of 95.7% for all assessments. Adherence was 100% successful and only 1 adverse event occurred (3%) and did not occur during any of the training or assessment visits. Analysis of interview data from 10 participants (5 exergaming, 5 traditional balance training) following the pilot intervention revealed that older adult fallers accept the use of a tailored exergame (Mira™) as a method to train postural control. Conclusions: A tailored exergaming intervention was successfully implemented and received well by participants, although amendments to the protocol and barriers to future participation for older adult fallers should be considered prior to implementing a future definitive trial.

Uptake of carers’ services across the UK is relatively low despite evidence of the positive effects of support services. The Carers (Scotland) Act 2016 places duties on local areas to provide personalised support to unpaid carers with eligible needs. However, is it not clear how to best plan local services to meet the diverse support needs, aspirations and preferences of unpaid carers. The preferences of unpaid carers of older people requires particular attention as this group of carers play a vital role enabling many older people to live at home, and are often in need of support themselves. This thesis uses a discrete choice experiment (DCE) to investigate carers’ preferences for support in Scotland. Applying a realist, interdisciplinary framework, it draws on a literature review, secondary analysis of interview data (n = 62), three focus groups with carers and practitioners, and a DCE survey (n = 112). It examines what matters to carers when choosing between different types of formal support, and investigates the heterogeneity of preferences for respite among different subgroups of carers. This thesis finds a high stated demand for respite and replacement care services amongst carers of older adults in Scotland. It demonstrates carers particularly value choice surrounding the support provider, and are willing to wait 12 months longer for replacement care provided by a familiar professional carer compared to an unfamiliar paid carer worker in order to take a short break. Reasons for not using support services include a perceived administrative and organisational burden, and lengthy waiting times. Together, this informs policy and practice in the design of carer support services, both in Scotland and beyond, and highlights the need for further research to understand the impact of accessibility and responsiveness of adult social services in the take-up of short breaks and other personalised forms of carer support.

Current English social care policy advocates ‘active ageing’, ‘ageing‐in‐place’ and ‘independence’, whilst promoting ‘choice and control’. Yet research has shown that these competing policy agendas relay mixed messages to older people. Latest figures show that over half of older people aged 65+ live with two or more health conditions, which affect their ability to carry out activities of daily living (ADLs) and instrumental activities of daily living (IADLs) in and around their home environment. Older people face an increasing risk of being left unsupported, owing to ongoing consequences of austerity measures affecting formal social care provision in recent years. Many studies have focused on who provides support, but little is known about how older people arrange support. This thesis aims to understand how older people who are living in the community negotiate arrangements for support and assistance with ADLs and IADLs from formal and informal sources, using a qualitative research approach. Semi‐structured interviews were conducted with older people aged 65+ (n=8) and members of their formal and informal support network (n=19). Data were analysed by combining thematic analysis with a symbolic interactionist approach. The findings indicate that older people tend not to adopt a direct approach for help with ADLs and IADLs from informal members, preferring to adopt ‘hinting’ to highlight unmet need. Older people usually adopt a direct approach when negotiating with formal members, or with informal members if recent reciprocity is evident. Importantly, older people accept help if it is offered. The findings have two main policy implications: First, to highlight awareness to formal support members about the language used by older people to draw attention to unmet need. Second, to ensure that older Personal Budget holders receive advice and support to make contingency support arrangements in emergency situations.

Addressing the issues raised by the ageing population, valuing the contribution of older people in the society and improving their quality of life are some important challenges of the modern society. Social participation is important to people for ageing well in later life. Staying socially active can help older people to maintain good physical and emotional health and well-being and cognitive function. However, participation in social activities seems to decrease with age due to physical disability, illness, loss of family and friends, loss of community and perceived lack of opportunities. However, the demographic shift of the twenty-first century coincided with the digital revolution and resulted in the emergence of a new world for participation called the online world. The online world provides opportunities for older people to take part in social activities similar to the physical world and it has changed the way people can communicate and interact with each other. The number of older people using these opportunities was relatively low compared to the other age groups. However, recent years have remarked tremendous growth in the number of older people making use of these opportunities. Therefore, this study explored the perceptions of older people about their social participation in the online world relative to their social participation in the physical world. Qualitative research approach with a generic qualitative design was used to address the research questions. Twenty semi-structured intensive face-to-face interviews were carried out to collect the data. Thematic analysis was carried out to generate the themes that address the research question. The results revealed the integration of the online world into the lifestyle of the people. The participants in this study perceived the online world as an addition to their lives, providing more opportunities to participate in different activities. The study also identified areas that need more attention to keep and attract older people into the online world. Furthermore, the study identified that older people using the online world experienced improved social connectedness and subjective well-being. The findings of this research will inform the areas to be improved for better online world experiences for older people.

Ageing in place has become a primary policy instrument around the world to tackle the challenges associated with ageing societies, including in China. Much research emphasises the societal benefits of ageing in place with reference to its cost efficiencies. While there is an emerging literature employing a person-centred approach and paying increasing attention to older people's wellbeing, this research still centres on the identification and theorisation of determinants of wellbeing. This study adopts a broader wellbeing approach and extends the new emphasis on the wellbeing of the oldest-old people ageing at home to the Chinese context. Applying an integrated conceptual framework, combining a relational understanding of wellbeing, theory of place and a life course perspective, the study aims to explore the experiences and meanings of wellbeing for and by older people themselves. The empirical focus of the research is a case study of two communities in Shanghai, where I conducted 6-months of fieldwork between 2015 and 2016 using qualitative research methods, including in-depth interviews, focus groups, observations and documentary analysis. The study finds that, while the new policy emphasis on ageing in place aligns with older people's own preferences of attaining wellbeing in later life, the idea of wellbeing involves a complex set of social dynamics and shows both individual diversity and common character among the older people studied. The meanings of wellbeing for and by the older people studied reflected the multifaceted nature of wellbeing, the linked nature of human life and the great influence of historical times, earlier life events and the place in which they live. The study offers one of the first attempts to apply an integrated wellbeing framework when analysing wellbeing in old age and represents one of few empirical studies on Chinese older people's later life. As such, it contributes to the wider literature and enriches our understanding of ageing and wellbeing, both theoretically and empirically.

Background & Objectives. In light of population ageing, policies aimed at extending working lives have been implemented in several higher income countries, including the UK. However, given older adults' substantial contributions through unremunerated forms of work, such as informal care and volunteering, longer working lives may have repercussions for engagement in unpaid activities, which are important for their economic value and their influence on older people's health and wellbeing. Using the British Household Panel Survey and its continuation, the UK Household Longitudinal Study, this thesis examined the effect of employment status on engagement in unpaid forms of work in mid to later life (55-70). Two different approaches were used. Firstly, pathways of engagement in multiple activities are examined using two-stage latent class analysis (LCA), to provide a nuanced picture of how individuals combine engagement in paid and unpaid activities over time. Secondly, the longitudinal relationship between employment status and engagement in informal caregiving and volunteering is examined using within-between random effects (WB-RE) models that disentangle direct influences from selection effects. Results. Findings using two-stage LCA identified three distinct engagement pathways: paid workers (43%), mixed activities (housework) (46%), and mixed activities (volunteers) (11%). Paid workers were more likely to work full-time and less likely to engage in unpaid work. Individuals classified in the other two pathways were more likely to combine paid and unpaid activities. Gender differences were conspicuous, as more women conformed to the second and third pathways. Being classified in one of the three engagement paths was associated to baseline sociodemographic and health characteristics. WB-RE models showed that full-time employment was consistently associated with lower odds of caregiving (any and at least 20 hours per week, hpw), through both within and between person effects. Time-lagged models showed that women who work part-time had lower odds of caregiving 20 or more hpw, while men in full-time self-employment had decreased odds of caregiving at all intensities (between person effects). Among caregivers, full-time employment was associated with lower odds of more intensive caregiving (20 hpw) at follow-up, according to both within and between person effects; additionally, part-time paid work and self-employment were negatively associated with providing more intensive care according to between person effects. Full-time employment was consistently negatively associated with monthly and weekly volunteering, through within and between person effects. Time-lagged models showed that part-time employment and full-time self-employment led to lower odds of monthly volunteering (within person effects) among men. Part-time employment also led to decreased odds of weekly volunteering. Men who were in part-time self-employment had higher odds of monthly and weekly volunteering (between person effects). Among female volunteers, full-time employment led to lower odds of more frequent volunteering at follow-up (within person effects). Among male and female volunteers, those who were in full-time self-employed had lower odds of more frequent volunteering (between person effects). Conclusion. Full-time employment led to a lower likelihood of engagement in caregiving and volunteering, with both direct and selection effects driving this relationship. The effect of part-time work and self-employment was mainly mediated through selection effects. Individuals' engagement in unpaid work should be taken into account in the context of longer working lives, as participation in full-time employment limits engagement in informal caregiving and volunteering in mid to later life. Findings have also important implications for active ageing related policies, as they emphasise the importance of gender, socioeconomic and health inequalities as determinants of engagement in paid and unpaid work in later life.

