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Background: Expressing end of life care wishes and preferences is a vital component of Advance Care Planning (ACP) which facilitates the provision of end of life care that is consistent with the patient's expressed values, beliefs and goals of care outcomes. There is an acknowledgement of the impact of contextual values on the process of expressing wishes and preferences. Aim: The aim of this study is to a gain a theoretical understanding of the process involved in expressing end of life care wishes and preferences based on the perspectives and experiences of advanced cancer patients and their family carers in Nigeria. Methods: Using a constructivist grounded theory study approach, fourteen qualitative interviews from eight patients with advanced cancer and six family members of patients with advanced cancer were analysed to construct a theoretical model that explains the process of expressing end of life care wishes and preferences in Nigeria. Results: "Rubbing minds together" explains a process by which patients with advanced cancer negotiate their way with their family members to facilitate expressing their end of life care wishes and preferences in the context of a cultural commitment to familial involvement in end of life decision making. The theory is composed of three interlinked components: controlling to seek relief, enduring and collaboration that acknowledges the ongoing overt and hidden compromises that occur in the end of life care communication in this context. Conclusion: This constructed theory emphasises the relational nature of end of life care communication in the African cancer context. This may increase healthcare professionals' understanding and be crucial to achieving an end of life care context that acknowledges and encourages family members' involvement and not only that of the patients, thereby enhancing end of life communication with Africans nearing the end of life.

Background: Breast cancer is the most common cancer for women, globally. Social, religious and healthcare contexts have been shown to influence women’s experiences of advanced breast cancer; however, research has tended to focus on resource-rich nations. There is limited research from low-resource contexts, and little is known on the experiences of Arab, Muslim and African women with advanced breast cancer. Aim: To explore and understand the experiences of advanced breast cancer in the Islamic Republic of Mauritania, West Africa. Methods: Using a constructivist Stakian multi-case study approach, eight cases were constructed around women (n=8) with advanced breast cancer, family members (n=10) and health professionals (n=9). Data were collected longitudinally (up to nine months per case) and consisted of interviews, audio-journals, a patient reported outcome measurement scale and a performance status scale. Withincase and cross-case analysis was undertaken, with thematic analysis of qualitative data. Findings: Three key themes were identified: 1. Destiny, 2. Patience & Acceptance and 3. Journeying in search of a cure. Mauritanian women appreciate that Allah is all powerful and maintains control over their destinies and their breast cancer. A fear of causing offence to Allah influences how they express negative experiences of breast cancer and its treatments. The women’s access to information and treatment is controlled by health professionals and families. Women are, therefore, required to use their own observations and interpretations to understand their breast cancer and empower their pursuit of treatment and a cure. Conclusion: Maure women’s experiences of advanced breast cancer in Mauritania are influenced by power imbalances. Allah is all-powerful. Families and health professionals exert power over Maure women’s access to information, healthcare decisions and how they express negative experiences. This thesis demonstrates that Maure women are cognisant of these challenges and, either, accept them as reality or attempt to work around them.

Background: The burden of cancer embodies the lived experiences and perspectives of people who have dealt with the challenges and difficulties of cancer. The landscape of cancer care in the United States has transitioned to a predominantly outpatient care system, so cancer care has become increasingly burdensome on the patient and family. Aim: The thesis describes the cancer care burden experiences of Chinese, Filipino and Indian American cancer-diagnosed immigrants and their family carers as well as explores the factors associated with their cancer care burdens. Method: Interpretivist and constructivist qualitative approaches were used to gather and analyse data from 9 cancer-diagnosed individuals and 9 family carers. Purposive and snowball sampling methods were employed. A semi-structured interview format was used for data collection. Results: The analysis generated three main themes that reflect cancer care burden experiences of the sample population: psychosocial burdens, burdens related to healthcare, and competing priorities. Several factors related to social, economic, cultural, and institutional context were found to have a relationship with the cancer care burdens. Conclusion: The findings illustrate that Asian American immigrant families deal with complex and multifaceted cancer care burdens that are connected to the social, economic and cultural conditions that shape their lives. Insight from the thesis is a critical first step for understanding the pathways of cancer care burdens amongst immigrant families.

