Purpose: Survival from childhood, teenage, and young adult cancer has increased substantially, with approximately 80% now surviving at least five-years. However, curative treatments are often associated with adverse late effects. This thesis investigated the risk of late adverse health and social outcomes following five-year survival of cancer diagnosed before age 40 years using the British Childhood Cancer Survivor Study (BCCSS) and Teenage and Young Adult Cancer Survivor Study (TY ACSS). Material and Methods: The BCCSS is a population-based cohort of 34,489 five-year survivors of childhood (< 15 years) cancer diagnosed from 1940-2006 in Great Britain. The TY ACSS is a population-based cohort of 200,945 five-year survivors of teenage and young adult (15-39 years) cancer diagnosed from 1971-2006 in England and Wales. Results: Some survivors were found to have increased risks of premature mortality, subsequent primary neoplasms, hospitalizations, poor quality-of-life, and psychosocial limitations. However, for premature mortality, the number of excess deaths is decreasing among those more recently diagnosed for several causes-of-death. Conclusions: Survivors of cancer diagnosed before age 40 are at an increased risk of a range of adverse late effects compared to that expected. The findings reported in this thesis will be useful for risk stratification, updating clinical guidelines, and informing survivors and clinicians.

‘Early diagnosis’ of Autism Spectrum Conditions (‘ASC’ hereafter) is often promoted as universally beneficial. Despite research identifying the earliest possible reliable diagnoses (at 14-24 months), many are diagnosed later in childhood, adolescence or adulthood. This study aims to: (i) explore the reasons for later diagnoses of ASC; and (ii) understand the impact of this on parents. Narrative methodology (including narrative interviews), afforded the unique benefit of keeping individual, chronological stories intact. This allowed exploration of both explanatory narratives (reasons for later diagnosis) and descriptive narratives (impact of later diagnosis) of two parents of young people who had received a ‘later’ diagnosis of ASC (aged 12 years and 16 years). Findings suggest that later diagnoses were interpreted to have arisen from a complex and highly individualised web of interacting factors. There were considerable differences in parental perceptions of the most beneficial time for the diagnosis, in hindsight. I advocate, therefore, an interactionist conceptualisation of ASC across the lifespan, and suggest that ‘early’ diagnosis is not always possible, necessary or beneficial. I invite further research to build upon these findings, with the ultimate aim of improving experiences and outcomes for children, young people and adults with autism and their families.

The quality of healthcare is increasingly the subject of scrutiny by a range of stakeholders, including healthcare provider organisations, health professionals and their representative bodies, healthcare purchasers and funders, policy makers and national governments, patients and users of health services. The use of a variety of quality measures has become widespread in the healthcare systems of many developed countries, including the United Kingdom. The twin tasks of measuring and improving the quality of care - often termed quality assurance - have been addressed by new arrangements for professional accountability, new approaches to managing and comparing organisational performance, and new statutory and legal mechanisms. Adverse events in healthcare, which can be loosely defined as instances which indicate or may indicate that a patient has received poor quality care, offer an important opportunity for quality measurement and improvement. There is extensive evidence that adverse events are relatively common, that they can have serious and lasting impacts on patients, and that they represent a considerable cost to healthcare organisations. Equally importantly, evidence in healthcare and experience in other sectors suggests that adverse events offer an important insight into the strengths and weaknesses of healthcare processes, and an invaluable opportunity to bring about improvements in the quality of care. Adverse events have been used quite widely, particularly in the United States of America, as the basis of a number of measures of the quality of healthcare. However, these measures have rarely been developed and tested rigorously before they have entered widespread usage, and there has been considerable debate about their advantages and disadvantages. A series of empirical studies were undertaken, using data collected through the use of adverse-event measures of quality in a British acute hospital, aimed at investigating the validity and reliability of those measures. The results showed that the adverse-event measures being tested had moderate to good face, content and construct validity. Although their validity was capable of improvement, it was still clear that they were measuring meaningful and important dimensions of the quality of healthcare. However, the reliability of the measures being tested was more mixed. While experimental studies of interrater and intrarater reliability indicated that they had moderate to good reliability (though, again, it was capable of improvement) observational studies suggested that the reliability in actual use might be lower than that found during testing. This research concludes that adverse-event measures of quality are important measures of the quality of healthcare, which should be used in healthcare quality assurance with two main provisos. Firstly, the development of measures should be more rigorous, and should pay more attention to both validity and reliability issues. Secondly, the routine use of such measures should incorporate some element of ongoing reliability testing, in order to ensure that good reliability is maintained.

