Background: Postpartum depression (PPD) is a complex mental health disorder that affects women during their childbearing years. It is a serious medical condition that occurs in approximately 13–20% of women after birth and has an adverse effect on both the mother and the infant. Certain dietary deficiencies in a pregnant or postnatal woman’s diet may cause postnatal depression. It is unclear whether Omega-3 polyunsaturated fatty acids (n-3 PUFAs) are effective for treating or preventing PPD. Objectives: To assess the best available evidence to date regarding the effect of n-3 PUFAs on the etiology, prevention and treatment of postnatal depression. Methods: A systematic review and narrative synthesis was conducted in order to address the gaps in knowledge. For the systematic review, a broad search of electronic databases of published quantitative literature was conducted. Quality appraisal was performed using the tools produced by the effective public health practice project (EPHPP). The narrative synthesis consists of four elements: 1) developing a theory; 2) developing a preliminary synthesis; 3) exploring relationships in the data; 4) assessing the robustness of the synthesis. Results: Out of 181 potential articles, a total of 17 studies met the inclusion criteria. The overwhelming majority of the studies found that n-3 PUFAs had no association with PPD evaluations versus only few ones observed a beneficial effect of n-3 PUFAs supplementation on depressive symptoms. Significant heterogeneity was observed among included studies which can be explained by dissimilar study designs, differences in study duration, time period of measurement and number of participants, and in varied dosages and types of supplemental n-3 PUFAs. Conclusions: Overall, This systematic review and narrative synthesis failed to find a significant positive association between n-3 PUFAs intake and PPD. However further investigation of the specific molecular mechanisms underlying the function of n-3 PUFAs in the brain and the factors related to the pathophysiological nature of depression is warranted.

Type 2 diabetes mellitus (T2DM) continues to be a national challenge for Canadians. African and Caribbean Immigrants are among the most affected groups and those at risk of developing comorbidities and related complications. It continues to prove challenging to treat T2DM for the affected individuals. Effectively treating the disease can help mitigate risk factors for related comorbidities and complications while improving the quality of life for those affected. There is increasing research, outside of Canada, showing the evidence for the effectiveness of culturally sensitive and adapted interventions to immigrant patients affected with T2DM. In light of the effectiveness of such interventions in many industrialized nations, a systematic review (SR) can offer the best evidence for the scope and consideration of such treatment approaches in Canada. This SR aimed to determine whether community-based diabetic interventions in Canada, are culturally sensitive to African and Caribbean minorities living with type II diabetes. A narrative synthesis was employed to report the effect of interventions seeking to affect outcomes of T2DM patients in Canada. Of the 63 articles included for full review, 60 were excluded for not meeting the criteria of having the target population explicitly identified and also not having any mention of cultural sensitivity. Three articles were included for the final review because the target population was explicitly identified. The final results showed that all interventions were found not to be culturally sensitive to African and Caribbean T2DM patients in Canada. Our results suggest a lack in Canadian literature. To the best of our knowledge, this is the very first systematic review on this subject matter in Canada. This review provides dependable information and recommendations to researchers, educators, clinicians, and policy makers for future research with T2DM African and Caribbean patients in Canada. RÉSUMÉ Le diabète de type 2 demeure un défi national pour les Canadiens. Les immigrants d’origine d’Afrique et des Caraïbes sont parmi les groupes les plus frappés et l'un des plus à risque de développer des troubles comorbides et de complications liées au diabète. Traiter le diabète continue à poser un défi chez les personnes affectées. Traiter efficacement cette maladie peut contribuer à réduire des principaux facteurs de risque quant aux troubles comorbides et complications, tout en améliorant la qualité de vie chez les personnes affectées. Un nombre grandissant de recherche, hors du Canada, démontrent avec des preuves concluantes que les interventions sensibles et culturellement adaptées aux immigrants affectés par le diabète sont efficaces. Étant donné l'efficacité de ces interventions dans nombreux pays industrialisés, une revue systématique peut nous offrir la meilleure preuve pour l'envergure relative à ce genre de traitement au Canada. La présente étude méthodique vise à déterminer si les interventions contre le diabète, en milieu communautaires au Canada, sont culturellement adaptées aux minorités ethniques d’origines d’Afrique et des Caraïbes souffrant de diabète de type II. Une synthèse narrative a été utilisée afin de signaler les effets des interventions par rapport aux résultats des patients souffrant du diabète de type 2. Parmi les 63 articles considérés pour une évaluation complète, 60 ont été exclus car ni la population cible ou la mention de la sensibilité culturelle n’a été explicitement identifiée. Trois articles ont été inclus pour l’évaluation finale car la population cible fut explicitement identifiée. Aucune des interventions n’est culturellement sensible aux patients Africains et Caribéen affecté par le diabète de type 2. Nos résultats démontrent un écart dans la littérature Canadienne. A ce que nous sachons, cette revue systématique est la première qui touche à cette question au Canada. Cette revue fournie des données fiables et recommandations qui permettront aux chercheurs, enseignants, cliniciens, et aux décideurs en matière de politiques de santé pour des recherches futures auprès des patients Africains et Caribéen souffrants du diabète de type 2 au Canada.

