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In the 21st century, young Christian women struggle with understanding and applying practical aspects of Biblical womanhood in their day-to-day lives. Extreme views make it difficult for young women to navigate life in a way that makes sense in the cultural context of the 21st century. Young women today struggle to utilize the full range of talents and gifts that God has given them, and more importantly, they struggle to align their lives with Scripture. The lack of knowledge concerning what Biblical womanhood is, combined with confusion about how it is applied, impacts not only the women themselves, but everyone in their close social networks, their families, their husbands (or husbands-to-be, if applicable), their children (if applicable), and the church body. The research conducted in this thesis showed that while a plethora of literature, Bible studies, and other resources dealing with Biblical womanhood exist, many of these resources do not address or celebrate the unique situations of young Christian women and the different ways in which Biblical womanhood can manifest itself in the lives of women. Additionally, many of these resources do not account for the unique situations of young women in postmodern America or how these women can embody Biblical womanhood even if they are not married and/or do not have children. This body of work seeks to acknowledge, celebrate, and destigmatize the incredible beauty and variety of Biblical womanhood, as well as its common threads, or foundation based on principles found in Scripture through a historical grammatical approach. By working in a modernized 1950s aesthetic, I aimed to accomplish these goals and to celebrate the importance of Biblical womanhood in the church and family; and its beauty. God gifted women in unique ways to reflect His image, bring Him glory, and fulfill God’s mission for the global and local church, the home, and society.

Background: Breast cancer-related upper limb lymphoedema (ULL) is a common sequelae of breast cancer treatment and early treatment is recommended (McLaughlin et al., 2017). Expert guidance recommends offering 2-phase decongestive lymphoedema treatment (DLT), although evidence is lacking for current treatment protocols (International Society of Lymphology, 2020; National Institute for Health and Care Excellence, 2009). However, women in the UK are routinely offered self-treatment with hosiery (Lymphoedema Framework, 2006). Aim: To determine the feasibility and acceptability of a trial to compare initial intensive-DLT with usual UK lymphoedema care for women newly presenting with ULL within 12 months of symptom onset (early-ULL). Methods: A systematic review of the evidence for clinical effectiveness of DLT for women with less than 12 months ULL duration (early-ULL) was undertaken using the Joanna Briggs Institute (JBI) method. The PICO framework was used to develop eligibility criteria and keywords for the search which was conducted in 2016, with updated searches in 2018 and 2022. The methodological quality of identified studies was assessed using the JBI critical appraisal instruments. Outcomes of interest were extracted using a form adapted from the JBI data extraction tool and results displayed in narrative and tabular format. The strength of evidence was rated using the GRADE system. Three studies were conducted between 2015-2017 using mixed methods and pragmatic study design. Study 1 used five focus group discussions in 2015 with 13 women and 13 lymphoedema practitioners to separately explore their experiences and opinions regarding lymphoedema treatment, assessment methods, use of intensive-DLT, and acceptability of the proposed feasibility study. Study 2 was a modified Delphi-method survey conducted as a one-day consensus event in 2015 with a panel of 13 UK expert clinicians and five service users using electronic voting technology to maintain anonymity. The survey considered five key areas of uncertainty relating to the proposed feasibility study and design of a future definitive trial, including components of the study population and proposed study interventions, treatment outcomes and defining criteria for successful and meaningful outcomes. Study 3 addressed the feasibility of conducting a future trial of treatment effectiveness for women with early-ULL. The original protocol for a feasibility randomised controlled trial (RCT) could not be conducted because lymphoedema services lacked capacity to provide the study intervention, so was redesigned as an observational mixed methods study to address most of the original study objectives. Forty-five women-participants and 11 lymphoedema practitioners were recruited from two study sites. Women completed three study visits over a three-month period with collected data including clinical measurements of arm size and symptom severity and self-report questionnaires which explored the impact of ULL and feasibility of the proposed trial. Subsequently, a subgroup of six women and six practitioners were interviewed to explore their study experiences and the acceptability and value of lymphoedema treatment and outcome measures. Results: The systematic