Although anxiety and depression are common in older adults, the medical terms may not be acceptable to them. Older people are more likely to perceive themselves as experiencing distress, and may also feel responsible for managing their own mood problems. To self-manage distress, older people could potentially engage with the internet to access health information or social support. This study aims to explore how older adults self-manage distress, with a particular focus on the role of the internet. This study is underpinned by social constructionism and takes a qualitative approach towards data collection and analysis. Eighteen older adults (11 females, aged 65 - 91 years) who self-identified as experiencing distress were recruited from community groups in North Staffordshire, England. To generate data, 'think-aloud' methods (including storyboards and an extract from an online forum) were embedded within semi-structured interviews. Data were analysed thematically utilising constant comparison methods. A public and patient involvement and engagement group contributed to development of the research questions and methods, offered their perspectives on the findings and helped to create a dissemination plan. Findings focus on participants' experiences of distress and actions taken, which included: pursuing independent activities, seeking social support and attending community groups and church. Five participants consulted a GP when distressed but reported being offered a lack of acceptable treatments. The internet was not considered a source of information about distress or mood problems and participants did not use the internet as a means of accessing social support. Implications for older adults, healthcare services and policy makers are discussed. When presented with a distressed older adult, GPs should begin by exploring the older person's own understanding of their distress and its causes, provide information about different management options and consider directing older people to local third sector services. GPs may also need to take into consideration that sign-posting older people to online support might not be acceptable.

The thesis explored the social and life course factors behind the prevalence and risk of multimorbidity and functional limitation as well as their unequal distribution in the ageing population of England. Multimorbidity is the co-occurrence of two or more diseases within a person. Functional limitations are restrictions in performing fundamental physical and mental actions used in daily life. The thesis identified previously unmeasured inequality in the population with multimorbidity and functional limitation. People aged 50-54 years with the least household wealth had the same prevalence of complex multimorbidity as those 20 years older in the most affluent category and the prevalence of functional limitations comparable to those 30 years older in the top wealth group. Further analysis included a range of material, psychosocial and behavioural determinants into the analysis. Household wealth, sense of control over personal life, physical activity and loneliness were associated with the risk of multimorbidity and functional limitation. Finally, the thesis developed a pathway model of how childhood circumstances – social class, adverse experiences and health – affect the risk of multimorbidity and functional limitation in old age. The material, psychosocial and behavioural pathways acted as magnifiers of inequalities from the early life period.

Internationally, concerns with the implications of population ageing have led to growing attention being paid to the economic contributions and dependency of older adults. Research on intergenerational support investigates older adults' exchanges of money and time with their family members, while productive ageing refers to their economic contributions to the broader society. So far, research on these topics at the aggregate level has mainly focussed on Europe and the United States (US). Comparisons of intergenerational transfer regimes are usually made between welfare states in Europe, while productive ageing is a US-centred concept that is not necessarily translatable to societies with different socio-cultural characteristics. In addition, only a few studies of individual-level relationships link intergenerational family transfers with older adults' participation in economically productive roles. This thesis addresses the gaps in the literature cited above with four empirical papers on intergenerational support, productive ageing and the interrelations between them in a cross-national comparative perspective. I use data from the Survey of Health, Ageing and Retirement in Europe, the Korean Longitudinal Study of Ageing, and a conjoint survey experiment. In the first paper, I compare transfers of financial, practical and coresidential support between parents aged 50 and above and their children in Italy and South Korea, two countries with similarly familistic approaches to welfare but different levels of social protection towards older adults. The second empirical paper develops a method for weighting and aggregating indicators into a composite scale based on a conjoint experiment on experts, which I use to compare operationalisations of productive ageing between a group of Italian and a group of South Korean academics. In the third paper, I compare the factors associated with participation in paid work and informal caregiving among middle-aged and older Italian and South Korean parents, focussing on the role of socioeconomic status and transfers of support with adult children. In the fourth paper, I study the association between daily grandchild care and grandparents' labour supply in Europe with a focus on gender and socioeconomic differences. Overall, the findings highlight the role of country-level policy and culture as well as gender, socioeconomic resources and family transfers in influencing older adults' contributions to welfare and the economy.

Exercise interventions are effective in preventing falls, however, few have involved people living with dementia and explored their experiences. The aim of this PhD thesis was to fill this gap by exploring the experiences of dyads (formed of a person living with mild-to-moderate dementia and their informal carer) taking part in a Tai Chi intervention program, including class and home-practice. Participants' acceptability of and adherence to the Tai Chi intervention was studied alongside the Intervention Pilot Phase (3/4 weeks long) and the Randomised Controlled Trial Phase (20 weeks long) of the TAi ChI for people with demenTia (TACIT) Trial respectively, to inform how to enable their sustained participation in this exercise intervention. Participants recruited from localities in the South of England's experiences were explored using qualitative methods. These included field notes (at both phases) to record researchers' observations during the classes and participants (n = 10 dyads and n = 22 dyads, respectively) and instructors' feedback at the end of each class, 2 focus groups (n = 7 dyads, 1 at each site in the Pilot Intervention Phase) and 15 dyadic interviews (in the Randomised Controlled Trial Phase). Thematic analysis was used to inductively code the field notes and transcripts, which were then deductively linked to theory. Findings suggest that a dementia friendly approach to the design of the intervention based on repetition and individualised support enacted participants' enjoyment and mastery of Tai Chi. Dyads discovered a new common activity and valued the importance of incorporating home-practice into their routines. Facilitators of adherence to the intervention point towards participants' enjoyment, perceived impact on well- being, social interactions with people in a similar situation and qualities of the instructor. Main adherence barriers to the intervention were difficulty following the booklet provided to support their home-practice, as well as unexpected or recurrent health problems and competing commitments. In conclusion, people living with dementia and their informal carers could benefit from getting involved in a Tai Chi exercise program. Programmes that provide opportunities for practising Tai Chi in class and at home could provide a normalised shared interest to support communication, well-being, and quality of life.

