This methodological investigation set out to examine the use of the Internet as a data collection tool: its potential for sampling gay and bisexual men and gathering data on sexual behaviour. The research took place in the context of the Internet and HIV study, an examination of high risk sexual behaviour among gay and bisexual men seeking sex on the Internet. The Internet and HIV study collected quantitative data using selfadministered questionnaires completed online or by pen-and-paper, and qualitative data using one-to-one interviews conducted face-to-face or online. Its design provides an invaluable opportunity for investigating Internet-based research methods. Methodological issues were explored through collection of primary data from respondents who had participated in the Internet and HIV study and secondary analysis of data collected for the study. The first area of exploration was the use of web surveys for sampling gay and bisexual men. The results indicated that participation in the Internet and HIV web survey was driven by an altruistic desire to contribute to research into sexual health promotion and HIV prevention. Drop out was most likely to occur in the early stages of the survey and minor differences in sub-group drop out were identified. Men who participated in the web survey were broadly similar to the MSM drawn from a national probability sample, but were more likely to participate in high risk sexual activity. Differences were more pronounced when the samples were restricted to London men. The second area of exploration was the effect of the Internet mode on data collection. The web survey reduced item nonresponse in comparison to the pen-and-paper survey but did not improve response to sensitive questions over and above this general mode effect. The results indicated that online synchronous interviews may be suited to a more structured format, given the difficulty of expressing complex ideas through typing in real time. It was concluded that the Internet has excellent potential for researching sexual behaviour among gay and bisexual men. It provides effective access to this population and more complete survey data than the traditional alternative. The application of online interviewing requires further exploration.

Background: There is increasing recognition of the need for service development for patients in the advanced stages of neurological conditions. This study explores the palliative care needs of people with advanced amyotrophic lateral sclerosis, multiple sclerosis, Parkinson’s disease and related disorders, and assesses the impact of a new specialist palliative care service (SPCS) Methods:. A mixed methods approach was adopted: • a qualitative needs assessment using in-depth interviews with patients and their family carers and focus groups of professionals involved in the care of this population. • a quantitative pilot-explorative randomized and controlled trial (RCT) to assess the impact of a new SPCS designed to meet the palliative care needs of the study population – using a waiting list methodology comparing the immediate provision of SPCS with standard care . Results: • Qualitative study: 22 patients, 21 family carers and 11 professionals participated to the needs assessment. The content analysis showed a high prevalence of problems. Professionals confirmed the high burden of problems, were positive about the creation of a new SPCS and their knowledge of specific palliative care topics seemed lacking. • Quantitative study: 50 patients, with 45 carers, participated in the explorative RCT. The comparison between the groups (FT-ST) after 16 weeks revealed significant improvement for the SPCS group for quality of life and in four physical symptoms - pain, breathlessness, sleep disturbance and intestinal symptoms Conclusions: This research confirms the high prevalence of physical symptoms, psychosocial issues and spiritual themes for people severely affected by advanced neurodegenerative disorders and that these can be helped by specialist palliative care. The input of a SPCS caused a significant improvement of the individual quality of life of the patients and improved symptom control for pain, breathlessness, quality of sleep and intestinal symptoms compared to standard best care alone.

The recent introduction of open formulary non-medical prescribing has created opportunities to radically change health care delivery. This thesis is the first of its kind to document the process of undertaking an examination of NMP in a chemotherapy setting. A purposeful sample of 23 stakeholders connected with the chemotherapy service in a local cancer setting was used including 12 doctors, 5 nurses, 4 pharmacists and 4 managers. A serial data collection technique with individual interviews followed by uni professional focus groups was adopted. Finally a multi professional focus group was held to determine the strategic way forward. A systematic qualitative data management package -NUDIST was used to code and theme data and this data was used as the basis for discussion. This thesis offers an insight into the working of the multidisciplinary team in relation to NMP. It establishes the concerns and issues of the professional stakeholders as well as areas of concurrence. It charts the complexities and difficulties faced when shifting responsibilities of professionals. It has used a novel approach to engage with stakeholders from within the day to day practices of the clinic and developed a framework for monitoring agreed progress. An action oriented approach was inherent to the study and dovetailed to understand the service and concurrently create an opportunity for development. Through its insider perspective it has highlighted the complexes of changing practice and attempted to move forward using a negotiation process. The study illuminated the key features necessary to maximise success of NMP in chemotherapy clinics and captures the importance of good working relationships. Whilst different models of nurse-led practice will emerge, fundamental and core to services is the need for good team working, established and effective communication strategies and perhaps most importantly avoiding isolation in practice. This study additionally reinforced that any evaluation takes place within pre- existing political contexts and in particular medical dominance. Not all medical colleagues agreed with or wanted NMP for their patients highlighting difficulties of developing new models of working within a resisting culture. Medical dominance should be acknowledged and strategies developed to work within this dominance to ensure the unique contribution of nursing is valued and seen. Insights from this study raise the need for further research and exploration of the usefulness and acceptability of NMP in chemotherapy.