review identified eight RCT and three descriptive studies providing weak evidence (grade B) for the effectiveness of decongestive treatments for early-ULL. No study recruited only women with less than 12-months duration, so studies were included when the mean ULL duration was < 9 months or findings were reported for one eligible group and the ineligible group excluded from the review. Heterogeneous data prevented comparison of findings for different treatment combinations. There is no evidence to justify change in current UK lymphoedema treatment. Study 1 found that women typically received self-treatment with hosiery, with women and practitioners having mixed views on whether this was optimal treatment. They highlighted the lack of service capacity to provide intensive-DLT to their patients and supported the notion of early intervention but differed in views on the role of intensive-DLT. Participants supported the need for a trial to identify effective treatment for women with previously untreated ULL. No group clearly articulated criteria for a good clinical outcome and all were unsure of what were reasonable expectations of treatment and appropriate treatment goals, but they all considered arm volume an important outcome. Study 2 found that experts agreed regarding key eligibility criteria for the future study, data collection necessary to describe 'usual' care, priority study outcomes and components of the comparator and one of the proposed interventions (classic intensive-DLT). They lacked sufficient expertise to agree the role of intermittent pneumatic compression within the proposed second study intervention (modified intensive-DLT) and were unable to define the criteria for treatment success or agreement on a clinically meaningful reduction in excess arm volume (EAV). Study 3 found that most feasibility criteria were achieved, including retention to the study with 80% completing all three study visits and 99% of possible data collected. Women reported the proposed study measurements and self-report questionnaires were acceptable. 'Usual' care, the future comparator, was confirmed to be self-treatment with hosiery, exercise, and skin care, with simple lymphatic drainage not routinely prescribed. Recruitment was below target, due to fewer than expected eligible women, and only five had untreated early-ULL. Their presenting excess arm volume was a median 6% (minimal swelling) which is below the typical 10% threshold for ULL research. Therefore, recruitment to a future trial could be challenging and would require multiple sites. Practitioners expected capacity to screen women for a future trial but that there would be lack of capacity to deliver the study intervention. An unexpected finding was that some practitioners thought many lymphoedema clinics would be unwilling or unable to implement trial findings which favoured intensive-DLT even if this was demonstrated to be more cost-effective than usual care alone. Other original feasibility criteria that could not be tested with an observational study included the intervention processes and their acceptability and testing the effect size for calculating the sample size for the future trial. Conclusion: There is a lack of evidence for the most effective treatment or combination of treatments for women presenting with early-ULL, and the optimal duration and frequency of treatment is unknown. The study findings demonstrate the need and desire of women and practitioners for robust research to determine the most effective and cost-effective treatment for women with early-ULL. The findings suggest it would be possible, with sufficient time and funding, to recruit an adequate sample and conduct a definitive trial. Further work is required to address those feasibility criteria which could not be tested in this observational study and to explore factors which would affect implementation of future findings which favour intensive-DLT. The findings suggest it is not prudent to continue with the proposed definitive trial as, due to current challenges for lymphoedema services which lack capacity to provide initial intensive-DLT, it is likely that future findings which favour intensive-DLT for women with early-ULL will not be implemented. Instead, researchers and clinicians should develop tools and strategies to equip women with knowledge and skills to improve treatment adherence and self-monitor their progress toward clearly defined and realistic goals; this should maximise treatment benefit and minimise treatment burden. Finally, this thesis has highlighted the need for UK practitioners and women to discover what can be achieved with the best available treatment, which is likely to be a form of self-treatment, particularly for women with early-ULL. Further work is required to identify facilitators, motivators, and barriers to implementing two-phase DLT as usual care for UK lymphoedema services. The study findings also demonstrate an urgent need for a national strategy to build lymphoedema research capacity in the UK and improve lymphoedema service provision. The findings of this feasibility study will be useful to researchers intending to study treatment effectiveness for women with ULL.