Female sexual pain is a common problem affecting women worldwide yet remains a poorly researched area of women’s sexual health. Dyspareunia and vaginismus are two types of sexual pain disorder each having psychological and physical health consequences for women and their partners. Part 1: A literature review of the qualitative research literature exploring women’s experiences of sexual pain disorders and their treatment was conducted adopting a narrative synthesis approach. Searches of psychological and medical electronic databases highlighted the paucity of research exploring women’s experiences of sexual pain disorders. Ten studies met the inclusion criteria for the review. The type of qualitative method and quality varied. Findings highlighted the complexity of women’s experiences of sexual pain. Positive experiences of treatment identified alternative benefits of treatment in addition to the traditional outcome of vaginal penetration and penetration without pain. Existing literature has focussed on dyspareunia, and further research is needed on vaginismus. Part 2: The research study used an Interpretative Phenomenological Analysis (IPA) of women’s experiences of vaginismus. Three women were interviewed about their experiences of vaginismus and the treatment they received. Interview transcripts were analysed using IPA. The findings identified the complexity of experiencing vaginismus, the struggle the women faced when trying to make sense of their vaginismus and the wider impact of these experiences on their identity. The findings highlight the value of psychological therapy with this client group and of the need to raise awareness amongst primary care professionals whom women with vaginismus are likely to consult in the first instance. Part 3: A critical appraisal of the research process is presented with focus on the experience of conducting qualitative research as a trainee clinical psychologist. A discussion of the findings is presented in the context of critical reflections on both the strengths and limitations of the study.

This thesis explores the perspectives of people on psychogenic non-epileptic seizures (PNES). It is presented in three separate papers: a systematic literature review; an empirical research paper and a critical reflection of the research process as a whole. The systematic literature review aimed to provide a detailed understanding of stakeholder perspectives on PNES. A systematic search identified relevant studies that were subsequently synthesised using thematic analysis and the broader principles of narrative synthesis. Three broad themes relating to stakeholder perspectives were identified: the nature of PNES as a condition; diagnosis; and management and treatment issues. It was found that both patients and professionals experienced uncertainties in relation to understanding and managing the condition. This highlighted the need for further information and awareness of PNES and the development of clear treatment guidelines. Important differences in opinion were also identified between patients and professionals and consideration was given to how these may disrupt the development of effective partnerships in care. The research into patients' and families' perspectives was found to be lacking and further research was identified as being needed in this area. The empirical paper reports an exploratory qualitative study that aimed to provide an in-depth understanding of the perceived treatment needs of patients with PNES. Semi-structured interviews were conducted and findings were analysed inductively using the principles of thematic analysis. Four key themes were identified: return to normality; post-diagnostic limbo; uncertainty and apprehension about therapy; and need for validation. Patients with PNES described clear goals for their recovery and clear ideas about their treatment needs. However, following their diagnosis, many felt caught in 'limbo' due to uncertainties about their diagnosis and as a result of a lack of post-diagnostic support. Being in 'limbo' also linked to patients' uncertainties about psychology meeting their needs and for some there was apprehension about the potential negative consequences of therapy. The clinical implications of the research are discussed and recommendations for future research are made. The third paper is a critical reflection of the research process as a whole. It provides an overview and evaluation of the first two papers and personal reflections of the lead researcher are offered throughout. Implications for further research and clinical practice are offered and a summary of the research as a whole is offered.