When children with cerebral palsy attend a mainstream school, their physical functioning may impact on day-to-day school activities and on their active participation. The Special Educational Needs Code of Practice (DfES 2001b) advocates a multi-agency approach to enable children with SEN to be included within the mainstream school system. Physiotherapists often work with school staff to manage the child’s physical needs within this environment and to deliver therapeutic interventions. Despite numerous government policies endorsing the inclusion of children with SEN within mainstream school, there has been little research into the detail of how this might be achieved for children with physical impairments. This qualitative study explores the physical management of children with cerebral palsy within mainstream school. In the first phase I conducted focus groups and semi-structured interviews exploring the views and experiences of parents of children with cerebral palsy, physiotherapists and school staff regarding the management of the child’s physiotherapy needs. The second phase utilised a case study approach to generate in-depth contextual knowledge of the issues faced when managing the child’s physical needs by exploring individual cases within three mainstream schools using observation, interviews and documents. Thematic analysis was used to analyse these data. Three main themes emerged from the findings of the study: how therapy and education services work together; the delicate balance to achieving participation; and how views of difference impact on the child’s management. I found that the way physical impairments were viewed within the current SEN framework, inhibited a holistic view of the child with physical impairments. It impacted on collaborative practice between agencies affecting how the child’s needs were met. I conclude that a more interactional model of viewing disability is required to ensure that the child’s needs are considered within the context of not only school but the child’s life as a whole.

The vision for maternity services focuses on women-centred care with choice, control and promoting normality at its centre, thus emphasising the need to empower women to make choices and decisions regarding their care in labour and birth. Some women will choose the medical model of care, however others prefer to be in control and choose to use non-pharmacological alternatives for pain control in labour such as Transcutaneous Electrical Nerve Stimulation (TENS). TENS has enabled the provision of non-invasive, mobile, self-controlled pain relief for women in labour and is used extensively by women in the UK who, when asked, assess it favourably and say they would use it again. Currently the available literature on TENS fails to consider individual women’s experiences of using TENS for labour and birth, this study therefore seeks to redress this balance. Set in the south of England, the study uses Interpretative Phenomenological Analysis (IPA) in order to explore the experiences of twenty purposively selected women, who were interviewed to expose their in-depth experiences of using TENS for pain control in labour and birth. The analysis of the verbatim transcripts revealed comprehensive findings ensuring an idiographic focus along with making claims for the larger group of women. In this study women used TENS as part of a combination of more natural pain control or as a ‘sole’ form of pain control for labour and birth. TENS was recognised as being part of a wider strategy for the maintenance of control in labour and normal birth for women. A super-ordinate theme of ‘control’ emerged from the data particularly relating to ‘internal control of self’, ‘external control of others’ and ‘control of the TENS machine’. Women’s positive experiences were enhanced by remaining mobile, using drug free pain control, being knowledgeable, having partners’ and midwives’ support, being distracted from their pain and trusting in TENS. By uncovering a group of women’s in-depth experiences of using TENS for pain control in labour and birth this study has filled a “gap” in the knowledge base. In addition, the findings suggest that TENS was identified as an ‘enabling mechanism’ for the women in order to be in control of a normalised birth. Women were able to maintain their independence, make decisions and actively take part in their pain control using TENS.