This thesis investigates the adverse outcomes amongst survivors of childhood cancer using the British Childhood Cancer Survivor Study (BCCSS) and the Pancare Childhood and Adolescent Cancer Survivor Care and Follow-up studies (PCSF). The specific aims were to investigate (1) adverse outcomes up to 50 years of follow-up in survivors of Wilms’ tumour; (2) risks of hospitalisations due to renal morbidities in childhood cancer survivors; (3) risk of subsequent primary neoplasms arising in the digestive system in survivors of childhood cancer; and (4) adverse outcomes beyond 50 years of follow-up in survivors of heritable retinoblastoma. This thesis demonstrated that survivors of Wilms’ tumour are at substantial risk of premature mortality, particularly for those who have survived 30 years from original diagnosis. This particular group of survivors have the highest risk of hospitalisations due to renal morbidities, such as chronic renal failure, and subsequent primary neoplasms in specific organs in the lower digestive system. Survivors of heritable retinoblastoma who received external beam radiotherapy experienced an increased risk of subsequent primary neoplasms developing above the shoulder, whereas those who received brachytherapy were similar to those who did not receive any radiotherapy and did not experience an increased risk of subsequent primary neoplasms.

This thesis is a corpus-based study of two spoken academic corpora in English as the (foreign) medium of instruction (EMI) context. The first corpus is compiled of transcripts of academic lectures by non-native speakers (NNS) from an EMI medical college in Saudi Arabia. To compare the data, a second corpus is compiled of similar transcripts by native speakers (NS) taken from the British Academic Spoken English (BASE) corpus. The first part of the research qualitatively and quantitatively investigates the use of English discourse markers (DMs) on two levels: Structural (e.g. okay, so, because) and Interactional (e.g. okay?, I mean, any questions?). Structural DMs are found to function frequently as Topic Initiators, Topic Developers, Summarizers, and Closers, and occur more frequently in NS lectures' discourse. Interactional DMs, which function as Confirmation Checks, Rephrasers and Elicitors, are found to occur more frequently in the NNS lectures. This thesis demonstrates that the uses of DMs by the NS and NNS lecturers are affected by discourse context, pedagogic goals, personal lecturing styles, interaction with students and the need to create a conducive learning environment. The second part explores the use of Arabic discourse markers (ADMs) in the NNS lecture discourse on similar Structural and Interactional levels. Interactional ADMs (e.g. ya3ni {means}, mufhoom? {understood}) have a higher overall frequency than Structural ADMs (fa {so}, laanu {because}). The third part of this thesis explores the pedagogical functions of English-Arabic code-switching (CS) in the NNS lectures. When the purpose of CS is to make meaning clearer and convey knowledge more efficiently, it is not a language barrier but an effective communicative strategy. The data shows that CS is used mainly in seven roles in the NNS lecture discourse: (1) solidarity, (2) reiteration, (3) elaboration, (4) topic, (5) elicitation, (6) checking comprehension and (7) classroom management.

Background: Breastfeeding has the potential to significantly improve public health. As part of UK government policy peer support interventions have been recommended to increase breastfeeding rates but the evidence base for this is of low quality. Methods: The aim of this thesis was to investigate the effect of breastfeeding peer support on initiation though a systematic review; on continuation through an RCT and a systematic review; and to explore women’s experiences through a qualitative study. Results: Universal peer support to improve breastfeeding initiation was ineffective. Peer support for breastfeeding continuation in both the RCT and review findings appears to be effective in low/middle income countries; when provided in an intensive schedule of contacts (>5 contacts); and given in the postnatal period. Women’s experience of peer support is generally positive and those interviewed gave several suggestions to how current local services may be modified. Conclusions: Peer support per se, in any format in the UK-setting, has not been supported. Targeted and intensive peer support may improve breastfeeding rates in the UK but this must be evaluated using high-quality methodologies. Peer support appears to be effective in the developing world, were it is intensive and targeted to those already considering breastfeeding.