The ageing population and predicted increase in the number of people with long-term conditions (LTCs) presents a challenge to healthcare systems when faced with demands to provide more cost-effective and sustainable services. Optimising citizens' health and wellbeing (HWB) could offer an efficient way to provide holistic care; however, it is not clear as to how to achieve this. This thesis demonstrates how my publications have helped to contribute to knowledge within the HWB arena for older adults and people with LTCs, and, specifically, to gain more understanding of their physical and psychosocial health needs and models of care that can promote their HWB. To offer context to these publications, this thesis provides a critical review of the relevant theory. This includes an appraisal of healthcare policy to highlight the issues faced by current health services, drivers for change and approaches to models of care. The concept of HWB has also been deliberated including a critical evaluation of its role in relation to healthy ageing and the wellbeing agenda. Six publications are contained within this thesis and, as a collective, reflect a mixed methods research design as they involve interviews, a focus group and surveys. The final publication, a theoretical paper, is an amalgamation of all the research findings discussed within the context of a critical review of the literature and linked explicitly to the physiotherapist's role in long-term condition management. The findings of the publications are from insights gained from the perspectives of people with LTCs, though, mainly from those with neuromuscular disorders and mental ill-health, as well as older adults. The publications' findings demonstrate the capacity of voluntary, community and social enterprises (VCSE) to provide integrated care that meets the holistic needs of those who access them whilst, potentially, addressing the social determinants of health. They also highlight the necessity for supporting people with LTCs to improve their life circumstances through their own personal empowerment. This includes the ability to facilitate their readiness to take on the responsibility with partnership working between the individual and the healthcare worker and psychological support when needed being identified as key. Developing the person's social skills and aptitude to build interdependent relationships have been determined as the ultimate goal to enhance capacity for community engagement and further access to HWB resources. The publications' findings also show that capitalising on the power of social networks to foster older adults' adherence to community physical activity (PA) groups may promote HWB and, thus, the ability to age healthily. It was also found that if older adults become embedded within the PA group's network they could shape the environment to fulfil their own needs. In addition, the findings advocate the necessity for a transformation in physiotherapy practice including enhancing the physiotherapists' role as health promoters. It is proposed that only by doing so; they can remain contemporary and continue to support the optimisation of the HWB of older adults and people with LTCs. Further to the publications, this thesis comprises a critical commentary that includes how VCSE can support healthcare services by promoting the HWB of people with LTCs and older adults. Finally, this thesis culminates in a critical discussion of the implications, for practice and policy, of the findings from my publications, with recommendations for further research.

In common with other developed countries, the UK population is ageing with today’s older workers facing pressures from greater financial stress. Reasons for this include changes to pension systems, increased longevity, and an increasing need for informal care provision. Understanding the retirement transition and different retirement outcomes is important for older adults themselves as well as for policy makers and organisations seeking to provide support to those forced to work well beyond traditional retirement ages. In this thesis, the English Longitudinal Study of Ageing dataset is used to investigate which segments of the ageing population are susceptible to experiencing lower subjective wellbeing in the retirement transition. It includes two studies: Firstly, informed primarily by social capital theory, it highlights the disparities in social connectedness between older workers receiving no pension, ‘bridge employees’ (working in a reduced capacity whilst in receipt of a pension) and those fully withdrawn from the labour market as well as the significance of close and supportive social networks in improving subjective wellbeing and reducing social isolation. Study two then focuses on the importance of the wider contextual landscape surrounding the retirement transition. It does so by including a second series of data analysis that focuses on a much narrower band of ages. Study one’s findings suggested that the significance of the effects of social capital on subjective wellbeing are dependent on labour force participation. For adults fully withdrawn from the labour market, social capital has a bigger positive effect on wellbeing than for workers not receiving a pension. Furthermore, bridge employees and workers with no pension experienced similar effects on wellbeing when it came to social capital and that bonding social capital had a bigger positive effect on subjective wellbeing for fully withdrawn adults than the bridging type of social capital. Study two’s findings suggested that resources older adults have to draw from are not only important in determining life satisfaction but also that they are shaped by the wider societal, political and economic contexts. The thesis then concludes with a detailed discussion on the theoretical and practical implications of the study’s findings and how these results relate to extant literature. In particular, it highlights the importance of better access to volunteering opportunities and social activities and services. In addition, providing work-based incentives that promote the development of social capital could improve retention of older workers, therefore keeping their experience and unique skillsets with the organisation. Also discussed is the importance of understanding contextual issues when policies relating to older workers are formulated and implemented.

Rehabilitation potential is the potential of an individual to benefit from interventions which aim to optimise and restore function after a period of ill-health or new onset of disability. Health professionals are frequently required to evaluate this potential to determine who may be most likely to benefit from the provision of ongoing rehabilitation services. This doctoral study explored decision-making related to the assessment of rehabilitation potential of older people in hospital and the recommendation of rehabilitation pathways. To explore this in real-time, and in the shared patient and professional context in which decision-making occurred, principles of ethnographic and case-study research were utilised. The case study site was one acute medical ward within a local acute hospital in the North East of England. Three phases of fieldwork were undertaken, including a 2-week orientation and mapping phase, an 8 week period centred on the practice of occupational therapists and physiotherapists in relation to five patient cases, and finally a phase which involved five in-depth interviews with individual health professionals. Data was generated through observation, interviews and the review of clinical records. The whole data-set was analysed using thematic analysis. Key findings highlight that rehabilitation in this context was understood as a process to facilitate physical improvements and associated with an organisational aim for optimum safety rather than optimum function. And, although idealised as a phase of care, rehabilitation was often linked to a specific place, with the evaluation of rehabilitation potential subsequently linked with a hospital transfer. Furthermore, rehabilitation potential was ambiguous and poorly explained to patients and families. Health professionals recognised that their evaluation of rehabilitation potential was linked to high-stakes decisions about access to, or withholding services, and therefore the ethical dimensions of this decision had far-reaching influence. The involvement of the older person in judgements about rehabilitation potential and pathways was minimal, and there were many critical challenges to older people receiving fair and just access to services. The research findings conclude that there are significant tensions between the context of acute hospital care and the philosophy and ideals of rehabilitation. Furthermore, findings can assist professionals to recognise and reconcile tensions in practice and to move towards reframing rehabilitation to place the individual needs of older people at the centre of service delivery.

This thesis aims to develop a better understanding of the livelihoods of older people in rural Thailand. It asks whether their involvement in socio-economic activities in their daily life enable them to maintain their livelihoods, highlights implications for Thai government policy. Drawing on a combination of the sustainable livelihoods framework and the gender perspective, the thesis examines the multiple activities performed by older men and women and analyses the factors affecting their engagement in these activities, and their access to different types of capital. The primary data is from 2 phases of fieldwork in a village in the North of Thailand, where 22 focus groups, 69 interviews and community maps and transect walks were conducted with the elderly. Further interviews with 75 carers of the elderly were conducted during the 2nd phase of fieldwork. The thesis highlights the broad range of socio-economic activities at household and community levels in which older men and women engaged, including agricultural and non-agricultural activities for the purpose of generating income and reciprocating or supporting family members and others. These activities enable older men and women to maintain their livelihoods despite of insufficient state support. They also reveal that family support is somewhat not the main support that it is commonly assumed to be in Thai culture, and that older people often continue to support their offspring and family members financially and non-financially. Older men are more likely to provide financial support, reflecting their roles as household leaders who are responsible for financial matters, whereas older women are more likely to provide support that is based on domestic work. Older men’s perspectives of involvement in activities are much focused on income generation, which makes it difficult for them to adapt in later life, situation when they may have to stop or decrease working. Older women are more likely to engage in domestic work and assist their spouses in farming. Both older men and women are willing to engage in any community activities, which in return provide them a link to cultivate other types of capital in maintaining their livelihoods. Therefore, ageing policy should take into account gender differences, the variation in livelihoods of the elderly, and the capacity of the community.

The intended outcome of a third sector telephone housing options service focusing on specialist housing is to empower older people to reassess their home environment. However, there is no existing academic research in this area. In an original contribution to knowledge, this study addresses the question: How, why, for whom and in what context is a third sector telephone I&A service efficacious in relation to instilling empowerment in older people considering specialist housing? This thesis takes a realist philosophical perspective and realist evaluation approach (context-mechanism-outcome configuration - CMOc). Key methods include a focus group with service advisors (to develop programme theory), access to the service setting, analysis of imparted information and realist/semi-structured interviews (n=31) with older information-seekers (n=16) one month (n=16) and four months (n=15) after engaging with the service. Tenure and access to deliberative networks are key areas of context. Against a backdrop of a shortage of specialist housing and subsequent complex conditions, those in private housing (mostly owner-occupiers) tend to seek empowerment. Social tenants, limited to a system where a low priority, already have experiential knowledge and seek accessible alternatives. It was common for participants to trust the service relative to negative prior experiences. Yet, in the majority of CMOc (n=8) outcomes tend to reflect an inability to act (social tenants) or uncertainty (mainstream residents) – the latter triggered by mechanisms such as apprehension. A key finding was that many information-seekers sought, desired or used the interviews for more substantive discussion. The current UK market and structure of I&A provision, both hampered by neo-liberal influences, are not conducive to older people reassessing their home. Firstly, this research further underlines the need to increase the supply of specialist housing. Secondly, this study challenges established thinking where information, and not the relational elements of substantive deliberation, is assumed to empower.

