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Evidence is accumulating to indicate exercise, for people with advanced cancer, can result in a range of benefits largely relating to the physical, psychological and social problems caused by the disease and treatment. However, most research has been in specialist settings with professional supervision, a context not possible to replicate for all who would benefit nor for an indefinite period of time. Studies which have investigated supervised exercise followed by a period of unsupervised exercise have found that typically participants do not continue to exercise once the supervised period ends. This study aimed to answer the question: What is the experience of people with advanced cancer participating in supervised exercise programmes delivered in health care facilities, and how can exercise adherence be encouraged and facilitated as people transition to an unsupervised home-based approach? A series of investigations, named here as 'Elements', were developed to explore and answer the research question. The study design was guided by the 'Person-Based Approach', a method of intervention design and development, proposed to encourage intervention acceptability and feasibility. The elements included: Element 1, a mixed method review exploring adherence in advanced cancer; Element 2, a qualitative review exploring how living with advance cancer may impact exercise adherence; Element 3, an empirical investigation of how participants with advanced cancer experience partaking in therapeutic exercise interventions; Element 4, the creation of a conceptual model to show what influences exercise adherence in advanced cancer. Findings from each element generated an increasing understanding of exercise adherence. Element 1 suggests how components of an intervention might influence adherence. Element 2 proposes how factors identified in daily life of people with advanced cancer may impact upon exercise behaviour. Element 3 identifies the meta-theme of 'moments of conscious decision', and the related themes of 'drivers of participation' and 'mitigation and accommodation of impediments'. Further sub themes explain and expand upon those two themes, and demonstrate the differences between the supervised and unsupervised periods. Element 4 demonstrates and explains how 'pre-existing factors', the 'demands of the home exercise protocol', 'home exercise determinants', and 'theoretical mechanisms' interact to influence a person's decision to exercise, and their performance of exercise. Recommendations are discussed in the form of guiding principles as per the person-based approach. These recommendations propose key objectives any intervention should aim to achieve to maximise adherence and key features an intervention should include to achieve those objectives. This study has shown how in order to perform unsupervised home exercise, participants need the 'motivation' and 'self-efficacy' to perform the exercise or the 'agency' to respond positively to occasions when motivation and self-efficacy are inadequate. Attempts to maximise adherence during the supervised period may not have a positive influence upon adherence in the subsequent unsupervised period and may in fact undermine or prevent the development of factors necessary to adhere to an unsupervised home intervention. A stepped approach involving combinations of continuing support and sufficient preparation to exercise without that support, may enhance 'motivation', 'self-efficacy' and 'agency' and lead to enhanced exercise behaviour after completion of supervised programmes.

Background: breast cancer in Ghana is characterised by a high mortality rate with 5-year survival approximated at 25%. This has mostly been attributed to advanced disease presentation. While advanced disease may be a salient factor contributing to the poor breast cancer survival in the country, it is increasingly being recognised that even when women present with early disease, some do not take up and or complete a recommended treatment. Many of these women return later with an advanced disease, which results in poor outcomes. The reasons for this have however, not been adequately explored and understood. The few studies conducted in this area identified pertinent cultural factors such as the disapproval of family members of women who take up surgical treatment (mastectomy), which means women often refuse surgery while other women choose traditional medicine (herbal and/or spiritual healing). Although cultural beliefs, values and practices seem fundamental in breast cancer treatment decision making, these studies were mostly quantitative, which are limited in allowing in-depth understanding. Moreover, studies were conducted on women who started treatment but had not completed the remaining courses of treatment. There was limited focus on women who are newly diagnosed and are considering whether or not to start treatment, which limits understanding concerning this patient group. It is essential to understand these issues in this patient group to guide interventions aimed at supporting treatment decision making in women who are newly diagnosed with breast cancer. This study aimed at exploring and understanding how the cultural context in Ghana influences treatment decision making for women with breast cancer attending a breast clinic in southern Ghana. Ethnographic approach was adopted. 89 hours of participant observation was conducted over a period of 16 weeks (July 2017 to November 2017), at a breast clinic, in a teaching hospital, in southern Ghana. 31 participants (16 women diagnosed with curative breast cancer and yet to start treatment; five nominated relatives; five nurses and five doctors) were included in the study. 29 participants took part in in-depth interviews following participant observation. Fieldnotes andinterview transcripts were analysed thematically and iteratively in keeping with ethnographic data analysis approach. The study found that quality information necessary for breast cancer treatment decision making is hidden from women. Factors that contribute to the hiddenness include unequal power relationships between patients and healthcare professionals (HCPs). Patients ascribed their passive and deferential behaviours to their cultural constructed role as laypersons who needed to submit to the experts. Doctors also deliberately miscommunicated treatment information with the intention of preventing patients from refusing treatment. This unequal power relationship, reinforced by a lack of patients' involvement in treatment decision making and lack of privacy during consultation to facilitate quality patient engagement, contributed to the hidden information around the disease and treatment. Furthermore, a lack of local terms in the local Twi language to explain the concepts in cancer and treatment, a lack of information materials appropriate for the women who attend the clinic, in addition to a prevalence of stigmas and taboos around cancer all act to effectively deny access to or hide quality information from women. Patients fill in the gap left by the lack of information with lay explanations around the disease and treatment. Decision making amongst participants was influenced by factors such as a belief in a spiritual cause of breast cancer; beliefs that cancer is incurable, and that mastectomy actually contributes to death. There were concerns that treatment would disrupt women's day-to-day gender roles, such as housekeeping; breastfeeding; trading; taking care of children, and these influenced their treatment decision making. Awareness of survivors and the belief that treatment will lead to a cure or prevent disease progression influenced women to consider biomedicine. Other factors include faith in God; and the easy access of traditional medicine as opposed the high financial cost (regardless of the National Health Insurance Scheme package) and hidden cost of biomedical treatment. While some of the factors (awareness of survivors; a belief that treat men twill lead to a cure or prevent disease progression and faith in God for bringing healing with biomedicine) pulled women towards biomedicine, majority of the factors pushed women away from it. This study has shown that breast cancer treatment decision making is underpinned by a complex interplay of structures, practices, beliefs and values which strongly influence women against biomedicine. These findings highlight the need for caregivers to be aware of the socio-cultural factors that limit access to quality information. Policymakers should also be aware that the cost of cancer treatment continues to be a barrier despite NHIS package. Policies that aim at addressing this financial barrier and increasing staffing levels with adequate logistics and staff cultural awareness training are recommended. The findings of this study make a significant contribution to the literature on how the cultural context in Ghana influences treatment decision making for women with breast cancer. This calls for a culturally appropriate treatment decision support intervention.