Prostate cancer diagnosis and treatment give rise to challenging physical and functional outcomes that can have long-term consequences for men's psychological and emotional well-being. A significant proportion of men experience psychological problems post-diagnosis and as a consequence of treatment. In recent years, improved treatments and screening mean men can enjoy longer survival, but if they are to live better rather than just longer, there is a requirement for timely psychological support in survivorship. Many men living with and beyond prostate cancer are reluctant to accept psychological support, which means that if support is to be provided it has to be emotionally relevant and engaging. Web-based programmes that incorporate user-driven models of communication and dialogue, whilst also reflecting men's illness identity, can achieve this. The thesis that follows considers the uniquely important characteristics and psychological support needs of this prostate cancer population; the extent to which they are being met and how men's experiences can be brought to the forefront in the development-to-implementation pathway of web-based intervention. Five publications form the central part of this research. A literature review article examined adjustment-focused and problem-focused psychosocial interventions for men with prostate cancer; it recommended that for beneficial outcomes there is a need to specifically address men's distress. A further publication reports the feasibility of a self-management intervention to help men cope with urinary symptoms after radiotherapy treatment; this study spawned recognition of the need to provide peer support and gave rise to a subsequent randomised controlled trial of the same intervention which incorporated filmed peer support based on participatory research methods. The third publication reports a large-scale survey to examine men's unmet supportive care needs after diagnosis and treatment for prostate cancer across seven European countries; this highlighted the long-term prevalence of men's need for support and its relationship with the health care support they had received. The next publication provided insights into men's experiential empathy by analysing the original filmed interviews to explore how men communicate their emotional reactions and coping strategies to other men. The most recent published article represents the culmination of learning from these previous studies and reports the development and feasibility testing of a web-based intervention, Getting Down to Coping, to help reduce men's psychological distress after diagnosis and treatment for prostate cancer. Developed in full collaboration and partnership with men with lived experience of prostate cancer the intervention offered cognitive-behavioural therapy and filmed peer support, whilst incorporating persuasive design techniques to encourage men's engagement and adherence. The intervention was uniquely developed for delivery within a clinical service for men with prostate cancer with clinically screened distress. The introduction chapter of this thesis discusses men's psychological needs, how these are not being met, and how web-based interventions can meet these needs. It then examines the research literature that sets the context for the web-based programme, Getting Down to Coping. The second chapter presents the five submitted publications. The concluding chapter explains the overall contribution of each publication to the programme of work and the wider knowledge base. The challenges and recommendations for moving the work forward to support psychological care for men living with and beyond prostate cancer are also presented.

Background information The premise of this study was that hearing deterioration, associated with treatment for head and neck cancer, has a negative impact on patients' quality of life. However, there have been no studies to assess this phenomenon in people receiving current UK treatment, and there is little information on the impact of subsequent hearing deterioration. Objective This study, conducted in one UK hospital, aimed to investigate the incidence and severity of hearing deterioration, and patient experience of it, following treatment for head and neck cancer. Design A sequential mixed methods explanatory design was chosen as it was the most appropriate for addressing the research aims. A critical realist framework underpinned the study. A prospective observational repeated measures design was employed to obtain quantitative data in Phase 1 of the study to assess changes in hearing at the end of treatment, and at 3-month follow-up post-treatment, using pre-treatment test level comparison. The Common Terminology Criteria for Adverse Events (version 4.03) were used to determine the incidence and severity of hearing deterioration. Results from Phase 1 were used to inform selection of participants for Phase 2 of the study. An approach informed by phenomenology using interview methodology, was used to explore patient experience of hearing deterioration. Study sample Fifty adults who had been diagnosed with head and neck cancer were recruited to Phase 1 of the study using a consecutive sampling approach. These participants were due to receive standard UK curative radiotherapy (intensity modulated radiotherapy) or chemoradiotherapy (including the use of cisplatin or carboplatin). From the 50 participants recruited, 13 who had hearing deterioration were selected using purposive sampling for one-to-one interviews to obtain in-depth information on their experience of hearing loss. Results The incidence of hearing deterioration was 57% in the 42 participants who completed testing at the end of treatment, and 50% percent in those who completed 3-month