Older adults exhibit marked declines in navigation skills; these difficulties become worse if individuals are showing early signs of cognitive impairment, which often results in disorientation, particularly in unfamiliar environments. Many of these individuals eventually face the challenge of having to learn their way around new surroundings e.g. with potential increased visits to hospitals or when moving into retirement housing or care-home environments. This PhD thesis aims to develop a clearer understanding of older adults’ route learning and route knowledge when learning routes through built environments. To gain a more complete understanding of the experiences typical and early atypical ageing adults encounter, I adopted a mixed- methods approach. Chapters 3, 4 and 8 report on data following a quantitative experimental psychology approach to measure route learning and route knowledge in virtual and real environments, whilst Chapters 6 and 7 report on data using a qualitative approach to data collection and analysis to gain an understanding of the lived orientation experiences people living in and visiting retirement settings encounter. The findings from the data chapters are discussed in relation to existing theory and literature surrounding the effects that typical and early atypical ageing has on the abilities to learn and remember routes. In particular this thesis contributes towards the understanding of how typical and atypical ageing affects route learning and route knowledge, and how the findings can be applied to critically improve the suggestions made in dementia friendly design guidelines. The thesis concludes that simplistic VR environments do reliably capture real world navigation performance, but are additionally beneficial in that they detect the earliest symptoms of early atypical ageing more so than real world navigation. This can have benefits in detecting and diagnosing early atypical ageing in a clinical setting.

Objectives The research objectives were to: 1) explore barriers to primary care access for socio-economically disadvantaged older people in rural areas; 2) develop an intervention to improve access for this group; and 3) test the feasibility of the trial design and intervention. Methods A mixed method design, drawing on realist principles and guided by a triangulation protocol, was used to explore barriers for this group using three studies: first, a realist review; second, a qualitative study of semi-structured interviews with older people and focus groups with health professionals; and third, an analysis of the English Longitudinal Study of Ageing using structural equation modelling (SEM). Findings were integrated using a mixed method matrix. Two strong themes from the integrated theory, the booking system and transport, were identified for intervention. Based on stakeholder dialogues with health professionals and patient representatives, an intervention was developed which was explored in a cluster feasibility trial. The intervention allowed practices to develop their own service changes assisted by a £1500 grant, four development meetings and support manual. The feasibility trial recruited four general practices, with three randomised to intervention and one to usual care. Findings The realist review generated a seven-step patient pathway highlighting important contexts and mechanisms. The qualitative study explored barriers, such as engaged telephone lines and limited appointments, and proposed the concept of a social contract, where patients are careful not to bother the doctor in return for goodwill. The cohort study was restricted by limited data but demonstrated the potential of SEM to quantify realist theory. Participant recruitment in the feasibility study was low (3%), but retention was good (91%) and data collection methods acceptable to participants. Practices were successfully able to develop their own service changes that gave them the freedom, time and resource to be innovative or provided an opportunity to implement existing ideas. Conclusion Some vulnerable older people face multiple challenges in accessing primary care. Practices were able to develop their own context-dependent solutions to address local issues.

This thesis investigated the role and purpose of generalist English day centres for older people, a largely ignored and under-researched part of social care that has been affected by changing policy, practice and funding contexts. Using mixed methods within an embedded multiple-case study design, this thesis paints an in-depth picture of four day centres. It reports perspectives of four participant groups (n=69), gathered in 2015-16 by interview and standardised measurement tools: centre attenders, their family carers, day centre personnel and local authority adult services staff. Findings illustrate the diversity of day centres and challenge assumptions concerning their continued relevance by evidencing that outcomes for their mainly housebound and socially isolated attenders, family carers and centre volunteers are precisely those targeted by social care and health policy. Centres were communities that ‘enabled’ and offset loss or isolation, thus supporting ageing in place through wellbeing. They promoted wellbeing in (younger) older volunteers, provided job satisfaction, supported carers and contributed something unique to their attenders’, volunteers’ and staff’s lives. Findings from the completion of the Adult Social Care Outcomes Toolkit indicated attenders’ and carers’ quality of life improvements were directly attributable to day centres. By monitoring attenders’ health and wellbeing and providing practical support, information and facilitating access to other services, centres offered added value. Fundamental to outcomes were the group environment and continuity that centres provided. Attenders’ experiences were mainly positive, but were sometimes negatively affected by increasing proportions of cognitively impaired attenders. Mainly, day centres were not stigmatised, but awareness of them before attending one was low. The study identified the potential for development and optimisation of day centres to maximise the impact of health and care services; partnership working with these, and with community organisations, were variable. Implications for policymakers and practice are made and recommendations for further research provided.

This research reports the findings of a multi-method study which explored how older people use new technologies to help with loneliness. A central concern is a 'loneliness paradox'; namely that despite the greater opportunities that exist for social contact using new technologies, loneliness persists among older people. Older people were defined as those 65 and over and new technologies were defined as computers, laptops, smartphones and tablets that combine both personal and mass broadcast communication. A multi-methods approach was used in this study, which involved a self-completion survey (paper or online) and semi-structured interviews. The fieldwork was undertaken between November 2015 and May 2016 using a purposive sampling procedure. Older people were recruited through working with charities, peer groups and social care organisations in a diverse conurbation (East Midlands UK) both in urban and rural locations. Visits were undertaken to day services, lunch clubs, social groups and residential care homes. Thirty semi-structured interviews were undertaken with a cross-section of older people and 126 self-completion questionnaires were returned. The research explored three areas: uses of new technologies by older people, whether they made any difference to loneliness, and the experiences of loneliness in the context of increasing use of new technologies. The study found that new technologies were used by older people to make social contact. However, this contact did not always help with loneliness. Further exploration of the experiences of loneliness highlighted a new framework to understanding loneliness and new technologies through the idea of four Modes of Loneliness (Existential Loneliness, Comparison Loneliness, Loss Loneliness and Alienation Loneliness) and three strategies for utilising new technologies to help; social contact, distraction and therapy. Case studies were used to highlight this alternative approach and to demonstrate how new technologies can be seen to help with loneliness for older people.

The phenomenon of elder abuse is of growing social concern worldwide and yet remains a relatively under-researched and under-theorised area. This is particularly the case in Hong Kong where elder abuse has only recently received any official recognition and is portrayed in a narrow and sensationalised way in public media. To compound matters Western concepts of elder abuse have been adopted and applied in a largely uncritical manner. The study described in this thesis explored perceptions of elder abuse amongst community dwelling older people and health and social care professionals in Hong Kong. The aim was to develop a culturally relevant conception and knowledge of elder abuse to further understanding and to suggest new approaches to addressing elder abuse. Applying the principles of constructivist grounded theory in this study, data were collected using in-depth interviews, vignettes and focus groups. Analyses revealed that participants used a number of subtle and often implicit processes when deciding if a behaviour was abusive. This involved ‘evaluating’ the behaviour against a set of ‘expectations’ to determine if it was potentially abusive or not. If it was seen as potentially abusive then efforts were made to try and ‘explain/excuse’ the behaviour. If it could not be ‘excused’ then professionals usually ‘exposed’ the abuse whereas older people often chose to ‘endure’ the abuse to avoid a potential ‘loss of face’. These differences in perceptions of abuse, and responses to it, between older people and professionals were largely as a result of how older people adhered to traditional Chinese cultural values, especially filial piety. Based on the results, a ‘contextual’ theory of elder abuse was developed. This suggested that if elder abuse is to be better understood then consideration has to be given to the interactions between six contexts: the individual; the relational; the community; the caregiving; the cultural and the societal. The thesis concludes with an overview of the actions that need to be taken in each of these contexts if new approaches to addressing elder abuse are to be developed.