Breast cancer is a disease that continues to rise across the world, and it is now the leading cause of death among Ghanaian women. Currently, an estimated 85% of new breast cancer patients are diagnosed at advanced stages, resulting from delay in seeking modern medical help. Although it is generally acknowledged that early detection and treatment of breast cancer improves survival, it is unclear why the majority of Ghanaian women take longer to present symptoms than those in Western world. The aims of this study are; to ascertain how specific sociocultural issues influence Ghanaian women’s appraisal of breast cancer symptoms, the meaning they ascribed to those symptoms, the significance of this experience on their timing and choice of healthcare utilisation, and whether these factors are different in Ghana from those identified in Western countries. A qualitative design involving purposive sampling was used to recruit 35 patients awaiting their first medical consultation at two healthcare facilities in Ghana, 27 members of the patients’ social networks, and eight healthcare professionals. The interviews were face-to-face audio recorded, semi-structured, and participants completed a demographic questionnaire. Additionally, field notes and a reflective diary were kept as supportive data. Thematic analysis was conducted to identify relevant themes. A computer software package was used for data management. The study found four main influential factors that contributed to late presentation within the sample; these are patients’ sociocultural backgrounds, specific manifestation of breast cancer signs, patients’ emotional responses towards those signs and symptoms, and existing healthcare system. The study has deepened the understanding of appraisal and help-seeking behaviour of Ghanaian women who discovered breast cancer symptoms. These insights would assist healthcare professionals to implement interventions capable of encouraging early symptom detection and presentation for modern medicine treatment.

Evidence suggests that non-adherence to medicines is an ongoing problem for people with diabetes and can adversely affect mortality, morbidity and health outcomes. Recent evidence and national guidance has reported patients’ medicine beliefs as an important antecedent of non-adherence, however, a review of the entire medicine beliefs literature has yet to be conducted and no research has explored the experience of nurses and patients involved in an exploration of patients’ medicine beliefs in routine practice settings. Conclusions from chapters 2 and 3 indicated nurse prescribers’ are not, but should be, exploring patients’ medicines beliefs in routine practice to optimise adherence and health outcomes. A mixed methods concurrent triangulation design was used to (a) quantitatively observe and measure nurse prescribers’ exploration in routine consultations, (b) qualitatively investigate the barriers and facilitators to nurse prescribers’ exploration, and (c) qualitatively investigate diabetes patients’ perceptions of consultation discussion having participated in consultations whereby nurse prescribers’ explored diabetes patients’ medicine beliefs. Findings were integrated in order to develop additional inferences. Fourteen nurse prescribers’ audio-recorded 154 routine consultations with diabetes patients over several time-points and 620 instances of medicine discussion were observed. Medicine beliefs sub-concepts, concerns and necessity, were conceptually mapped to MEDICODE themes and the analysis indicated nurse prescribers’ were moderately exploring patients’ medicine beliefs. A thematic analysis of thirty interviews with nurse prescribers identified a range of nurse, patient, and contextual tensions that influenced nurses’ exploration attempts. These included patients’ willingness to engage, different exploration approaches by nurses, patient characteristics, and a wide range of contextual problems such as inadequate time, disruptive settings, and competing agendas. Thematic findings from 28 patient interviews also identified a range of perceptions about the experience of having their medicine beliefs explored. Nurse-patient rapport was considered vital for exploration by both nurses and patients. All three study components were integrated in the discussion and developed into a conceptual model of the perceptions and influences on patients’ medicine beliefs exploration by nurse prescribers. This thesis was the first attempt to understand the practical reality of this consultation activity. Exploration of patients’ medicine beliefs in routine practice settings was difficult and subject to a number of tensions, facilitators and barriers within the context of diabetes care. Importantly, future research can utilise these findings to develop strategies to support interventions.