Head and neck cancer (H&NC) and its possible treatment options are diverse and multifaceted. This thesis demonstrates these complexities and describes three studies that have used different methodological approaches to include, rather than overlook these aspects. The first established which aspects of patients’ experiences are overlooked if health care professionals rely upon health related quality of life questionnaires to represent the experience of patients. The second identified that the multi-disciplinary team (MDT) working with the patients use humane judgement, not technical expertise, to predict patients’ symptoms pre treatment. The third, with reference to the previous two, used Q-Methodology to explore the experience of H&NC patients during and after their treatment. Five interpretations were identified: • Meaning and attachment to illness • Overwhelmed by the disease • Change and recovery • Surviving or not • Keep control- for the greater good of others This unique study has developed a framework through which the MDT can start to translate H&NC patients’ experiences and help enable them to influence their care directly. It also suggests ways in which the framework can be applied to the clinical environment.

This thesis consists of research and clinical components and is submitted as partial fulfilment of a doctorate degree in Clinical Psychology. Volume 1, the research component, comprises of a literature review, an empirical paper and a public domain paper. The systematic literature review looks at evidence linking attachment and caregiving in adult couples. The empirical paper explores the experiences of individuals with a partners diagnosed with Motor Neurone Disease (MND). Lastly, a public domain provides a summary of the empirical paper. Volume II, the clinical component, contains clinical practice reports conducted within placements from adult, child, learning disability older adult specialities. The first report contains a behavioural and systemic formulation of a 3 year-old who was referred as her mother was having difficulties managing her behaviour. The second report describes an evaluation of the Experiences of practitioners interpreting and delivering Triple P (Positive Parenting Programme) groups in South Asian Community languages. The third report presents a single case experimental design concerning a behavioural approach to challenging behaviour displayed by a 7-year old boy with learning disabilities and autism. The fourth report is a case study of a Cognitive Behavioural approach used with a man diagnosed with Persistent Paranoid Delusional Disorder. Finally, the fifth report is an abstract of an oral case presentation of a small-scale service related project around a multiple family therapy group for adolescents with anorexia nervosa.

Magnetic Resonance Spectroscopic Imaging (MRSI) is a functional MRI technique allowing non-invasive biochemical mapping of the brain. MRSI is advantageous for characterising many neurological conditions; however, its clinical application is limited by lengthy scan time and low spatial resolution, which are intrinsically linked. This research investigated the potential of Compressed Sensing (CS) to speed-up MRSI or enhance spatial resolution. CS allows accelerated acquisition by reducing the data sampling requirements, whilst preserving image quality. The focus of this work was the effect of CS-MRSI at different acceleration factors upon spatial integrity. CS reconstruction software was developed and applied to retrospective MRSI data. Imaging test objects and software simulations were developed to assess MRSI spatial resolution via metabolite edge response measurements. CS-MRSI was also investigated in realistic scenarios using data from healthy volunteers and a child with Optic Pathway Glioma (OPG). The potential of CS-MRSI to enable high-resolution MRSI in feasible scan times was investigated using simulations of focal and infiltrative OPG. Results suggest that CS-MRSI can reduce scan duration by up to a factor of 5 whilst simultaneously eliminating ringing artefacts and increasing spatial resolution compared with conventionally filtered MRSI. Therefore, CS could greatly increase the clinical utility of MRSI.

Over 275,000 women died of pregnancy related causes in 2015. Most occur in resource-poor settings and are preventable. This study aimed to improve the working lives of maternity healthcare workers in Malawi to enable delivery of higher quality care, using Appreciative Inquiry (AI); a positive-focused, participatory action cycle. Following a systematic review and narrative synthesis of AI, an ethnographic study and Interpretative Phenomenological perspective were utilised to understand working lives. Before the intervention was implemented, working lives were assessed through validated questionnaires for staff and patient satisfaction surveys. AI has been used in healthcare, but little empirical evidence for its effectiveness exists. Staff wanted to do a good job, but were confined by a lack of resources, knowledge and support. The longitudinal survey of staff showed significant improvements in general wellbeing and home-work interface, and patient satisfaction improved. AI also improved staff relationships and made work easier and happier. Qualitative work suggested this was because staff were working better together, underpinned by everyone meeting together. From these findings a theory of change was developed. AI showed great promise. However, further research, in the form of a large-scale trial, is needed to empirically demonstrate the effectiveness of AI in healthcare.