Health disparities among older adults are multifactorial. Risk factors are embedded from a matrix of biological, social, psychological, and contextual exposures, accumulated across the life trajectory. Sociologists have to date almost exclusively focused on the social aspects of health and overlooked biological and genetic potential, leading to estimation bias of social factors. Moreover, the majority of research examining the link between health and socioeconomic status (SES) seldom presents a causal inference. A knowledge gap also exists between the West and China. While there is a well-established relationship between SES and health among older people in Western societies, the SES-health gradient has not yet been established in different social and historical context. The three independent essays in this thesis adopts a biosocial approach integrating life course perspective and fundamental causes theory, in order to bridge the disjointed knowledge on contextual, social and biological influences on health, measured by objective indicators of biomarkers and cognitive ability. I use data from the China Health and Retirement Longitudinal Survey (CHARLS) and the Health and Retirement Study (HRS) from the US to tackle the following three research questions:1) How do macro level contextual factors and individual socioeconomic status influence health in China? 2) Is the well-established relationship between socioeconomic status and health causal? 3) How do genetic factors moderate demographic and socio-economic effects on the decline of cognitive functions? The key findings are: first, the individual level SES-health link is consistent across China and the U.S among the older population. Provincial variations in economic development, income inequality, and health infrastructure are associated with a range of health outcomes for Chinese midlife and older adults. Second, genetic risk score helps to identify a causal educational effect on health. Third, the genetic effect of education changes with age and across cognitive domains among the HRS sample.

This case-study research report explores “active older people participating in creative dance”, implications and benefits for individuals and society and ways people from different work sectors, organisations and academic disciplines can work together. The research period March 2011 – 2016 includes social/political contexts where financial recession, demographic change and the ageing population require new solutions to meet local and national challenges. The research’s four phases involve new work and research with increasing reflexivity between them benefitting practice and informing the research. There are three aspects of inquiry: older people who have chosen to dance at this stage of their lives, my work practice and desk-top research including social gerontology, dance, community development, boundary-spanning, image, connectedness and spirituality. The research adapts overtime, benefitting from my varied positionalities as an older person and dancer having access to others choosing to dance, using skills and expertise from my previous teaching and management careers and voluntary work to new evolving work activities. This includes founding/managing a local grassroots older people’s creative dance organisation, performing dance, local and national networking and advising. The research includes conversations with some dance-providers and decision-makers in addition to in-depth phenomenological conversational interviews with eleven non-professional older dancers. Examples of the older dancers’ narratives bring new insights and vibrancy to the research. Their texts were carefully transcribed, then using NVIVO 10 software, analysed and interpreted. Emerging topics interweave with other data and evidence from literature and new reports, autoethnography, observations and live evidence from work activities. Self-designed models, tools and matrices give the research underpinning structures and ways to analyse, interpret and synthesise the different data. The research becomes an analytical, reflexive, creative “dancing-journey”. Topics emerge from themes involving individuals, active older people, dance, especially creative dance, participation, images and challenging perceptions. It increasingly becomes multidisciplinary with transdisciplinarity (Gibbs & Maguire 2015; Nicolescu, 2008). The results include fifteen findings and ten recommendations. Relevant terminology for those aged 50-105+ years is lacking, and they are not one cohort but individuals and groups with different life-styles and needs. Ageism needs to be actively challenged. “Active older people’s creative dance” is becoming mainstream and more dance choices need to be available. Decision/policy makers need to consider dance activities seriously because dance contributes to many older people becoming involved in arts, leisure and cultural activities and having better health and wellbeing in later life. Collaboration between different factions of the dance world will give dance more recognition and a stronger voice. More age-friendly environments are needed with dance being available for all who want to participate. Grass-roots organisations and independent dance-artists/facilitators require support and resources. Boundary-spanning and joined-up thinking across organisations encourages new solutions to be found to meet some 21st century issues. Dance challenges perceptions about ageing, contributing to understanding, connectedness and spirituality and brings people together. This work-based research makes a timely contribution, bringing together older people’s voices, work-based practice, theory and learning to create new knowledge that can inform future research and practice, whether large or small scale.

An ageing population is a challenge faced by many developed and developing countries. By understanding the needs in health and well-being of the elderly governments can ensure policies and services are as efficient as possible, in order to provide the best care amidst growing demand. The thesis analyses categorical data from the English Longitudinal Study of Ageing (ELSA) and Brazil’s National Household Sample Survey (PNAD) to form measurement models for aspects of health, economic well-being and subjective well-being in the elderly, in England and Brazil. Applying structural equation modelling (SEM), a measurement model for health and economic well-being in both countries was constructed using categorical variables from the survey data, as well as for subjective well-being in England. For health the variables represented self-reported morbidity and functional status, while for economic well-being variables represented housing quality and durables owned within the household. Psychometric measures of satisfaction with life, quality of life, loneliness and depression constituted subjective well-being. Based on empirical evidence from exploratory factor analysis (EFA), the latent structure of each aspect was defined. Multilevel structural equation modelling was applied to the PNAD to capture the hierarchical structure, whereby individuals were clustered by household then the households were clustered by sector and the sectors clustered by municipality. Meanwhile, the longitudinal dynamic of the ELSA allowed for a multivariate latent growth modelling, using multiple indicators to model the trajectories of subjective well-being in multiple aspects. Health and economic well-being were positively associated in both countries. Metabolic health was a factor that was identified in both England and Brazil, while musculoskeletal health was identified only in Brazil. In England, economic well-being had two separate factors relating to the inside and outside of the household. Health and household quality significantly influenced subjective well-being, but not neighbourhood quality, with better health and economic wellbeing associated with greater subjective well-being. In the multilevel SEM a different structure of latent constructs was identified for the health of the sectors of elderly individuals, and the variables had different priorities. In both countries, health was significantly better for men, but worse for those of non-white race and with older age. Regional disparities were also present in health and economic well-being. In Brazil, economic well-being was worse with older age, in rural areas, male gender and non-white race. In England, economic well-being was better for older age with no difference between the genders and races. Subjective well-being was persistently better for men and those that were married, while being persistently worse for those of non-white race or divorced/separated marital status. Those that were widowed recovered from initially lower subjective well-being. Marital status was highly influential to the subjective well-being of the elderly with significant impact from becoming divorced or widowed and benefits from getting remarried.

Research has shown that loneliness and social isolation have a significant negative impact on the physical and psychological health of older adults living in the UK, impacting not only on their quality of life, but on society as a whole through increased use of health services. There is a movement, however, that is committed to alleviating loneliness in older adults through befriending: where an unrelated volunteer gives their time to provide companionship on a regular basis to an individual in their own home. Drawing on the author’s personal experience as a befriender, there is an emotive and affective dimension to caring, that is often contradictory and conflictual, and that is missing from the current, predominantly descriptive qualitative literature in this area. Applying psychoanalytic concepts to sociological and psychological research, specifically the free association narrative interview technique (Hollway and Jefferson, 2000) and using transference and countertransference to support analysis and interpretation, produces data that contradicts previous views of the volunteer as rational, intentional, and coherent in their understanding and explanation of their own behaviour. This study has shown that the befriending experience is highly affective and often conflictual, producing similar anxiety that the both the befriender and the organisation through which they volunteer strive to alleviate. There are conflicting tensions between caring and sacrifice and in between being a friend but in fact restricted in the ‘behaviours’ that constitute this friendship. A richer understanding of the experience of befriending, from the point of view of the befriender, can help support organisations in the recruitment and retention of volunteer befrienders, as well as helping to develop further befriending services for older people based on this new knowledge.

