The experience of living with age related macular degeneration:A longitudinal study into the impact of age related macular degeneration on quality of life

In this thesis I contribute to the understanding of the experience of living with Age-Related Macular Degeneration (AMD) and its impact on quality of life through the use of a pragmatically guided mixed methods approach. AMD is a condition resulting in the loss of central vision in old age which can have a huge impact on the lives of patients. This thesis includes: literature reviewing; qualitative meta-synthesis; surveys and descriptive statistics; observation; and analysis of in-depth interviewing, in order to build a picture of what it is like for older people to live with AMD. I present the findings from six separate studies each designed to answer specific research questions. I begin with a mixed methods study to determine how well the most commonly used measure of quality of life for AMD patients’ represents patient experiences. I then go on to investigate the experiences of patients with AMD through a meta-synthesis of qualitative research and finally present four of my own empirical studies three of which investigate the experiences of patients with different types of AMD: early dry AMD, treatable wet AMD and advanced wet AMD and the final study investigates what it is like for a couple living together with AMD. Throughout the qualitative studies I use Interpretative Phenomenological Analysis (IPA) to develop an understanding of the experiences and life contexts of patients with AMD. Through rigorous analysis, I identify a range of themes which highlight the shared and divergent experiences of individuals with AMD and the need to acknowledge patients’ past, present and potential future life contexts and experiences when providing services to older people with AMD. I relate the findings of the six studies to the wider psychological literature on chronic illness and make recommendations for services for patients with AMD to be provided holistically within a lifeworld-led health care model.

Regional policy variation in Germany:the diversity of living conditions in a 'unitary federal state'

The German federal system is conventionally understood as highly co-ordinated between federal and regional governments and aimed at producing a 'uniformity' of living conditions. This view has increasingly been challenged as new work focuses on innovation and diversity at the regional level, and also as a consequence of reforms to the federal system that took place in 2006. This contribution attempts to establish a more systematic basis for assessing and explaining the scope and significance of regional policy variation in Germany. Our findings suggest that - despite institutional structures that foster intense co-ordination between central and regional governments and apparent popular preferences for uniformity of policy outcomes - the extent of policy variation in Germany is much greater than conventionally understood and driven both by structural factors and partisan choices at the regional level. © 2014 © 2014 Taylor & Francis.

Encouraging the intellectual craft of living research:tattoos, theory and time

This chapter contributes to the anthology on learning to research - researching to learn because it emphases a need to design curricula that enables living research, and on-going researcher development, rather than one that restricts student and staff activities, within a marketised approach towards time. In recent decades higher education (HE) has come to be valued for its contribution to the global economy. Referred to as the neo-liberal university, a strong prioritisation has been placed on meeting the needs of industry by providing a better workforce. This perspective emphasises the role of a degree in HE to secure future material affluence, rather than to study as an on-going investment in the self (Molesworth , Nixon & Scullion, 2009: 280). Students are treated primarily as consumers in this model, where through their tuition fees they purchase a product, rather than benefit from the transformative potential university education offers for the whole of life.Given that HE is now measured by the numbers of students it attracts, and later places into well-paid jobs, there is an intense pressure on time, which has led to a method where the learning experiences of students are broken down into discrete modules. Whilst this provides consistency, students can come to view research processes in a fragmented way within the modular system. Topics are presented chronologically, week-by-week and students simply complete a set of tasks to ‘have a degree’, rather than to ‘be learners’ (Molesworth , Nixon & Scullion, 2009: 277) who are living their research, in relation to their own past, present and future. The idea of living research in this context is my own adaptation of an approach suggested by C. Wright Mills (1959) in The Sociological Imagination. Mills advises that successful scholars do not split their work from the rest of their lives, but treat scholarship as a choice of how to live, as well as a choice of career. The marketised slant in HE thus creates a tension firstly, for students who are learning to research. Mills would encourage them to be creative, not instrumental, in their use of time, yet they are journeying through a system that is structured for a swift progression towards a high paid job, rather than crafted for reflexive inquiry, that transforms their understanding throughout life. Many universities are placing a strong focus on discrete skills for student employability, but I suggest that embedding the transformative skills emphasised by Mills empowers students and builds their confidence to help them make connections that aid their employability. Secondly, the marketised approach creates a problem for staff designing the curriculum, if students do not easily make links across time over their years of study and whole programmes. By researching to learn, staff can discover new methods to apply in their design of the curriculum, to help students make important and creative connections across their programmes of study.