follow-up testing. At 3-month follow-up, 26% of participants had major (Grade 3) hearing deterioration in at least one ear. Patients who had chemoradiotherapy were more likely to experience hearing deterioration compared with those who had had radiotherapy only (p=0.01). Older patients were more at risk of hearing deterioration than younger participants (p=0.03), but if hearing deterioration occurred it appeared that younger patients suffered more severe deterioration than older patients (p=0.02). Aural change (including hyperacusis) experienced by some participants during treatment required a change in treatment regimen for them. Participants reporting either minor (Grade 1) or major hearing deterioration were adversely affected by their aural symptoms that manifested with treatment, and the impact of tinnitus (the incidence of which is not covered by existing studies), was extensive in head and neck cancer survivors. Another emerging finding in this study was that middle ear dysfunction, in the early post treatment phase, had a negative impact on patient experience. A further novel finding was that participants with bilateral mild-moderate or moderate severity, mid-high frequency sudden-onset hearing loss required lip-reading to assist their communication. There was evidence that some participants played down their aural symptoms, yet hearing deterioration had a negative impact on their overall quality of life, including generating a sense of loss (principally in older patients) and isolation (associated with younger patients). Finally, there was varied experience among participants receiving information on their hearing test results and on the process of receiving support for their hearing and tinnitus concerns. Conclusions and recommendations This current study provides evidence that could be used to increase awareness of the potential scale and impact of hearing deterioration following head and neck cancer treatment, in the early post treatment period. A larger multi-centre UK study would test the issues identified in the study to inform national policy, clinical practice and education. The study suggests a number of changes for consideration in improving current clinical practice when designing care provision of patients preparing for and recovering from radiotherapy or chemoradiotherapy for head and neck cancer. One key recommendation is for the adoption of a multidisciplinary approach in developing appropriate protocols to inform and support patients about hearing and tinnitus concerns that may occur with their treatment.

Inflammatory bowel disease (IBD) affects 300,000 people in the United Kingdom (UK). The condition is characterised by periods of remission and relapse. Forty percent of people with IBD in remission and 72-86% of people with active IBD report fatigue to be their most troublesome symptom. IBD-fatigue affects people’s daily functioning and impacts on their quality of life. However, there is limited understanding of the concept of fatigue and the impact that fatigue has on the everyday life of people with IBD. There are no previous studies exploring how people try to manage IBD-fatigue on a daily basis. Aims: This study aims to explore the concept of fatigue as experienced by people with IBD, what impact fatigue has on their lives, and how they manage it. Methods: Descriptive phenomenology was used to achieve the aims of the study. One-off in-depth interviews were conducted with twenty participants. Interviews were digitally recorded and transcribed verbatim. Data were analysed using Moustakas’ method (1994). This involved analysing the data at individual and group levels for textural and structural descriptions. Results: Five main themes, with many textural and structural sub-themes were identified. A wide range of terminology, including metaphors and similes, were used to describe fatigue reflecting its complicated and complex nature. Fatigue was presented as invisible, unpredictable, with constantly fluctuating daily patterns and severity. This made reporting fatigue difficult and at times lead to participants being challenged about its authenticity. The array of physical, psychological, cognitive and situational factors were perceived to contribute to fatigue, and different methods (e.g. sleep and rest, pacing, energy preservation, exercise, stress reduction, asking for help) were attempted by participants to manage fatigue. Most methods were not used systematically, possibly resulting in their apparently limited effectiveness. Impact of fatigue was perceived as negative, with participants constantly comparing their life and themselves as they were before fatigue and how much they have lost. They felt that fatigue is in control of their life and each day they had to fight another battle to defeat fatigue. Participants felt imprisoned in their fatigued unreliable body leaving them frustrated, isolated and lacking self-confidence. They reported loss of self and self-identity, resisting to accept the ‘new fatigued me’. Conclusion: Due to its complicated and complex nature, IBD-fatigue is not fully understood by individuals affected by it, and they have difficulties clearly explaining it to others. The invisibility of IBD-fatigue often leads to its existence being questioned by self and others. The negative and debilitating impact of IBD-fatigue affects all aspects of an individual’s life. Individuals affected by IBD-fatigue need support from healthcare professionals to help them to understand and manage this complex symptom. The findings from this study need to be taken into consideration by healthcare practitioners involved in the care of IBD patients. To fully understand the phenomenon of fatigue a longitudinal study is required to explore fatigue over time.

