Nearly three hundred thousand maternal deaths occur worldwide every year. More than 99% of deaths occur in developing countries. The use of skilled birth attendants is low in those countries where maternal mortality rates are high and most of these deaths could be prevented if skilled birth attendant services were available. Only 36 percent of women use skilled birth attendants in Nepal. There are many reasons for non-use of skilled birth attendant services, such as inequalities, lack of access to services, role of gender and culture and lack of women’s autonomy in decision-making. The purpose of this study was to explore the views, experiences and perceptions of women influencing utilisation of skilled birth attendants in rural Nepal. Listening to the women’s voices and views were central to this study in order to understand why women use or does not use skilled birth attendants. Women’s individual characteristics, family, community and organisation factors are interconnected in regards to uptake of skilled birth attendants, as well as policy factors. A case-study approach using mixed methods was taken to explore the women’s experiences and perceptions in a hill district of western Nepal. Interviews were conducted with 24 ‘new mothers’ aged 18-49 years and five mothers-in-law, two husbands and a father-in-law. A survey was conducted of 100 qualified skilled birth attendants (doctors, nurses and midwives) to understand service providers view towards women’s use of skilled birth attendant in two hospitals (one private and one public hospital): 56 SBAs responded. The qualitative data were analysed using a thematic analysis approach and descriptive statistics were derived from the quantitative data. The study found that individual characteristic of women, the location and infrastructure of health facilities, cultural and gender factors, including women’s expectations and preferences about skilled care use, affected uptake of skilled birth attendant services. Socio-cultural and political contexts were found to be interconnected in health service utilisation. Socio-economic inequality based on caste and gender, access to qualitative services and women’s lack of autonomy are some of the factors that influence the uptake of care by skilled birth attendants. This study asserts that capturing women’s experiences and perceptions is essential in order to improve the uptake of skilled birth attendants. Understanding women's views and voices provided a clear picture of what women want and need during pregnancy and childbirth. The empirical evidence derived from this study about the poor standards of care received in hospital and the preference for locally based services could be used along with other evidence to review current policy and inform future plans. Development should be aimed at improving professional standards and access while making maternal health services in Nepal more women-centred.

Previous research conceptualises posttraumatic growth (PTG) as a phenomenon experienced by some people after breast cancer. In this thesis, I consider an alternative understanding of PTG; as discursive identity performance in the context of breast cancer survivorship. First, a critical review of literature on PTG after cancer is presented, with attention to rigour and methodological diversity and also with regard to the fit between existing research and counselling psychology values. It is concluded that much of the existing research is framed within a realist perspective, and accordingly, accounts of PTG are viewed as stable internal beliefs rather than socially constructed ways of managing identity. The social context in which survivorship occurs has not been adequately explored and there is a paucity of work from within the UK, and especially from amongst counselling psychologists, who, arguably, have a significant contribution to make within the psycho-oncology arena. An area for research is marked out, from the epistemological position of social construction, to explore women's accounts of life after cancer, and how they orient to and make use of PTG in this context. Following consideration of the approach taken (a synthesis of two forms of discourse analysis), I present my research with four women who were interviewed about their experiences of life after breast cancer. The analysis highlights the fine grained features of the women's talk as they manage their post-cancer identities discursively negotiating the social and moral obligation to survive well. A number of discourses, including the ‘PTG discourse’ are drawn upon, making a number of subject positions available. Notably, the PTG discourse closes down talk of troubles. Implications for theory, and for counselling psychology practice within psycho-oncology, are discussed.

Microvesicles (MVs) are small, plasma membrane derived vesicles that are shed constitutively or upon activation from both normal and malignant cells. Apart from physiological roles, MVs have also been implicated to play a role in various pathologies particularly cancer. Aspects of MV biogenesis and function have therefore become emerging targets for further research and cancer therapy. In light with the current research this thesis reports for the first time a novel function of peptidylarginine deiminase (PAD) isozymes (elevated in cancer cells) in the biogenesis of MVs. It was reported here that during the stimulation of cancer cells to microvesiculate, PAD expression and deimination of cytoskeletal-actins is increased. Inhibiting the enzyme with pan-PAD inhibitor chloramidine, abrogated the deimination of cytoskeletal actins as well as reduced the release of MVs. Furthermore, combining chloramidine with anticancer drug methotrexate increased the cytotoxic effect of the drug synergistically on different types of cancer cells. It is also reported for the first time the cytotoxic and anti-proliferative effects of myocyte MVs on prostate cancer cells. Treating prostate cancer cells with MVs from myocytes reduced proliferation and induced apoptosis. Furthermore mass spectrometry analysis of the MVs revealed a candidate protein gelsolin that has been reported to exhibit anti-tumourigenic properties.