‘Everything’s from the inside out with PCOS’:exploring women’s experiences of living with Polycystic Ovary Syndrome (PCOS) and co-morbidities through Skype™ interviews

Polycystic ovary syndrome is an endocrine disorder affecting 1 in 10 women. Women with polycystic ovary syndrome can experience co-morbidities, including depressive symptoms. This research explores the experience of living with polycystic ovary syndrome and co-morbidities. Totally, 10 participants with polycystic ovary syndrome took part in Skype™ interviews and analysed using thematic analysis. Four themes emerged from the data: change (to life plans and changing nature of condition); support (healthcare professionals, education and relationships); co-morbidities (living with other conditions and depression, self-harm and suicidal ideation) and identity (feminine identity and us and them). The findings highlight the need for screening of women with polycystic ovary syndrome for depressive disorders.

Living together with age related macular degeneration:an interpretative phenomenological analysis of sense-making within a dyadic relationship

In this article, we present an idiographic analysis of a couple's experience of living and coming to terms with age-related macular degeneration. Interpretative phenomenological analysis was used to explore three joint interviews, conducted over an 18-month period, with a married couple (aged 82 and 77 years) both living with age-related macular degeneration. Three themes are discussed: the disruption of vision impairment, managing mutual deterioration and resilience through togetherness. We discuss the existential challenges of vision impairment and consider the applicability of Galvin and Todres' typology of well-being as a means of understanding well-being in older adults.

Living well to the end:a phenomenological analysis of life in extra care housing

OBJECTIVES: To understand older adults' experiences of moving into extra care housing which offers enrichment activities alongside social and healthcare support. DESIGN: A longitudinal study was conducted which adopted a phenomenological approach to data generation and analysis. METHODS: Semi-structured interviews were conducted in the first 18 months of living in extra care housing. Interpretative phenomenological analysis was used because its commitment to idiography enabled an in-depth analysis of the subjective lived experience of moving into extra care housing. Themes generated inductively were examined against an existential-phenomenological theory of well-being. RESULTS: Learning to live in an extra care community showed negotiating new relationships was not straightforward; maintaining friendships outside the community became more difficult as capacity declined. In springboard for opportunity/confinement, living in extra care provided new opportunities for social engagement and a restored sense of self. Over time horizons began to shrink as incapacities grew. Seeking care illustrated reticence to seek care, due to embarrassment and a sense of duty to one's partner. Becoming aged presented an ontological challenge. Nevertheless, some showed a readiness for death, a sense of homecoming. CONCLUSIONS: An authentic later life was possible but residents required emotional and social support to live through the transition and challenges of becoming aged. Enhancement activities boosted residents' quality of life but the range of activities could be extended to cater better for quieter, smaller scale events within the community; volunteer activity facilitators could be used here. Peer mentoring may help build new relationships and opportunities for interactive stimulation. Acknowledging the importance of feeling-empathic imagination-in caregiving may help staff and residents relate better to each other, thus helping individuals to become ontologically secure and live well to the end.

Measuring the influence of similarity on category-specific effects

There is evidence for both advantages and disadvantages in normal recognition of living over nonliving things. This paradox has been attributed to high levels of perceptual similarity within living categories having a different effect on performance in different contexts. However, since living things are intrinsically more similar to each other, previous studies could not determine whether the various category effects were due to perceptual similarity, or to other characteristics of living things. We used novel animal and vehicle stimuli that were matched for similarity to measure the influence of perceptual similarity in different contexts. We found that displaying highly similar objects in blocked sets reduced their perceived similarity, eliminating the detrimental effect on naming performance. Experiment 1 demonstrated a disadvantage for highly similar objects in name learning and name verification using mixed groups of similar and dissimilar animals and vehicles. Experiment 2 demonstrated no disadvantage for the same highly similar objects when they were blocked, e.g., similar animals presented alone. Thus, perceptual similarity, rather than other characteristics particular to living things, is affected by context, and could create apparent category effects under certain testing conditions.

Does normal processing provide evidence of specialised semantic subsystems?

Category-specific disorders are frequently explained by suggesting that living and non-living things are processed in separate subsystems (e.g. Caramazza & Shelton, 1998). If subsystems exist, there should be benefits for normal processing, beyond the influence of structural similarity. However, no previous study has separated the relative influences of similarity and semantic category. We created novel examples of living and non-living things so category and similarity could be manipulated independently. Pre-tests ensured that our images evoked appropriate semantic information and were matched for familiarity. Participants were trained to associate names with the images and then performed a name-verification task under two levels of time pressure. We found no significant advantage for living things alongside strong effects of similarity. Our results suggest that similarity rather than category is the key determinant of speed and accuracy in normal semantic processing. We discuss the implications of this finding for neuropsychological studies. © 2005 Psychology Press Ltd.