Background: The underutilization of formal, facility-based maternal care is a major contributor to the high maternal mortality rates among women living in rural Africa. Increasing the use of formal maternal care requires exploration of important maternal health issues affecting community members and comprehension of how they perceive the use of formal and traditional maternal care. This thesis aimed to identify the key factors, challenges, and needs of rural populations for the uptake of formal maternal care. Paper 1 explored rural women's preferred choices for sources of maternal care as well as the factors that contribute to their preferences in Africa. Paper 2 explored elders' perceptions about reasons for the underutilization of maternal healthcare and maternal death, as well as potential solutions to improve formal care use in rural Nigeria. Methods: 1) In paper 1, a systematic search on Ovid Medline, Embase, CINAHL, and Global Health identified 40 qualitative studies that elicited women's preferences for maternal care in rural Africa. Reviewers collated the findings and reported on patterns identified across findings using the narrative synthesis method. 2) Data were collected through 9 community conversations with 158 elders in 9 rural Nigerian communities. The data were analyzed inductively through thematic analysis. Results: 1) A variety of preferences for formal, traditional and both formal and traditional maternal care during antepartum, intrapartum and postpartum periods were identified. The majority of the studies reported preferences for formal antenatal care or a combination of traditional and formal antenatal care. During intrapartum, rural women held a wide range of preferences, including facility-based births, traditional births in a domestic setting, as well as a combination of formal and traditional care depending on the onset of complications. The majority of the studies reported preferences for traditional postnatal care involving traditional attendants, self-care, and cultural rituals that fend off witchcraft. The factors that contributed to these preferences were related to the perceived need of formal or traditional maternal care, accessibility to formal or traditional care, and cultural and religious norms, beliefs and obligations. 2) The perceived reasons for the underuse of formal maternal care included poor qualities of care, physical and financial inaccessibility of facility-based services, and lack of knowledge and awareness. Reasons for women's maternal deaths included malaria and blood displacement, facility-based service deficiencies, uptake of traditional maternal care, and poor community awareness and negligence. Increased access to high-quality care, health promotion and education, community support and supernatural assistance were the proffered solutions. Conclusions: The major areas that need improvement across rural Africa include human and material resources availability, technical and interpersonal quality of care in health facilities, physical accessibility, financial accessibility, sociocultural accessibility, cultural and religious sensitivity, and community knowledge and awareness. Generally, the findings reflect the need for multifaceted interventions that engage target populations and consider local contexts, realities, and related needs in order to develop locally acceptable interventions. Such interventions will increase the likelihood of effective and long-lasting positive changes in healthcare utilization and maternal mortality.

Olika träningsprogram används vid rehabilitering av Akillestendinopati och skiljer sig åt avseende frekvens, intensitet, typ av träning och hur patienter skall förhålla sig till smärta när de tränar. Vilken nivå av smärta som är mest effektiv vid träning är ej tidigare utforskat. Syftet med denna litteraturöversikt är därför att jämföra träningsprogram som skall utföras med smärta med program som tillåter viss smärta samt med program som skall utföras smärtfritt vid rehabilitering av Akillestendinopati i senans mellanportion. Litteraturöversikten utfördes systematiskt och följde riktlinjerna enligt PRISMA. Studier från PubMed och Web of Science inkluderades. Endast studiedeltagare med Akillestendinopati i senans mellanportion som utförde träningsterapi som behandling och utvärderades med VISA-A inkluderades. Risk för bias bedömdes enligt Rob 2 tool för RCT-studier och ROBINS-1 tool för CCT-studier. En narrativ syntes användes som analysmetod och evidensgraderingen utfördes med GRADE. Åtta studier inkluderades i litteraturöversikten och samtliga av dessa innehöll träningsprogram som skulle utföras med smärta. Två studier involverade träningsprogram som tillät viss typ av smärta och ingen studie involverade träning som skulle utföras smärtfritt. Träningsterapi oavsett typ av träningsprogram visade sig vara associerat med förbättrade VISA-A värden och det går ej att avgöra vilken av dessa träningsprogram som är mest effektiv. Den här litteraturöversikten pekar mot att träning med smärta, som gäller vid Alfredsons standardprogram från 1998, är effektivt och har bäst evidens av de träningsprogram som presenteras i litteraturöversikten. Fler högkvalitativa interventionsstudier behövs för att öka evidensen för att träna utan krav på smärta vid Akillestendinopati i mellanportionen. / Different loading programs are used when rehabilitating Achilles tendinopathy varying regarding frequency, intensity, type of training and how to approach pain. The level of pain which is most effective in training, when rehabilitating Achilles tendinopathy, has not yet been explored. Therefore, the purpose of this review is to compare loading programs when inducing pain is a criterion with loading programs allowing some pain and with loading programs inducing no pain when rehabilitating midportion Achilles tendinopathy. The review was conducted systematically and followed the guidelines presented by PRISMA. Studies from PubMed and Web of Science were included. Only participants with midportion Achilles tendinopathy that rehabilitated with a loading program and were evaluated with VISA-A were included. Risk of bias was evaluated with the Rob 2 tool for RCT-studies and with ROBINS-1 tool for CCT-studies. A narrative synthesis was conducted, and the level of evidence was set with GRADE. Eight studies were included and all of them involved training with pain. Two studies included loading programs that allowed some pain and no study included training without pain. All loading programs included are associated with improved VISA-A scores and none are more superior than the others. This review shows that training with pain, as in Alfredsons eccentric loading program from 1998, is effective and has the best level of evidence of the different loading programs presented in this review. More high-quality studies are needed to increase the evidence for training when pain is not a criterion in midportion Achilles tendinopathy.