Later life loneliness is a major social issue as it is increasing alongside an upward global population trend which predicts that nearly 22% of the world population will be aged 60 years or over by 2050. This ‘silver tsunami’, an unparalleled growth of the older population, will exert socioeconomic pressure globally on healthcare, housing demand, consumer segmentation, etc. This thesis suggests that currently there is an underrepresentation of radical innovation, and underutilisation of digital technologies in developing loneliness interventions for older adults, and argues that due to the unprecedented nature of this demographic surge, we cannot rely on conventional ways of thinking and doing things. This thesis proposes a theoretical framework called Social Innovation for Active Ageing (SIFAA), as a way to develop more radical-digital loneliness interventions. SIFAA blends social innovation and activity theory of ageing and in doing so, expands current knowledge in both areas. To highlight the strengths and limitations of SIFAA, this thesis uses a triangulated approach, and discusses findings from a systematic literature review, interviews with experts, and an action research based trial. While the 196 loneliness interventions examined in the systematic literature review highlight the current gap in knowledge represented by a lack of radical-digital loneliness interventions, the interviews with 9 experts emphasise possible reasons for this gap. The action research based trial carried out during 16 weeks of ethnographic fieldwork on the other hand, offers practical insights into operationalising SIFAA to conceive and implement a radical-digital loneliness intervention for older adults. This thesis also highlights the vital role that digital technologies can play in facilitating the development and implementation of radical loneliness interventions. By suggesting the hybridisation of social innovation and activity theory of ageing, this research argues that a contextual view be adapted to design suitable loneliness interventions for older adults, such that the ageing population becomes a part of the solution, and not just the problem. This thesis suggests that by using creative tools and techniques, designers can either help develop new radical-digital loneliness interventions, or transform or scale existing interventions such that they represent radical innovation, and utilise digital technologies. It offers a framework utilising SIFAA that uses the tools and techniques developed during this study to deploy radical-digital loneliness interventions. The discussion herein is aimed at making a positive contribution to the field of developing, implementing, and evaluating non- pharmacological loneliness interventions for older adults.

The recognition of abuse and neglect of vulnerable adults is a relatively new phenomenon. In the academic community adult protection research has received sparse attention. A decade of commentary by researchers, practitioners and campaign agencies indicates a general consensus about the confusing and ambiguous nature of the term 'vulnerability'. A few studies have drawn attention to confusion over what constitutes vulnerability, noting the lack of clarity over definitions. Fewer still have sought to elicit the views of staff on applying this concept. This study explores what signs of vulnerability professionals in human services employ when assessing the risk of abuse/exploitation to adults and what contextual factors or operators have a bearing on their conceptualisation and subsequent responses. Additionally, it explores how the findings and recommendations of Serious Case Reviews (SCRs) could be understood in the light of this. The study exploits the researcher's insider position, giving voice to practitioners by describing and interpreting the conceptualisation of vulnerability from the perspective of current police officers, health or social care practitioners working in safeguarding adults practice. A mixed qualitative methods design was used including document analysis, focus group discussions, individual interviews and direct field observations of practice. The demographic and thematic analysis of SCR reports provided another layer of data. It is argued that professional conceptualisation of vulnerability to abuse is highly differentiated, identifying characteristics which fall into 3 domains. These relate to an adult's personhood (Character), their Circumstance (Context) and the Conduct or Condition of persons who exploit them. Characteristics of these categories included inability to understand, inability to communicate, inability to protect oneself, neediness and reliance on others, lack of relationship skills, and the status of being cared for. Despite this differentiated concept of vulnerability professionals described constraints acting upon their understanding, and their authority and autonomy to act. These organisational constraints served to reduce the shutter size on the lens of practitioner gaze on vulnerability. With reference to Lipsky's model of Street Level Bureaucracy and use of discretion, it is argued that the constraints on professional response to vulnerability are a function of criteria in law and policy, and the legitimised work by employers. This thesis argues that to understand the findings of SCRs and implied criticism of practitioner understanding of vulnerability, there has to be an understanding of the context and other influences on decision making in practice. It suggests description rather than definition of vulnerability to policy makers to liberate professionals from criteria driven decision making. This approach concurs with the views of Judge J Munby (2006) who was careful to avoid a definition of a vulnerable adult and emphasised that the characteristics outlined were 'descriptive, not definitive: indicative rather than prescriptive'.

Wales has an increasing number of older people, who typically have complex healthcare needs, and a diminishing pool of family members available to provide informal care. Care & Repair Cymru are funded by Welsh Government to facilitate independent living at home and their Caseworker service plays an important role in achieving this. However, to date there have been no empirical studies that have examined the individuals who deliver the Caseworker service. The rationale underpinning this research is to fill a knowledge gap about how Caseworkers are acting as link agents to facilitate independent living for older people ageing in place in Wales. It is grounded in a policy context of welfare retrenchment and the promotion of partnership working. An exploratory sequential mixed methods approach was adopted to examine the patterns of interactions between Caseworkers across Care & Repair Cymru agencies in Wales, their professional links with external organisations and the relationships they develop with their clients. Data was gathered from four study populations using self-completion questionnaires, individual face-to-face interviews and focus groups. Social network analysis, bivariate statistical analyses and thematic analysis were used to map and interpret data. In sum, the thesis found that Caseworkers represent a highly specialised workforce, playing a key role as link agents in facilitating independent living for older people who live at home. As an interpretive framework, social capital, human capital and emotion work theories help us to understand the sum of competencies that Caseworkers have developed and draw upon to work collaboratively in achieving this objective. Findings show that the context in which Caseworkers are operating (including agency location and certain issues encountered as part of delivering services) influences how they link with others to deliver services.

Low levels of physical activity (PA) and high levels of sedentary behaviour (SB) among older adults, carry considerable burdens to physical (e.g., premature mortality, chronic diseases and all-cause dementia risk) and psychosocial (e.g., self-perceived quality of life, wellbeing and self-efficacy for exercise) health. Numerous large scale interventions designed to engage physically inactive older adults have shown the potential that interventions guided by theoretical frameworks, consider implementation at scale across levels of the socioecological model and are designed, implemented and delivered in close partnership with stakeholders can have among this population. This thesis aimed to investigate the effectiveness of Sport England’s Get Healthy Get Active (GHGA) PA intervention. GHGA was delivered by Sefton Metropolitan Borough Council (SMBC) and was designed to engage inactive older adults in PA for at least once a week for 30 minutes. The purpose of Chapter 3 was to elicit subjective views of older adults about perceived facilitators and barriers to PA participation and to inform the design, delivery and recruitment strategies of Sport England’s GHGA PA intervention. Analyses revealed time of day, cost and social support to be key predictors in promoting PA. Sessions that avoid taking place in the early morning or late afternoon, are free of charge, and promote social interaction were also significant predictors of older adults’ PA participation. Wrist- and hip-based accelerometers are now common in assessing PA in population-based studies, however no raw acceleration cutpoints for moderate-to-vigorous PA (MVPA) and SB exist for older adults. Chapter 4 was the first to test a laboratory-based protocol using activities representative of older adults’ PA behaviours, to generate behaviourally valid, population specific wrist- and hip-based raw acceleration cutpoints for SB and MVPA in older adults. These cut-points were subsequently applied within Chapter 5, along with self-reported measures of SB, PA and health indicators, to investigate time spent in MVPA and SB, and measures of quality of life (QoL), self-rated health (SRH), self-assessment of physical fitness (SAPF), and self-efficacy for exercise (SEE). Chapter 6 addressed the main objective of the thesis which was to assess the effectiveness of the GHGA PA intervention on PA levels among inactive older adults ≥ 65 years of age. The GHGA PA intervention was effective in increasing QoL, SRH, SAPF, and SEE scores over time after adjustment for covariates. However, the intervention was ineffective in both reducing time spent in SB and increasing time spent in MVPA. As a measure of intervention fidelity, Chapter 7 evaluated whether the GHGA multi-component PA intervention was implemented as intended. Results from both deliverer interviews and session observations revealed that a high degree of intervention fidelity was maintained throughout the GHGA PA sessions within five core domains including: Study Design, Provider Training, Intervention Delivery, Intervention Receipt and Enactment. This thesis contributes to the understanding of feasible and acceptable PA strategies in older adults. Future research is needed to establish whole system-oriented multi-component community-based interventions that are effective at increasing PA levels in older adults.