The cationic ring-opening polymerization of cyclic ethers

The kinetics and mechanisms of ring opening polymerization and copolymerizntion of different cyclic ethers were studied using mainly a cationic system of iinitiation. BF30Et2/ethanediol. The cyclic ethers reacted differently showing that ring strain and basicity are the main driving forces in cationic ring opening polymerizaion. In most cases it was found that the degree of polymerization is controlled kinetically via terminations with the counterion and the monomers, and that the contribution of each type of reaction to the overall termination differs markedly. The Gel permeation chromatography studies showed that the molecular weight distribution of the samples of polyoxetanes were bimodal. This was in accordance with previous work establishing that the cyclic tetramer is found in much higher proportions than any of the other cyclic oligomers. However the molecular weight distribution of the copolymers made from oxetane and THF or from oxetane and oxepane were shown to be unimodal. These observations could be explained by a change in the structure of the growing end involved in the cationic polymerization. In addition crown ethers like dibenzo-crown-6 and compounds such as veratrole are believed to stabilise the propagating end and promote the formation of living polymers from oxetane.

The polymerization of lactic acid anhydrosulphite by anionic initiators

This thesis is primarily concerned with the synthesis and polymerization of 5-methyl-1;3, 2-dioxathiolan-4-one-2-oxide (lactic acid anhydrosulphite (LAAS)) using anionic initiators under various conditions. Poly(lactic acid) is a biodegradable polymer which finds many uses in biomedical applications such as drug-delivery and wound-support systems. For such applications it is desirable to produce polymers having predictable molecular weight distributions and crystallinity, The use of anionic initiators offers a potential route to the creation of living polymers. The synthesis of LAAS was achieved by means of an established route though the procedure was modified to some extent and a new method of purification of the monomer using copper oxides was introduced, Chromatographic purification methods were also examined but found to be ineffective. An unusual impurity was discovered in some syntheses and this was identified by means of 1H and 13C NMR, elemental analysis and GC-MS. Since poly-α-esters having hydroxyl-bearing substituents might be expected to have high equilibrium water contents and hence low surface tension characteristics which might aid bio-compatibility, synthesis of gluconic acid anhydrosulphite was also attempted and the product characterised by 1H and 13C NMR. The kinetics of the decomposition of lactic acid anhydrosulphite by lithium tert-butoxide in nitrobenzene has been examined by means of gas evolution measurements. The kinetics of the reaction with potassium tert-butoxide (and also sec-butyl lithium) in tetrahydrofuran has been studied using calorimetric techniques. LAAS was block co-polymerized with styrene and also with 1,3-butadiene in tetrahydrofuran (in the latter case a statistical co-polymer was also produced).

Intellectual alienation in a fragmented society and universe, as illustrated in the work of Wolfgang Koeppen (1906- )

This text is concerned with the intellectual and social alienation experienced by a twentieth century German writer (1906 - ).·the alienation begins in the context of German society, but this context is later globalised. The thesis first discusses the social and· intellectual origins and the salient features of this alienated stance, before proceeding to a detailed analysis of its recurring symptoms and later intensification in each of the author's main works, chronologically surveyed, supported by reference to minor writings. From the novels of the thirties' showing the burgher-artist conflict, and its symbolic dichotomies, the renunciation of traditional German values, and the ambiguous confrontation with new disruptive socio-political forces, we move to the post-war trilogy (1951-54), with its roots in the German social and political experience of the thirties' onwards. The latter, however, is merely a background for the presentation of a much more comprehensive view of the human condition:- a pessimistic vision of the repetitiveness and incorrigibility of this condition, the possibility of the apocalypse, the bankruptcy and ineffectiveness of European religion and culture, the 'absurd' meaninglessness of history, the intellectual artist's position and role(s) in mass-culture and an abstract, technologised mass-society, the central theme of fragmentation - of the structure of reality, society and personality, the artist's relation to this fragmentation, intensified in the twentieth,century. Style and language are consonant with this world-picture. Many of these features recur in the travel-books (1958-61); diachronic as well as synchronic approaches characterise the presentation of various modes of contemporary society in America, Russia, France and other European countries. Important features of intellectual alienation are:- the changelessness of historical motifs (e.g. tyranny, aggression), the conventions of burgher society, both old and new forms, the qualitative depreciation and standardisation of living, industrialisation and technology in complex, vulnerable and concemtrated urban societies, ambiguities of fragmented pluralism. Reference is made .to other travel-writers.