Cancer survivorship is increasing year on year due to an aging population and improvements in cancer screening and treatments. The experience of survivorship can be challenging; individuals living with and beyond cancer can face a burden of survivorship. Cancer survivors not only experience symptom burden (the severity and impact of biopsychosocial consequences of disease and its treatment), there is also evidence that individuals living with chronic conditions experience treatment burden (the ‘work’ required of them in managing their condition and its symptoms). Traditional clinic-based approaches to relieving the burden of cancer survivors may not be sustainable or the most beneficial. eHealth interventions are developing exponentially and there is an expectation that they can improve the experience of cancer survivorship. This thesis considers the impact of eHealth supportive care interventions on the burden of those living with and beyond cancer, reporting the experience of adult cancer survivors and the perceptions of health care professionals (HCPs). Five publications form the body of this thesis. The first publication indicates that while most cancer survivors want to be fully informed many do not receive sufficient information in all areas (e.g. psychosocial issues), thus supporting the consideration of alternative approaches to providing cancer survivors with supportive care. Two publications report positive impact of a telephone follow-up intervention on the burden of survivorship. Two publications consider HCP perceptions of remote symptom monitoring and internet care plans. These papers report that HCPs perceive eHealth interventions to increase burden for specific groups of cancer survivors depending on individual patient factors, the context of their care, and the content of the intervention. This body of work supports the potential of eHealth to alleviate the burden of cancer survivors but acknowledges that the complexity of for whom and how these benefits occur warrants exploration through further research. Involving cancer survivors and HCPs in the development of eHealth supportive care interventions is key to creating and implementing sustainable effective solutions to relieving the burden of future cancer survivors.

Cancer chemotherapy can reduce immunity. The lowered immune response increases the risk of infection that can develop into a life threatening secondary complication called neutropenic sepsis. The neutropenic sepsis causes a significant number of hospital admissions and an estimated 700 deaths within the United Kingdom (UK) each year. Delays in patients reporting symptoms of neutropenic sepsis may exacerbate the problem, causing longer and more costly hospital stays and a greater risk of death. Furthermore, chemotherapy treatment may also be delayed, which may affect prognosis. This study took an ethnographic and constructivist grounded theory approach to develop a theory to explain why patients delay presenting to hospital with neutropenic sepsis. A longitudinal element of the study involved non-participant observation of women with breast cancer being provided with information about neutropenic sepsis by oncology doctors and chemotherapy nurses. Interviews were carried out, with observed patients following the observation and at the end of treatment. A retrospective element involved interviews with women with breast cancer who had developed neutropenic sepsis, their carers and doctors and nurses who worked within oncology and Accident and Emergency (A&E) departments. Analyses commenced with the earliest data gathered and a rich theoretical picture was built through comparing perspectives, pursuing areas of inquiry and recruiting particular participants who became of interest to the developing theory. A grounded theory evolved, which suggests patients may delay presenting to hospital with neutropenic sepsis because the seriousness of it is underplayed by clinicians, patients and their carers. Findings of this study have immediate implications for clinical practice to ensure patients and their carers are adequately supported by clinicians to understand the seriousness and be equipped to identify and report neutropenic sepsis. Furthermore, study findings should inform the design of future research to develop interventions, to promote earlier recognition and treatment for this important chemotherapy complication.