This research was jointly funded by the Economic and Social Research Council (ESRC) and the Engineering and Physical Sciences Research Council (EPSRC). As such, its underpinning and innovative aim was to explore the use of Operational Research (OR) techniques, a research area traditionally associated with the EPSRC, to address key societal problems traditionally associated with the ESRC. The ageing population presents many significant challenges for social care services at both a national and local level, one of which is to meet the demand for long-term care. The population of people aged over 65 will continue to grow for some time as the ―baby boom‖ generation ages. The concern for policy planners is whether there will be enough resources in place to handle the expected strain on the system in the future. The research presented in this thesis addresses this key issue, and was carried out in collaboration with the Adult Services Department of Hampshire County Council (HCC). The overarching aim of this thesis was to develop computer models (using data local to Hampshire) which would be of practical use in estimating the future demand and planning the supply of long-term care in Hampshire. A cell-based model was built to forecast the demand for long-term care in Hampshire from people aged 65 and over for the period 2009 to 2026. An important part of this research was to understand the main drivers of future demand for long-term care and to predict the future number of people with a disability. Hampshire County Council has already tried to address these issues of demographic change through a modernisation programme. Part of this has been the establishment of a contact centre called Hantsdirect. A discrete-event simulation model of the contact centre was developed. The two models were combined to explore the short- and long-term performance of the contact centre in the light of demographic change. This hybrid model has enabled HCC to explore the short- and long-term performance of the contact centre. This study combines OR with Gerontology, Demography and Social Policy. This research is novel as it iteratively combines a compartmental population model with a discrete-event simulation model. From an OR perspective, the aim was not only to explore the use of modelling in social care (where, unlike healthcare, there has not hitherto been a lot of research), but also to investigate the potential for combining different modelling approaches in order to obtain additional value from the modelling. This novel approach in a social care setting is one of the main contributions of this thesis.

Breast milk is acknowledged and recommended as the best food for babies by the World Health Organization. However, globally the proportion of mothers who breastfeed is still low and this is particularly the case in Thailand. The aim of this study is to improve women’s ability to breastfeed. A two phase study was designed. Phase I was to better understand women’s experiences and breastfeeding support needs, which formed the development of the ‘Breastfeeding Support Package’. The package, which consisted of the tool and leaflets, was to be administered by the nurses with the postpartum women. Phase II aimed to explore mother’s and nurses’ experiences following the use of the package. A pragmatic qualitative approach was used throughout. A government hospital in Bangkok, Thailand, was the setting for this research. Purposive sampling was used to recruit the participants for both phases of the study. In Phase I, semi-structured interviews of 17 mothers who visited the Family Planning Clinical, post-delivery, were undertaken. Thematic analysis was used to examine the data. For phase II, three groups of participants were involved: five participants from phase 1, five postpartum women and five nurses working on the postpartum ward. Telephone interviews were used to assess face validity to the tool while semi-structured interviews were used to investigate mothers’ and nurses’ experiences regarding the use of the package. Three themes that contributed to women’s experience of breastfeeding were ‘knowledge and attitude towards breastfeeding’, ‘practicality’ and ‘support’. Three themes that contributed to ‘women’s needs of breastfeeding support’ were ‘knowledge’, ‘attitude’, and ‘practice’. The use of the package could open a ‘platform to communication’ regarding women’s needs and act as a ‘platform to support’ for nurses. The postpartum women were able to better communicate their needs regarding breastfeeding support with the nurses, as well as receiving the support they required. The packaged worked well with present conditions and environment at the postpartum ward of the hospital.