Ecological studies on:(a) the use of colonisation samplers in relation to biological surveillance of river water quality (b) the requirements of freshwater gastropoda

Some of the factors affecting colonisation of a colonisation sampler, the Standard Aufwuchs Unit (S. Auf. U.) were investigated, namely immersion period, whether anchored on the bottom or suspended, and the influence of riffles. It was concluded that a four-week immersion period was best. S. Auf. U. anchored on the bottom collected both more taxa and individuals than suspended ones. Fewer taxa but more individuals colonised S. Auf. U. in the potamon zone compared to the rhithron zone with a consequent reduction in the values of pollution indexes and diversity. It was concluded that a completely different scoring system was necessary for lowland rivers. Macroinvertebrates colonising S. Auf. U. in simulated streams, lowland rivers and the R. Churnet reflected water quality. A variety of pollution and diversity indexes were applied to results from lowland river sites. Instead of these, it was recommended that an abbreviated species - relative abundance list be used to summarise biological data for use in lowland river surveillance. An intensive study of gastropod populations was made in simulated streams. Lynnaea peregra increased in abundance whereas Potamopyrgas jenkinsi decreased with increasing sewage effluent concentration. No clear-cut differences in reproduction were observed. The presence/absence of eight gastropod taxa was compared with concentrations of various pollutants in lowland rivers. On the basis of all field work it appeared that ammonia, nitrite, copper and zinc were the toxicants most likely to be detrimental to gastropods and that P. jenkinsi and Theodoxus fluviatilis were the least tolerant taxa. 96h acute toxicity tests of P. jenkinsi using ammonia and copper were carried out in a flow-through system after a variety of static range finding tests. P. jenkinsi was intolerant to both toxicants compared to reports on other taxa and the results suggested that these toxicants would affect distribution of this species in the field.

The anatomical and functional correlates of category-specificity

The dramatic effects of brain damage can provide some of the most interesting insights into the nature of normal cognitive performance. In recent years a number of neuropsychological studies have reported a particular form of cognitive impairment where patients have problems recognising objects from one category but remain able to recognise those from others. The most frequent ‘category-specific’ pattern is an impairment identifying living things, compared to nonliving things. The reverse pattern of dissociation, i.e., an impairment recognising and naming nonliving things relative to living things, has been reported albeit much less frequently. The objective of the work carried out in this thesis was to investigate the organising principles and anatomical correlates of stored knowledge for categories of living and nonliving things. Three complementary cognitive neuropsychological research techniques were employed to assess how, and where, this knowledge is represented in the brain: (i) studies of normal (neurologically intact) subjects, (ii) case-studies of neurologically impaired patients with selective deficits in object recognition, and (iii) studies of the anatomical correlates of stored knowledge for living and nonliving things on the brain using magnetoencephalography (MEG). The main empirical findings showed that semantic knowledge about living and nonliving things is principally encoded in terms of sensory and functional features, respectively. In two case-study chapters evidence was found supporting the view that category-specific impairments can arise from damage to a pre-semantic system, rather than the assumption often made that the system involved must be semantic. In the MEG study, rather than finding evidence for the involvement of specific brain areas for different object categories, it appeared that, when subjects named and categorised living and nonliving things, a non-differentiated neural system was involved.

What do we know about the experience of age related macular degeneration? A systematic review and meta-synthesis of qualitative research

Age Related Macular Degeneration (AMD) is the leading cause of registerable blindness with a high medical and societal cost burden. Much of the research examining experiences of living with AMD has been conducted independently with small sample sizes and has failed to impact on practice. Meta-synthesis of qualitative research can improve the understanding of the experience of living with AMD by drawing together findings of qualitative studies. This article presents a systematic review and meta-synthesis of qualitative studies investigating the experience of AMD (literature searched up to April 2012; published studies identified range from 1996 to 2009). The review highlights themes relating to: functional limitations, adaptation and independence; feelings about the future with vision impairment; interaction with the health service; social engagement; disclosure; and the emotional impacts of living with AMD. Attention to the experience of living with AMD can help us to better understand the needs of patients. This meta-synthesis aimed to bring together the findings of qualitative research studies and highlights important areas for consideration when caring for patients with AMD. Our findings suggest that a holistic approach to service provision and support for AMD is needed which takes into account individuals' needs and experiences when coping with and adjusting to living with AMD. This support should aim to reduce stigma, increase social engagement, and develop the psychological resources of patients with AMD.

Shifting accountability:a longitudinal qualitative study of diabetes causation accounts

We undertook a longitudinal qualitative study involving of 20 patients from Scotland who had type 2 diabetes. We looked at their perceptions and understandings of why they had developed diabetes and how, and why, their causation accounts had changed or remained stable over time. Respondents, all of whom were white, were interviewed four times over a 4-year period (at baseline, 6, 12 and 48 months). Their causation accounts often shifted, sometimes subtly, sometimes radically, over the 4 years. The experiential dimensions of living with, observing, and managing their disease over time were central to understanding the continuities and changes we observed. We also highlight how, through a process of removing, adding and/or de-emphasising explanatory factors, causation accounts could be used as “resources” to justify or enable present treatment choices. We use our work to support critiques of social cognition theories, with their emphasis upon beliefs being antecedent to behaviours. We also provide reflections upon the implications of our findings for qualitative research designs and sampling strategies.