Background: Severe alcoholism is associated with cognitive deficits which research has shown to effect social functioning. Theory of Mind (ToM), the ability to make judgments based on another’s state of mind, has only recently been explored in alcohol research. Previous research has shown that alcoholism is associated with deficits in conscious, deliberate emotional processing and humour processing. However, ToM encompasses many social functions, including the ability to take another’s visual perspective, but little is known about how cognitive deficits caused through alcoholism may affect these processes. Aim: The aim of the experiments in this thesis was to explore how alcoholism may effect automatic visual-spatial processing and the effect of emotional valence of stimuli on this automatic process. Methods: Visual processing was measured by asking participants to respond to a dot probe appearing as either congruent (above/below) or incongruent (left/right) to facial stimuli which conveyed a neutral or emotional expression (e.g.a fearful or happy face). Participants were also asked to quantify the level of the emotion expressed using a 7 point-Likert scale. Results: The results from the visuo-spatial processing trials (VSPT) show that alcoholism is not associated with any impairment in VSPT; both alcoholics and non-alcoholics showed a perspective reaction time cost when the perspective differed from their own. This can be taken as evidence for automatic VSPT. However, the relevance of the fearful facial expression did cause a reaction time cost for the non-alcoholics that was not demonstrated by the alcoholics. However, both the alcoholics and non-alcoholics showed a delayed response to happy faces when the perspective differed from their own. To address the question as to why it may be the case that alcoholics did not react differently to neutral and fearful faces, participants were asked to rate the faces for emotional content. In these trials alcoholics rated the neutral faces as containing more emotion than the non-alcoholics. Conclusions: The VSPT studies in this thesis suggest that alcoholics do not show any deficits in visual perspective taking, although this research is in its infancy so greater exploration is required. What appears most significant from the experiments is that the emotional content of the stimuli presented creates processing differences between the alcoholics and non-alcoholics as evidenced by their reaction time differences and ratings of the faces. The extent to which these processing differences will effect alcoholic’s day to day lives is not known.

Introduction Overall the evidence is consistent and robust that UK South Asian communities are at elevated risk of lifestyle related disease. A potential worsening of obesity related risk in South Asian children carries implications for persisting disparities in chronic disease across generations making it advantageous to target this specific group for obesity prevention. Psychosocial factors are particularly important in obesity and key to understanding the determinants of dietary and physical activity behaviour, and factors that might influence behaviour modification in South Asians. The study aims to identify beliefs and perceptions that contribute to health risk and health protective behaviours in young UK South Asian families and to develop a theory which can be used to define specific objectives that lead to effective behaviour change to improve health outcomes for this population. Design Grounded theory methodology was applied to investigate how factors influence South Asian mother’s decisions to engage in health behaviours for themselves and their children taking into account specific beliefs and practices influencing health behaviours. Semi-structured interviews were carried out with seven female participants who were mothers to young children aged 5-12 years of age. Results The grounded theory is underpinned by three categories that emerged out of analysis of the data; cultural identity, health beliefs and barriers. These categories and their properties, tell the story of the influences and pressures on South Asian mothers as they attempt to negotiate a healthy family lifestyle. The data emerged to form a grounded theory of the balancing act South Asian mothers engage in to negotiate a healthy family lifestyle. Conclusions This study contributes to an improved understanding of the unique factors influencing young South Asian family’s health behaviours and recognition of the need to help them to find a healthier lifestyle balance. In addition, it has revealed how these factors relate to the initiation and maintenance of a healthy lifestyle and will be of use to health professionals and service providers when designing interventions to address and prevent health inequalities among this group. Emphasising the need to involve both the family and their community in interventions, in order for them to be effective. Limitations of these findings and their implications for future research and practice are considered.