An increasing proportion of people in the United Kingdom are living longer with long-term conditions. The National Health Service is facing the challenge of increased pressure on its service provision. A number of key health policy initiatives encourage individuals to make informed choices and purport to give them rights and control over their own health and healthcare. Within this context, people are actively encouraged to self-care, manage diseases, and make decisions and choices about healthcare in an informed way. To facilitate this, it is important to gain an understanding of the health information seeking behaviours of older people. Health information is available from various sources but little is known about the health information seeking behaviours of older people and what affects this. By exploring this, it helps to reveal how health information is sought regarding on-going health conditions and provides greater depth in understanding the health information seeking process. The study explores older people's experiences and views on their health information seeking behaviours and endeavours to gain a better understanding of these experiences and views. The study draws on constructivist grounded theory with two phases to data collection: Nine participants completed un-structured diaries over two months with follow up semi-structured interviews, a further twenty participants participated in semi-structured interviews. Major categories were inductively drawn from participant's responses. Strategies of health information seeking behaviours are not necessarily fixed, but subject to change over time. The analysis suggested three main categories that explained the health information seeking behaviours of older people. Three interrelated conceptual categories were identified: (1) Regulating self (2) Self managing and (3) Self-mobilisation. These categories formed the basis of the emergent substantive theory called 'navigating later life'. There were different patterns of behaviours between participants which captured variations in information seeking; these informed the development of a typology of health information seekers. Ageing in the 21st century is a complex process; with older people inhabiting a world of more choice, multiple sources of knowledge, changed healthcare roles and increased self-care undertaken within the home. The study provides important insights for healthcare professionals and raises implications for strategies aimed at improving older people's access to appropriate health information. The navigation model provides a potentially valuable tool for policy makers when considering the support older people require to self-care.

This thesis adopts a longitudinal approach towards examining the income mobility of older people aged 50 and over in England and aged 45 and over in South Korea over the period between 2006 and 2012, using panel data from the English Longitudinal Study of Ageing (ELSA) and the Korean Longitudinal Study of Ageing (KLoSA). This study of income mobility among older people points to pension income insecurity issues, which carry utmost significance when life expectancy and retirement duration are increasing. The comparative analysis brought insights into the ways in which different institutional settings may be responsible, and what policy reforms can be introduced to offset the adverse impact of income mobility on the wellbeing of older people. This research analysed the income mobility of older people using the unit of household equivalised disposable income and aggregate summary measures. The research also investigated the factors that significantly influence income mobility in old age at the microscopic level using multivariate analysis. The findings from the analysis of absolute income mobility suggest that older people in England show much more income stability than their Korean counterparts. From the relative income mobility analysis, older people in both countries experienced a low rate of change in their position in the income distribution over the measured period. In both countries, there was income rigidity among the high-income and low-income classes. The examination on what lies behind income mobility and the comparison of the determinants of income mobility in the two countries revealed that income growth has very little impact on aggregate mobility in England, while it is crucial for the mobility levels in Korea. Finally, the findings on the factors affecting income mobility of older people revealed that demographic characteristics, employment status, health status, educational level, and income attributes (welfare) are significantly associated with income mobility. A notable difference is that changes in living arrangements and a higher share of state benefits are associated with positive (upward) income mobility in Korea, whereas these factors are associated with downward income mobility in England. The transition into widowhood is associated with downward income mobility in England but has no significant effect in Korea. The empirical results highlight the benefits of cross-national comparative study on the income dynamics of older people, and how different contexts, welfare systems, and labour market affect the income mobility in later life. In Korea, the focus should be on finding the ways to expand social welfare services and income security policies so that the welfare state can be more responsive to income risk in old age. In contrast, means-tested income support policy in England should be investigated further in order to help middle-income class vulnerability in economic risks.

This thesis develops our understanding of the roles and processes underlying the co-production of public services. The co-production concept encapsulates the joint contribution made by service users and service providers to the delivery of services, acknowledging the expertise, inputs and role of service users. There has been an expanding stream of literature within the public management field focusing on co-production, recently enhanced through combinatory insights drawn from the service management literature. The thesis builds on this perspective, and addresses a current gap in understanding regarding the processes and roles that underpin the concept of co-production. In particular the research questions consider: the factors that facilitate co-production; the features of co-production that are evident within everyday service interactions; how service users and employees interact within the processes of co-production; and how these impact upon the delivery of public services at an individual level. The research for the thesis is undertaken within the context of community health and social care services for older people, at two locations in Scotland. An interpretivist, constructionist approach is taken to the inductive study which adopts a qualitative case study methodology. The research findings are drawn from semi-structured interviews with managers, older people and employees delivering services, together with observations of meetings and service interactions. Extant research has often conflated the roles of employees and public service organisations, and equal attention is rarely paid to the co-productive roles of service users and employees. The study makes a theoretical contribution by: developing the concept of active co-production; highlighting the complexities of the roles and processes underpinning co-production; revealing the different types of learning occurring within co-production; and developing a model to explicate the processes that combine the expertise of older people and employees, during the delivery of public services. On a practical level the study also highlights how more advanced and ‘active’ forms of co-production have developed, and the impact this has on the delivery of health and social care services for older people in Scotland.

This research explores what makes it possible for older members to live in intergenerational intentional communities in the South of England. These are uncommon entities within the UK; they are purposefully communally organised living arrangements adopting philosophies of mutual support. There is growing interest in intentional communities as potentially positive housing choices for later life, but no research has been undertaken exploring ageing in them. I used a Bourdesian theoretical framework, exploring the economic, social and cultural capital that individuals commonly drew on in order to become members of their community (habitus) and to live day-to-day. I enhanced this approach by incorporating theorising from the fields of housing, cultural gerontology and care ethics, contributing to debates about the use of Bourdesian methods. I used qualitative research methods: a telephone survey of 22 communities and 23 interviews with members aged over 50, within 9 communities. I found that half the communities had members aged over 60; all were intergenerational. I identified key economic differences between communities: individual-ownership models, which required individual financial investment upon entry (CoHousing) and social-ownership models, which did not (Housing Co-operatives and a squat); two were hybrid models. The social-ownership intentional communities were more open to diverse potential new members. The cost of living was often very low, though this depended on the age of the community (generational capital) and the extent of sharing by members (collaboration). Long-standing housing Co-operatives had accumulated affordability capital and represented more radical transgression of the orthodoxies of UK housing and household formation under neo-liberal capitalist conditions (practical utopias). The cost of living in the CoHousing communities was individualised and similar to conventional homeownership. The CoHousing communities were more aligned with dominant property systems, gaining symbolic power through this. Whilst participants from both types of communities shared certain dispositions and affinities (habitus), there was there was diversity based on traditional distinctions such as social or occupational class, or housing pathways. Bourdesian-type social and cultural capital were important, but in the form of alternative capital - constituted by critical thinking about conventional choices in life (reflexivity) and adoption of alternative, resistant hierarchies of cultural and social values. This enabled interviewees' agency and provided currency within the communities. It was sometimes linked to individual experiences of 1970s counter culture movements. Living in an intentional community at one point in life did not necessarily equate to a lifetime's commitment to this lifestyle - individual affiliation to a community could also be fleeting and ambivalent. Emotional work made living in all communities possible, including tolerance and adaptability. Compromise was structured into all communities decision-making to varying degrees (consensus decision-making). Interviewees considered contributing to community life, friendships, commitment and consideration of the needs of others (informal ethics of reciprocal care) important. Ageing and reciprocal relations of care were delicate matters, not spoken of explicitly in any community. Some interviewees were sure about staying in their community into older age. Most felt ambivalent. There were normative feelings about ageing, such as fears of dependency and determination to remain active (dominant discourses of successful ageing). Whilst intergenerational living was considered positive by all, some tensions were revealed. The ageing of established communities seemed to be challenging their informal and implicit value and mutual support systems. I argued intentional communities might benefit from greater acknowledgement and consideration of issues raised by ageing, to effectively support those moving into later life. By shining a light on these unnoticed, often transgressive experiments in community living, I have shed light onto taken-for-granted housing choices in the UK and to show how limited those choices have become, particularly in older age.

