Objectives To determine obstetric, maternal and fetal variables that increase the risk of postnatal urinary and anal incontinence. To establish how anal and urinary incontinence impact on Quality of Life (QoL) with particular reference to sexual psychology. Finally, to ascertain the extent of disclosure of incontinence problems to partners and health professionals. Design A longitudinal, prospective, repeated measures, cohort study using five data sources. Data was collected in the last trimester of pregnancy, at 6 weeks postnatal, 6 months postnatal and finally at one year postnatal. Setting Wirral University Teaching Hospital NHS Foundation Trust. Participants Primiparous women with no pre-existing disease (N=516). Participants were recruited after a normal 20 week obstetric ultrasound scan. Results Stress incontinence was reported by 39.7% antenatally, 28.2% at 6 weeks postnatal, 31% at 6 months and 26.5% at one year postnatal. Urge incontinence was reported by 23.5% antenatally, 21.2% at 6 weeks, 21.4% at 6 months and 16.4% at one year postnatal. Anal incontinence at one year postnatal was reported by 9.39%. Those participants under the age of 20yrs had higher rates of postnatal urge incontinence (p<.001) possibly associated with increased rates of infection in this group. BMI>30 was associated with higher rates of antenatal stress incontinence but was not significant in the postnatal period. BMI<20 was associated with an increase in postnatal urge incontinence. Prolonged periods of time in labour without bladder emptying was associated with increased rates of both urinary incontinence (OR 2.36) and anal incontinence (p=.026). Forceps delivery was associated with postnatal stress incontinence (OR 2.41). Although caesarean section appeared protective against urinary incontinence initially, long-term data show a progressive increase in reported rates of urinary incontinence even after elective caesarean section. Elective caesarean section was protective for anal incontinence. Faecal incontinence was significantly higher (OR 3.26) in the group who had their labour induced (12.1%) compared to those who had a spontaneous labour (4.6%). Perineal trauma was not associated with anal incontinence. However, it was associated with urinary incontinence throughout the postnatal year with anal sphincter disruption having the highest rates of stress incontinence (p<.005). Birth weight, duration of labour, feeding method, epidural anaesthesia and smoking were not significant. Overall, urinary incontinence appears to be a regressive condition, although the impact on QoL is cumulative and seems to increase over time. Some participants had a progressive, deteriorating condition which appears to be associated with a higher BMI or >6 hours from bladder emptying to delivery of the baby. Urinary and anal incontinence had a detrimental effect on all QoL domains. Those reporting nocturnal enuresis, pain, intercourse incontinence and urge incontinence were effected the most. The greatest impact is on the emotion domain. Only 8.7% with urinary incontinence and 9.7% with anal incontinence discussed their symptoms with a health professional. Discussion with a partner was 32.8% and 21.4% respectively. The most common reasons for non-disclosure were embarrassment, fear of not being taken seriously and not wanting to waste the time of the health professional. Those participants who did disclose tended to have multiple symptoms. Pregnancy and childbirth appear to have a detrimental impact on sexual psychology, irrespective of continence status. Those who reported incontinence appear to have less sexual depression than the continent group suggesting the adoption of defense mechanisms to preserve the sexual Self. Conclusion Generally, urinary incontinence is a regressive condition. Risk factors for a progressive condition have been identified. Younger pregnant women appear to be more prone to infection which can sensitise the bladder and result in long term urinary incontinence. Prolonged periods of time in labour without voiding increases the risk of urinary and anal incontinence and is associated with a deterioration of symptoms over time. Whilst for all other modes of delivery the rate of UI decreased over time, in the elective CS group, the rate of UI increased steadily throughout the postnatal year. These findings support previous studies and suggest a degree of under-recognition or under-reporting of anal sphincter trauma leading to dysfunction. The impact of incontinence on quality of life domains shows clear evidence that the condition has a detrimental impact on many aspects of an individuals well being. Those women reporting intercourse incontinence had the greatest impact on QoL domains. Few women seek help for their condition and a number of personal and organisational factors have been highlighted which contribute to keeping incontinence both secret and taboo. It is clear that what incontinent women think is affecting the way they feel and ultimately their behaviour. Psychological defence mechanisms are employed to justify their inaction.