The thesis has been prepared in a paper-based format and includes three papers: Paper 1, a systematic review; Paper 2, an empirical study; and Paper 3, a critical appraisal and reflection on the work. Paper 1 has been prepared for submission to Neuro-Oncology. The paper presents a systematic review of 21 studies concerning the relationships of demographic, clinical and mental health factors on health-related quality of life (HRQoL) and psychological functioning in adults with primary malignant brain tumours. The review was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) principles. Methodological qualities of studies included were appraised using a checklist based on the Newcastle-Ottawa Scale (Wells et al, n.d.).Findings were synthesised narratively adhering to published guidelines (Popay et al, 2006). The review identified evidence for factors relating to HRQoL and psychological functioning, offered several considerations for clinical practice, and outlined recommendations for improving the methodological rigour of future research. Paper 2 has been prepared for submission to Psycho-Oncology and presents the findings of a qualitative study of patients’ psychological adjustment to glioblastoma, the most aggressive and most common form of brain tumour in adults. Semi-structured interviews were conducted with 10 participants 3.3-5.1 months post-diagnosis. Data were analysed using a constructivist grounded theory methodology (Charmaz, 2014). Analysis yielded three theoretical categories describing processes of maintaining continuity with the past, reframing the present and changing to accommodate an uncertain future. The implications of these findings on current supportive interventions are discussed. Paper 3 is not intended for publication. It offers a critical appraisal of the individual papers and the research process overall, considering their strengths and limitations. The paper also discusses issues of reflexivity encountered during the empirical study, and considers the implications of this research for the author’s professional development as a clinical psychologist.

Psychotherapists in full-time, long-term private practice face a variety of occupational demands. They usually maintain private practices for long periods of their lives often under difficult circumstances and emotional pressures and have come to sustain their practices. From literature it is revealed that various demands, as well as benefits and successes are part and parcel of working in private practice full-time. These various factors can have an impact on the well-being of psychotherapists. Apart from the literature review, the personal experience of the researcher, a psychotherapist in full-time private practice, also contributed to ideas and hypotheses about the study. From a position of exploration and further enquiry, the researcher was interested to explore the experiences of psychotherapists in full-time private practice from a fortigenic perspective. A second objective was to determine if this study could contribute to the development of the theoretical assumptions of positive psychology. The research is grounded in the theoretical perspective of positive psychology and fortigenesis. Both these fields are relatively new in psychology and seem to still be forging a niche within the discipline. This perspective was deliberately chosen due to the applicability to the exploration of strengths and vigour, with regards to the maintenance of the professional context of the psychotherapist. The qualitative research process is presented in a narrative approach by means of narrative synthesis and synergy. The findings of the research conversations are presented in the form of a literary short story. Suggestions are made about the fortigenic qualities of psychotherapists essential for maintaining their work in full-time private practice. It’s applicability and usefulness is discussed. Furthermore, suggestions are made with regards to the field of positive psychology and the way forward for this sub-discipline. Ideas relating to narrative research and qualitative research are also discussed. / Thesis (PhD)--University of Pretoria, 2010. / Psychology / unrestricted