Modernity has brought many benefits (e.g. technological advances, material comfort, longer life expectancy and improved health). However, it is argued that we are now experiencing 'diminishing returns‘ from and 'adverse effects‘ of a Modernist worldview (Hanlon et al 2011; 2012a; 2012b). Evolutionary theories and models of paradigm change (e.g. Beck and Cowan 2006; Senge et al 2005; Scharmer 2009; Wilber 2001) offer a way of thinking about how our worldviews emerge and shift in response to existential challenges and so called 'wicked problems‘ (Rittel and Webber 1973). This study aimed to explore people‘s experiences of co-production and wicked problems in the context of care for older people in light of theoretical perspectives of evolutionary paradigm change. Method: This study adopted a parallel process of a) an instrumental case study to explore the substantive topics of co-production and wicked problems in the context of care for older people and b) the development of an analytical lens informed by concepts associated with evolutionary theories of paradigm change, through which empirical case study findings were re-interpreted. The case was an older people‘s residential care service within a Scottish Local Authority. This encompassed 11 care homes for older people. 30 in-depth qualitative semi-structured interviews were undertaken with frontline Care Workers, Care Home Unit Managers, Senior Managers and Key Theoretical informants. A constructivist-grounded theory approach was taken to data analysis to produce narratives around care, change and problems. These narratives were then re-interpreted through an evolutionary paradigm change lens. Findings: Using an evolutionary paradigm lens enabled an exploration of the underpinning worldview that is giving rise to patterns of activity and way of organising care observed in the case study. It also led to a reframing of care for older people as an existential issue rather than a conventional wicked problem. Co-production was reinterpreted as a yearning for connection, humanity and aliveness within our health and social care services in response to the dehumanising tendencies and effects of the Modernist paradigm. However, it was found that the organisational response to this yearning was rooted in a dominant Modernist way of thinking, being and doing. Instances of so-called 'horizon capture‘ (Sharpe 2013) were witnessed, suggesting that the spirit of co-production could become thwarted and subsumed within mechanistic approaches. Conclusion: An evolutionary paradigm change lens yields ideas and novel perspectives which may be of use to those in the public sector who are seeking to navigate the uncharted territories inherent to being at the edge of an emerging paradigm.

This study proposed an early psychological intervention for promoting mental health and well-being in older adults. The study is significant since there are the needs for such interventions for this age group that is becoming a major world population. The aim of this research was to investigate the efficacy of the proposed positive psychology hypnosis intervention (PPHI) in promoting mental well-being in older adults, the participants' subjective experience, and perceived changes in their mental well-being after receiving the intervention. The PPHI was developed by applying positive psychology's well-being model and theory, as well as positive psychological exercises. In addition, hypnosis was used as a delivery approach. The study examined the effectiveness of the PPHI using a randomised controlled trial involving a mixed- methods design, where the PPHI was compared to relaxation intervention and control group. The participants were generally healthy adults aged 60 and over. It was hypothesised that the PPHI would be more effective than the relaxation intervention in terms of well-being enhancement and would present significant effects compared to the control group. The data was collected via questionnaires before and after the 4- session intervention process, along with three interviews (pre and post-intervention, and follow-up). The statistical analysis employed a MANCOVA test, and interview data was analysed by thematic analysis. The findings from the research show that the PPHI is effective for enhancing older adults' psychological well-being. Moreover, the results of the PPHI are superior to relaxation, as well as present significant effects compared to the control group. The positive results presented in this study determine that the PPHI can be another option for an early or preventative intervention for older adults, particularly for enhancing happiness, well-being, and mental health.

This research explored older Slovenians’ occupations, including the ways in which the transition into a care home influenced their occupational engagement. The research encompassed three stages. Stage 1 investigated Slovenian older people’s individual experiences of occupational engagement, with a particular emphasis on their personally meaningful occupations. Stage 2 aimed to enhance understanding of the impact of transition into a care home on older Slovenians’ meaningful occupations. Finally, Stage 3 sought to provide an insight into older people’s occupational engagement in one Slovenian care home. The first two stages of this research took a phenomenological approach; focusing on the participants’ individual experiences of occupational engagement; using Interpretative Phenomenological Analysis (IPA) to approach and analyse the data. Ten older adults were interviewed in Stage 1 and six older adults were interviewed in Stage 2 at three time points: before the relocation into a care home, one month after and six months after the relocation. The final stage was ethnographic in nature; exploring occupational engagement among Slovenian care home residents as a culture-sharing group; using observations for collecting the data and analysing the resulting field notes using Thematic Analysis. The findings consistently highlighted the significance of occupations and routines in participants’ everyday lives as important parts of their identities. The first two stages highlighted the importance of a continuous experience of meaning in occupation, across participants’ lives and throughout their transition into a care home. Some of these meanings were specific to Slovenian socio-cultural, historic and geographical context. The participants especially valued productive occupations such as gardening, family-related occupations such as looking after and passing knowledge to younger generations and occupations related to particular places, such as spending time at their weekend cottages and home surroundings, walking familiar pathways or hiking Slovenian mountains. These Slovenian older adults purposefully engaged in health-promoting occupations in order to maintain their health, in turn influencing their occupational engagement. Since their everyday routines were related to particular places, Stages 2 and 3 highlighted that some of these occupations were disrupted by their new living environment. The care home residents managed this situation by trying to maintain their engagement in occupations that they perceived personally meaningful and enjoyable. This research is foundational in the Slovenian context, with the findings also being transferrable to individuals and contexts outside Slovenia. From exploring the impact of older people’s living environments on their meaningful occupational engagement, the findings contribute original knowledge to occupational science regarding the link between occupation, place, identity and the transactional perspective of occupation. This indicates the need to develop further therapeutic programmes and services for older people making the transition to care home living.

Background Exercise has well known health benefits for older people, however, for some older people with compromised health and mobility participating in exercise is challenging. Chair based exercise is a pragmatic and accessible form of exercise that may be offered in this context, however, there is a lack of good quality evidence and a lack of standardisation in delivery. Method This thesis used the Medical Research Council’s framework for the development and evaluation of complex interventions to develop a community delivered chair based exercise intervention – Progressive Assisted Chair Exercise (PACE). Multiple research methods were undertaken to develop a theoretically driven intervention with a clear rationale for how it was anticipated to work. This included an expert consensus development process, a systematic review of randomised controlled trial literature, and identification of literature on the physiological and behaviour change principles of exercise for older people. The PACE intervention was then tested in a pre and post cohort study in an NHS community service to establish the feasibility of the intervention and whether it resulted in the anticipated outcomes. The acceptability of the intervention was explored through focus groups with older people. Results Experts agreed on a set of 46 principles of chair based exercise through a Delphi technique. The systematic review of randomised controlled trials identified a lack of consistent and good quality evidence for the health benefits of existing programmes. Greater focus on the development of programmes that were underpinned by a sound theoretical framework was recommended. Using the findings from the expert consensus, the systematic review and published guidelines on exercise for older people the PACE intervention was developed to include a 12 week multi-component progressive group or home based programme delivered by a healthcare professional with the knowledge and skills of working with older people and targeted at older people who were unable to participate in standing exercise programmes. The pre and post cohort study demonstrated that the programme was feasible to deliver when tailored to account for individual preferences and the fluctuating health needs of older people. The programme was acceptable to older people when targeted appropriately at those unable to participate in standing programmes and when individual preferences and needs were accounted for. The primary criteria for success of clinically meaningful improvements in lower limb muscle strength and progression to supported standing exercise were observed. Conclusions The PACE intervention as a complex intervention was sufficiently developed and modelled to warrant formal evaluation. Further feasibility work is needed to optimise the evaluation method through a feasibility randomised controlled trial. Further development work for care home and acute rehabilitation populations is indicated.