The global increase in obesity prevalence has led to a surge in metabolic disease in both adults and children. Furthermore, the burden of obesity and its related morbidities is not equally distributed across the UK population, with those from minority ethnic groups particularly affected. Effective paediatric epidemiological monitoring and clinical referral requires improved tools for assessing body fatness, and other body composition measures related to metabolic disease are needed. Presently the body mass index (BMI) used to identify overweight and obesity suffers from poor sensitivity and specificity, leading to misclassification of children, especially those from minority ethnic groups. Additionally BMI gives no indication of body fat distribution. Assessment tools specifically for African and Caribbean childhood populations are lacking and the aim of this thesis was to develop a range of assessment tools specifically for this population group. This thesis comprised four studies. In the first study the equations in the Tanita BC-418 bioimpedance (BIA) system used to predict fat mass (FM) and appendicular skeletal muscle mass (SMMa) were re-validated using dual-energy x-ray absorptiometry (DXA) as the criterion method in a sample of 44 African and Caribbean children aged 5-18 years. FM (kg) and SMMa (kg) were quantified by DXA and linear regression analysis used to produce new equations based on height2 /impedance. The key findings from this study were that BIA generally under-estimated FM and over-estimated SMMa in this population group, irrespective of age and gender. In the second study, the corrected measures of FM and SMMa were applied to an existing dataset of 1,336 African/Caribbean children aged between 5-16y whose body composition had been measured using the Tanita BC418 system. Percentile charts for %FM, %FFM, SMMa (kg), %SMMa and SMMa/FMM x 100 were generated using the software LMS Chartmaker. In the third study, blood pressure percentile charts and tables were developed based on data (n, 900) extracted for African and Caribbean children aged 5-18 years from the Health Survey for England data archives, 1991-2008. The centile curves for the anthropometric measures revealed gender and age-related patterns which compared closely to equivalent charts for Caucasian children. Finally in the fourth study, percentile charts and tables for waist circumference (cm) were developed using the same sample population. The findings from these studies provide the tools and preliminary evidence to support the use of African-Caribbean specific references for body composition and blood pressure measures in children and youths in the UK. The overall conclusion from this thesis indicates that paediatric overweight and obesity varies across different ethnic groups and this variation needs to be considered in the context of obesity surveillance and clinical assessment which themselves are determined by national obesity policy formulation and implementation. These are the first body composition percentile charts for African and Caribbean children living in the UK. These charts should replace BMI charts used for obesity assessment in paediatric and epidemiological settings as they are better tools for assessing overweight, obesity and sarcopenia.

Smoking is a deep-rooted and complex psychological, behavioural, social and physiological practice. Smoking is reinforced by positive reinforcement outcomes and negative withdrawals symptoms experienced during abstinence (Marks et al., 2006). Furthermore smoking is a primary contributing factor in health inequality (Raw, McNeill, & West, 1998). Current data suggests that smoking rates in England have fallen to their lowest rate in over eighty years (Brown & West, 2014). Despite the downwards trend in smoking prevalence, smoking remains the UK’s biggest preventable cause of premature mortality (Twigg, Moon, & Walker, 2004). It has been acknowledged that the specialist Stop Smoking support programmes provided by the NHS have helped reduce smoking prevalence (Bauld, Bell, McCullough, Richardson, & Greaves, 2010). Whilst there has been a vast amount of research investigating the most effective behavioural and pharmacological support models (Lancaster, Stead, Silagy, & Sowden, 2000) there has been little research on the impact of smoking cessation advisor smoking status and clinical effectiveness (Lindson-Hawley, Begh, McDermott, McEwen, & Lycett, 2013). This study aimed to identify factors that contribute to NHS Stop Smoking advisor performance. Factors analysed included: advisor smoking status (historic and present); attitudes and beliefs towards smoking; level of training; proportion of time spent supporting patients; and number of patients supported. This study implemented a quantitative cross-sectional design. An online survey was used which consisted of three standardised questionnaires. The sample consisted of Stop Smoking advisors (n=159) from 24 London boroughs. The results were analysed using an ordinal logistic regression. The regression model showed no significant impact on the majority of the variables investigated. The non-contributing variables included: level of training; years practiced; level of advisor education; and number of patients supported in a given year. The model did however show that proportion of time spent delivering smoking cessation support significantly influenced quit rate. The results reinforce previous literature by Lindson-Hawley et al. (2013) which suggests smoking status does not significantly influence smoking practitioners’ outcomes or attitudes towards smoking. Proportion of time spent providing support was found to be a significant factor in predicting quit rate. These results suggest that these factors should be considered when recruiting, commissioning and training new smoking cessation advisors or provider organisations.

Microvesicles are heterogeneous population of micro-particles released constitutively and upon induction from healthy and unhealthy cells. The role of cancer cell derived-MV in intercellular communication gains an intensive aria of research. The influence of leukaemia cell derived-MVs in this study was determined on normal prostate epithelial cell lines. PNT2 cells were treated with Jurkat cell derived-MVs lost epithelial characteristic (decreased epithelial marker E-cadherin) and gained mesenchymal phenotype (increased expression of mesenchymal marker Vimentin). TGF-β and intracellular Ca2+ concentration were partially involved in Epithelial Mesenchymal Transition (EMT) process. PNT2 cells acquire mesenchymal characteristic produced high level of resistances against apoptotic signals after exposed to serum starvation and anti-cancer drug docetaxel, produce excessive level of MMP-9 and 2/3 of total TPNT2 cell population were arrested in the G2/M phase of the cell cycle, and halts cell proliferation. The influence of carcinoma cell derived-MVs on tumour microenvironment was examined through use of Non-small lung cancer cells (A549) derived-MVs on primary lung fibroblasts (MRC5). MRC5 cells were treated with A549 cell derived-MV produced significantly high level of myofibroblasts marker alpha-smooth muscle actin (α-SMA) cytoskeleton protein and FGF. MVs were isolated from the myofibroblasts were enriched with α-SMA protein. Primary fibroblasts were treated with MVs released myofibroblasts expressed high level of α-MSA protein. Elements present in the CGM cause aggregation of cancer cell MVs and significantly reduced the effects of MVs on the target cells.