Introduction The health of young people in England is an area of concern, nationally and internationally. This has prompted a range of strategies and policies to try to address how health may be improved. However, there has not necessarily been agreement as to how this should best be done. There appeared a case for consideration of alternative or additional approaches to health promotion. Aim This research aimed to construct an assets based model to shape health promotion practice and policy for young people in England. Methods A narrative synthesis was undertaken and highlighted the lack of information regarding which assets might be important for young people’s health in England. This programme of research was developed from those initial findings. Quantitative and qualitative methods were employed to gain a more comprehensive understanding than could be gained by individual methods. This mixed methods research involved secondary data analysis of the Health Behaviours in School Aged Children (HBSC) dataset using regression analysis to identify the assets associated with life satisfaction for English youth. Focus groups and interviews were employed to capture the views of young people regarding assets, health and health promotion. Findings were discussed with practitioners to gather their ideas as to the potential of an assets approach. The different research methods were drawn together by the underpinning theoretical frameworks provided by Assets models and the New Social Studies of Childhood. Results Two themes emerged from the narrative synthesis providing suggestions for health promotion; the ecological approach acknowledged the range of settings that young people inhabit, whilst the holistic approach recognised the interrelationship between risks and assets. Critical discussion consolidated the research findings to propose a list of health promoting assets for young people in England; constructive relationships, safety, positive attributes, independence and opportunity. These findings were brought together into a descriptive model to guide health promotion policy and practice (Figure 1). Constructive relationships appeared as a core asset, providing a foundation from which young people could develop. Having positive attributes was also fundamental to this process, which emphasises the importance of promoting physical and mental health simultaneously. Safety was the third core asset identified through the research strands. There was variation between young people regarding the definition of, and priority assigned to, the additional assets of independence and opportunity. Figure 1: Assets model to shape health promotion with young people Conclusion This research contributes to previous work in the field of assets models by providing new insight into the relatively little researched area of assets approaches to health promotion with young people in England. The complex interrelationships between mental health and assets have been highlighted; providing challenge to frameworks that focus on the quantitative accumulation of assets. The inclusion of young people’s perspectives provided new depth to previous theoretical models and interpretation of quantitative findings. The variation highlighted within this research raises implications for tackling health inequalities. This assets based model provides a framework to shape professional practice and policy thus providing the potential to improve young people’s health and wellbeing in a sustainable and non-stigmatising way.

As an innovation Evidence-Based Practice (EBP) is designed as a tool for clinical problem solving. According to its theory of use EBP will bring a difference for policy makers, for professionals, for researchers and for service users. One question to be asked is whether EBP actually leads to the radical social change it is designed to accomplish. The aim of the study is to describe and analyse the outcome of the effort to establish EBP, with a focus on the case of social work in Sweden. The research questions are: What is EBP? Why are efforts made to establish EBP? What is the outcome of the EBP project? How can the outcome of the EBP project be explained? The case study was conducted on a critical realistic meta-theoretical ground with a focus on explanation of social change with an explicit actor-structure perspective. Methodologically, a narrative synthesis of studies was made. As a complement primary data were collected to fill empirical gaps. The state of things was described before and after the EBP-initiatives. Several helping theories – Kuhn’s theory of paradigm, program theory, neo-institutional theory and theory of diffusion – were used to analyse the empirically mapped outcome of the EBP project. The results show that the import of the original model of Evidence-Based Medicine (EBM) to social work is a part of a wider social movement in the helping and educational professions. The new model has influenced social work as a discipline, as a field of practice and as a field of policy. There are examples of full-scale implementations of EBP, although EBP has not reached a general status as daily practice. Some obstacles remain. The gradual adaption of EBP corresponds to criteria hold by Kuhn for a paradigm shift. Acceptance of the model has contributed to change the structure and function of social systems. At an organizational level, this change means on-going institutionalization. The innovation is influencing the way institutional actors conduct their work. Although the structural conditions have been optimal, the EBP-model has been debated with heat. The EBP-debate and policy-driven infrastructural efforts have brought a more in-depth examination of the model. So-called coercive, normative, and regulative isomorphisms were used to change organizations. The degree of institutionalization depended on the individuals and the organizations willingness and preparedness to change, to understand, and to put the model into practice. When actors used a less strict version of the original EBP model, the pace of cultural and institutional change slowed down.