Change is a common feature of nursing, influenced by prevailing governments as part of their political agendas. These changes have impacted both on the context within which nursing takes place as well as on the actual role of the nurse. For change agents who are implementing these changes, it is imperative that they are aware of how nurses respond to change in order that they can plan the most effective strategies. This thesis investigated how nurses understand their own practice changes, the process that they undergo, how resistance to change manifests and if nursing rituals have an impact on the process. Finally the thesis made recommendations based on the findings to facilitate effective practice change and development. The study was conducted in two parts. In-depth interviews with eight nurses from one acute NHS Trust made up the first part of the study. A further two interviews were conducted with eleven mental health nurses from an early intervention team in one NHS Mental Health Partnership Trust, and this constituted the second part of the study. Constructivist grounded theory was the research method employed in the design of the study. An underpinning theoretical framework of structural anthropology with specific reference to the work of Levi-Strauss was used to present the final grounded theory. The study found that nurses understood the process of practice change as a spiral with the most significant aspects of practice change at the bottom. These were the day-to-day changes that may or may not lead to permanent change. At the top of the hierarchy and of least significance were the changes imposed by their employing organisations or nationally. The overall personal process of practice change and development was identified from the study as a process that centres on the experiences that participants have in their workplace, a process of sense making, learning and intuition. A Practice Change Model in the form of a continuum was developed that described how nurses respond to practice change and development. The significance of this study is that the thesis was able to identify strategies for promoting effective practice change and development, aimed at nurses in practice, change agents at an organisational and national level, and the clinical link role within higher education.

Women with raised BMIs ≥30kg/m2 have now become the ‘norm’ in maternity practice due to the recent obesity epidemic. To date only very limited research evidence exists highlighting midwives’ experiences of caring for this group of women. This thesis aims to provide original research on what it means to midwives and student midwives on the point of qualification to care for this client group throughout the childbirth continuum.

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

Through ethnographic fieldwork conducted in a hospital in rural Uganda, the study explores how continuing professional development (CPD) of nurses is supported through utilisation of information and communications technology (ICT), and how policy and culture can influence this process. The existing research literature raised three questions: what facilitates and restricts learning and using computer technology? What are the nurses’ views and experiences of using ICT? Is nurses’ professional development and how they utilise ICT influenced by policy and culture? The literature, drawn from international sources, is reviewed in chronological order to reflect the development of ICT and its use in health services and CPD. Policies and theories are analysed to gauge their relevance to the research aims and questions. These include Walt’s policy analysis theory; Hofstede et al.’s dimensions of national culture; Rogers’ diffusion of technology theory; Davies’ technology acceptance model; and theories of culture. These theories are synthesised into a model of influence. Early in the research, a macro study of Uganda was undertaken covering the political, economic, sociocultural, technological, legal and environmental (PESTLE) impacts on the ICT infrastructure, health and nursing. Spradley’s (1979, 1980) developmental research sequence (DRS) formed the methodological framework, providing a systematic and comprehensive approach to data collection and analysis. Its twelve steps were applied to participant observation and ethnographic interviews, offering a progressive approach to data analysis through domain, taxonomic and componential analysis. Spradley’s DRS enabled dimensions of contrast to be identified and the discovery of unique cultural themes. Four field visits took place between 2009 and 2012, each lasting two weeks. Participant observation was undertaken on each visit, and interviews and focus groups on the third and fourth visits, facilitating exploration of ICT developments, computer skills training, education and CPD. Informants expressed their views about cultural influences on technology development, and their knowledge of policies and how they impacted on ICT adoption and nurses’ computer skills development. The study makes a unique contribution to knowledge by analysing the influences of culture and policy on nurses’ CPD and utilisation of computer skills. Major findings include the significance of cultural themes amongst factors influencing ICT adoption, CPD and development of nurses’ computer skills. Knowledge of the local culture, as well as the underpinning theories, contributes to the successful construction of teaching strategies for this professional group. The impact of policies has been influential in building the national and local ICT infrastructure, but CPD and nurses’ computer skills have developed in the research location due to local capacity building rather than the direct impact of policies.