Protein calorie malnutrition (PCM) is one of the most serious public health problems in the developing world, including Sudan. This condition was investigated through studies which examined three main areas: prevalence and seasonal variation, influencing demographic factors and impact on brain function with use of electroencephalogram (EEG) assessment before and after clinical and nutritional interventions. All 466 children admitted to the Khartoum Teaching Hospital and Ibn Oaf Children Emergency Hospital during July to September 2009 (the wet season) and during February to April 2010 (the dry season) were eligible for the study on the prevalence, seasonal variation and demographic factors influencing which influence the incidence of PCM. Questionnaires were employed to collect pertinent demographic, nutritional and anthropometric data. The impact of PCM on brain function were examined through a case-control study of 48 children admitted to the Ibn oaf Children Hospital in Khartoum between July 2011 to July 2012 (16 underweight, 16 with kwashiorkor, and 16 with marasmus), The data obtained were compared with those of 12 healthy and well-nourished children. EEGs, clinical and neuropsychological assessment were performed on admission and at two time points after discharge (week 4 and 12). The overall prevalence of PCM was 1.15%, and the distribution of marasmus, kwashiorkor and marasmic kwashiorkor 67.0, 23.0 and 10.0% respectively. Analysis of the 24-hour dietary recall revealed that the protein (p= 0.001), fat (p= 0.020), carbohydrates (p= 0.005) and energy (p=0.0028) consumption were statistically significantly lower than the recommended daily allowances. The coefficient of interaction between seasons and cofactors indicated that the wet season influenced significantly (p<0.0001) the incidence of PCM when the length of residence, paternal education, and sugar consumption were taken into consideration individually. In terms of demographic factors, mothers who delivered their first baby before they were 18 years old, mothers with a BMI of less than 18.5 Kg /m2 , a birth interval of less than 2 years, children aged 6-11 months (for marasmus), children aged 12-23 months (for kwashiorkor), children whose mid-upper arm circumference was less than 12.5cm and the number of children in a family were all highly associated with the incidence of PCM (p<0.001). Neuro-cognitive investigation of the children showed that 70.8% had abnormal EEG patterns and 50-70% neuropsychological abnormalities. However, after four weeks treatment, 84.4% of the protein calorie malnourished children exhibited normal EEG patterns. In conclusion, this study has revealed a high prevalence of PCM in Sudanese children with more cases during the wet season than the dry season. In addition, it has identified a number of predisposing demographic factors which must be addressed in order to help reduce the prevalence the disorder. Clinical and nutritional treatment of the children improved considerably clinical, neuropsychological and EEG outcomes. A more promising strategy to improve PCM outcomes may be to tackle the major risk factors for PCM: seasonality and demographic factors. It is envisaged that earlier intervention with the treatments would be beneficial. Future programmes should investigate the long-term impact of PCM on cognitive function including school performance. This study has generated important information about the prevalence of protein calorie malnutrition and pre-disposing socio-economic factors. Nevertheless it has some limitations. The main limitations are: first, there is potential recall bias among respondents answering questions relating to household food consumption, and events happening in the past, such as the child’s history of illness and breastfeeding patterns immediately after birth and then after. Second, information on some important confounding variables such as infection was not collected which could cause problems in interpreting the results. Third, the non-truly statement of the subjects regarding income which may cause bias was another limitation. Lastly, Lack of an address system limited follow-up with some patients. Overall, the findings have important implications for research policy and programme efforts towards improved growth monitoring and designing of interventions to mitigate protein calorie malnutrition and its determinants.

Aims There is a lack of sufficient knowledge about the stress experience in counselling psychology training. Previous research suffered methodological issues and there was a specific lack of qualitative studies. This research aims to contribute towards the topic as it explores the experience of stress in counselling psychology training from the perspective of young final year female trainees. Design Semi-structured interviews were conducted with eight final year female trainees (aged between 25 and 30) in order to explore their experiences of stress and major stressors in counselling psychology doctoral training. Method Interpretative phenomenological analysis was used to analyse the verbatim transcripts of interviews. Findings The process of analysis identified three superordinate themes: ‘identifying ambivalence in training’ (refers to the trainees’ mixed views about stress in training); ‘the impact of training on self and self-and-other’ (refers to the perceived lack of life outside of the training and high risk of failure); and ‘managing the lack of boundaries in training’ (refers to the process of merging with training and being forced to age). The themes are considered in relation to relevant existing literature. Conclusions Findings imply that young female trainees perceive stress as an integral element of training, which is both destructive and promoting their growth. It is suggested that training programmes should consider developing targeted interventions to support these trainees. Evaluation of the current study is followed by recommendations for future research.