This study investigates the experiences of South Asian women being treated for breast cancer within a British system of health and social care that recognises racialised inequalities in care and is striving to provide culturally sensitive care to an increasingly diverse population. The research was conducted in a National Health Service (NHS) Trust in an outer London suburb. It is a qualitative exploratory study based on eighteen in- depth interviews and participant observation of interactions between women with breast cancer and health care professionals. The interviews were conducted in three languages: English, Gujarati and Hindi. In examining whole person care from the perspectives of both health care professionals and South Asian women, this thesis demonstrates how ethnicity as both a category of social difference and a process of social identification can present significant challenges for holistic care at different stages of the patient pathway. The concept of othering is used to make sense of the complicated relationships between health care professionals and South Asian women and to examine the extent to which care is responsive to differences of ethnicity, culture and faith. The findings from participant observation and qualitative interview data suggest that health professionals can often reduce the complex experiences of South Asian women to cultural difference. Such thinking can serve to compromise therapeutic relationships in which mutual power sharing and decision making is inhibited. However, cultural stereotyping is not a uniform process and can be transformed in situ so that some women are able to access personalised and holistic care. Whilst recognising that the needs of South Asian are complex evidence from this study suggests that othering can be a central process through which health care professionals contribute to the marginalisation of South Asian women within health care services.

Students learning in blended learning and classroom environments benefit from social interaction and vicarious learning experience with their peers and tutors. In comparison, students learning via self-directed Web-based learning cannot benefit from these advantages and may feel isolated. This research investigates if the presence of virtual persuasive agents presented as avatars, happy images and encouraging text can provide social support similar to real peers and improve students’ Web-based learning self-efficacy (WBLSE). This research also examines if low and high fidelity virtual persuasive agents can provide social support in a similar way. This study uses Bandura’s (1982) self-efficacy theory as a framework for changing nursing students’ beliefs in using the Web for learning. The basis for including virtual persuasive agents in this research stems from the media equation theory (Reeves & Nass, 1996) which holds that Computers are Social Actors (CASA) and that people respond to Web-based media as if they were social actors. Adopting the User-Centred Design approach, a bespoke Web-based training package was developed for changing pre-registration and post-registration nursing students’ WBLSE. In a quasi-experimental design, the package was delivered in three separate studies to different groups of pre-registration and post-registration nursing students. Several important findings contributed to the WBLSE body of knowledge. Overall, the training package was found to be effective with the nursing students’ WBLSE improving equally in the intervention groups in all studies. Pre-registration students showed the greatest improvement when learning by self-direction supported by virtual persuasive agents, whereas post-registration students improved when learning in a blended setting without their support. Low-fidelity virtual persuasive agents were sufficient in providing social support for pre-registration students in self-directed settings. The implications for Web-based learning in nurse education, research and practice are discussed.

Background In 2014, 27.0% of births in England and Wales were to mothers born outside of the UK. Compared to their white British peers, minority ethnic and migrant women are at a significantly higher risk of maternal and perinatal mortality, along with lower maternity care satisfaction. Although existing literature highlights the importance of midwife-woman relationships in care satisfaction and pregnancy outcomes health professionals report difficulty in providing services to minority ethnic and migrant women. However little research has explored the factors contributing to the midwife-woman relationship for migrant and minority ethnic women. Research Aims To explore relationships between migrant Pakistani women and midwives in South Wales; focusing on the factors contributing to these relationships, and the ways in which these factors might affect women’s experiences of care. Method A focused ethnography in South Wales; semi-structured interviews with 10 migrant Pakistani participants (eight pregnant women, one husband and one mother) and 11 practising midwives, fieldwork in the local migrant Pakistani community and local maternity services, observations of antenatal booking appointments, and longitudinal reviewing of relevant media outputs, such as UK news reports of issues relating to migrant people. Data were analysed concurrently with collection using thematic analysis. Findings The midwife-woman relationship was important for participants’ experiences of care. A number of social and ecological factors influenced this relationship; including family relationships, culture and religion, differing healthcare systems, authoritative knowledge, and communication of information. However, differences were seen between midwives and women in the perceived importance of these themes. Findings therefore suggest that in order to understand how midwife-woman relationships are created and maintained, more needs to be done to recognise and address these differences. Due to the complexity of the relationships between themes a social ecological model of relationships is forwarded as a means of visually capturing the complexity of the findings, as well as potentially shaping midwifery education and clinical midwifery practices. Conclusions and Implications Findings from this study provide new theoretical insights into the complex social and ecological factors at play during maternity care for migrant Pakistani women. These findings can therefore be used to create meaningful dialogue between women and midwives, encourage collaborative learning and knowledge production, and facilitate future midwifery education and research.