Cancer can have major implications for those who receive a diagnosis, not only as a result of its physical impact, but its emotional one. The emotional impact can not only be distressing in itself, it can also affect behaviour and therefore, has been linked to poorer treatment adherence. The experience of difficult self-directed emotions, such as guilt, shame and disgust have provoked particular interest, particularly due to their association with rejection and avoidance. Therefore, insight into how and when these emotions are experienced within the cancer treatment journey are important to understand, in order that optimum support can be provided. The first paper is a thematic synthesis that explores the emotional experiences of people undergoing cancer treatment with a curative intent. The synthesis is structured by a sequential framework of four key transition points within the cancer journey, and the emotional experiences synthesised within each one. The temporal transition points were: Being diagnosed and facing treatment; Getting rid of cancer; Changed body and stigma; Reflections on the emotional journey having completed treatment. The synthesis demonstrates how emotions and feelings evolve and change in type, frequency and intensity across the curative cancer journey. The second study uses narrative analysis methodology to explore difficult self-directed emotions throughout cancer treatment and into recovery. The analysis focuses on how and when the emotions of disgust, guilt, shame and fear arise, as well as resulting changes to the sense of self. The findings demonstrate how many factors, such as relationships, current stressors, past experiences and resources (personal and systemic) can impact on emotional experiences. The critical appraisal focuses on strengths and weaknesses of the studies, particularly in relational to emotional research considerations more generally.

Background: Cervical cancer is the second cause of cancer related mortality for Filipino women. Mortality rates of cervical cancer are high amongst Filipino women; however, uptake of cervical cancer screening (e.g., pap-testing) is low. In 2015, 2.34 million overseas Filipino workers (OFW) were recorded. Migration may present additional barriers to accessing pap-testing. Gaining understanding of barriers and facilitators to pap-testing for OFWs is crucial to improve uptake of pap-testing. Methods: An explanatory sequential mixed-methods research design was adopted comprising two phases, a web-based cross-sectional survey (N=480), followed by web-based qualitative interviews (N=8). A socio-ecological conceptual framework was used to explore barriers and pap-test uptake. Bivariate and multivariate logistic regression analyses were used to assess key determinants of pap-testing. Qualitative results were analysed using thematic content analysis. Results: The sample included 480 OFWs (59.3% domestic workers) living and working in 28 different countries (mean age 36.69, age range 23-58). The largest proportion of women who participated lived in Hong Kong (24.4%). Nearly all (96.4%) of OFWs were aware of pap-testing but less than half (43.5%) had ever engaged in pap-testing. Statistically significant predictors of pap testing were: marital status; fear of outcome of pap-test; having sufficient time; recommendation from health care provider; and collectivism values. Exploration of results through interviews, revealed additional findings and social and structural contexts not conducive to pap-testing, including poverty and the overriding need to provide financially for family. Conclusion: This study demonstrated the complexity and multifactorial characteristics of pap-testing following the socio-ecological framework. For OFWs, individual, social-cultural, and institutional barriers to pap-testing were embedded in structural barriers, resulting in health inequalities. Recommendations targeted at multiple levels offer the potential for further understanding and the development of culturally appropriate interventions, with the ultimate aim of increasing OFWs’ uptake of pap-testing.

Background: Tuberculosis remains an important public health problem especially in sub-Saharan Africa. Nigeria currently ranks 4th among the 22 high Tuberculosis (TB) burden countries with an estimated prevalence of 338/100,000 population. Few studies have utilized spatial data analysis techniques in the understanding of the pattern of distribution and possible correlates of TB especially in Africa. This study examines the spatial distribution of TB and its associated socioeconomic determinants in Nigeria. Methods: The study used an ecological design based on the 774 Local Government Areas (LGAs) in Nigeria as the spatial units. Initial exploratory analysis used measures of spatial autocorrelation (Global and Local Moran’s test statistics). The associations between TB incidence and nine covariates were assessed using a spatial regression analysis in the R statistical package. Result: A total of 100,217 TB cases were notified in 2013. There is significant spatial autocorrelation among case notifications rates (CNR). Spatial regression analysis identifies 138 (17%) of LGAs with high TB risks and finds a significant relationship between household size, urban residence access to transportation, population density, number of TB diagnostic services and TB. An index defining socioeconomic status, living in a single room, TB treatment centres and total health facilities are not significantly associated with TB CNR. Conclusion: The study presents a national picture of TB spatial heterogeneity at the lowest administrative level in Nigeria with the identification of high risk LGAs. This information can assist policy makers to rationally plan targeted specific interventions to effectively control TB while addressing the underlying socioeconomic risk factors in the country.