thanks to the new friends I have made during my PhD who have helped me through this time in my life. Atiya, Frauke, Phil, Malcolm, Sarah, Sophie & Mike, I appreciate your friendship in times of need and I hope that I will be able to repay this debt when it comes to you submitting your theses. Most of all, I need to thank Kevin for his constant support and friendship. I could not have done this without you. Finally, I would like to acknowledge the ladies and their families who have taken part in my research and who have shared such an important time in their lives with me. I dedicate this PhD thesis to them. Chapter 1: Introduction There are more than 200 types of cancer, and each has different causes, symptoms and treatments. In 2010, 324,579 new cases of cancer were diagnosed in the UK (around 890 people every day), and in the same year, about 1.8 million people are living with and/or beyond a cancer diagnosis (Cancer Research UK, 2010). The following thesis focuses on one group of cancers called gynaecological cancer. This chapter will introduce some of the relevant government literature that is pertinent to the diagnosis and treatment of cancer, with an extended section on the importance of patient reported outcomes. The chapter will then introduce the topic of gynaecological cancer and the different treatments that are commonly used; some of the psychological issues associated with the diagnosis and treatment of cancer will be discussed. Finally, the literature surrounding stress (and subsequent coping) that is relevant to gynaecological cancer is explored, and an overview of the research questions answered within this thesis will be presented. Government policy surrounding the provision of cancer services In 2007 the Cancer Reform Strategy set a clear direction for the development of cancer services in England over the following five years (DoH, 2007). The 2007 strategy highlighted that it was essential for patients and survivors of cancer to have access to services that
Multilevel Modelling Multilevel Models (MLMs) contain variables that are measured at different levels. These levels are nested within each other and form a hierarchy. MLMs explicitly model the hierarchical nature of data at each individual level within the hierarchy, starting with the lowest level. MLMs can also be used to analyse repeated measures data where the data from each individual is analysed (in this case over the 11 weeks) on the individual level and then incorporated into a higher level analysis (in this case intervention group). MLMs fit a straight line to each individual’s data from the dataset based on a simple linear regression, allowing for the intercepts to vary dependent on the individual, but assume that these intercepts fall within a normal distribution (Kreft & de Leeuw, 1998). Rationale for using the model In the current research it is clear that the data is grouped or nested in a hierarchical structure. Variation at the individual level is likely to be nested within the intervention level. Thus the random component (individual level) needs to be modelled within the fixed component (intervention level), making the MLM framework highly applicable. Additionally, this type of analysis has also been used in previous research using diary methods when exploring the efficacy of yoga for patients with cancer, which highlight its potential use in this research (Carson et al., 2007). Analysis of the Data GAM, GLS and MLM analyses were conducted separately on visual analogue raw scores and change scores. The first set of analyses was conducted using the visual analogue scale scores over the 11 weeks. The raw scores were used for this analysis allowing us to account for actual variation between the two intervention groups. Change scores were computed by subtracting the week 0 score from the week in question, so for week 4, the equation was (VAS week 4 score – VAS week 0 score = Week 4 change score). Use of the change in VAS scores relative to week 0 (as week 0 was a baseline control) allowed for observation of any trends/relationships between the intervention and time, and the effect it had on the change in QoL from week 0. This analysis allowed us to see if there were any differences between the groups taking part in the intervention independent of their starting QoL.
Please note: diagram removed for copyright reasons, please see caption for reference information. Discussion of recruitment Staff Engagement There were a number of factors that impacted on the recruitment for the RCT, the first being the challenge of engaging staff in the research, and building a good working relationship within a team (MDT) at the Royal Derby Hospital. The structure of the gynaecological-oncology department is included in Chapter 1 of this thesis, and this structure had both positive and negative effects on recruitment. The support for this trial within the gynaecological-oncology department came predominantly from the Senior Gynaecological-Oncologist (SGO) within the department, and the CNSs. Although the SGO saw, or was responsible for the care of approximately one third of all gynaecological-oncology patients seen at the Royal Derby Hospital, a high proportion were seen by other consultants, registrars and nurses within the department. The SGO was involved in the trial from the early planning stages and was aware of much of the literature surrounding the efficacy of certain types of CAM with the cancer population, in particular the literature surrounding yoga. This was also similar with regards to the CNSs – they were included early on in the planning phase and were asked for input about the design of the trial. One issue for lack of ‘buy-in’ from the medical staff was their attitude towards . Research in this area has highlighted a number of different perspectives. Milden & Stokols’ (2004) qualitative research into physicians’ attitudes towards CAM highlighted that clinicians in America felt that they did not have enough knowledge about CAM, and that they believed more education was required before
Appendix 4 Audit Approval Letter for ERP Appendix 5 Approval Letter: PREC Appendix 6 Patient Invitation to participate in ERP Evaluation Appendix 7 Patient Information Sheet for ERP Evaluation Appendix 8 Statement of Informed Consent for ERP Evaluation Appendix 9 Thank you/Debrief Letter for ERP Evaluation Appendix 10 A summary table of the main themes and subthemes that emerged from the IPA Appendix 11 Participant Information Sheet – Yoga intervention Appendix 12 Invitation to Participate – Yoga intervention Appendix 13 Statement of Informed Consent – Yoga intervention Appendix 14 Data Collection Form – Yoga intervention Appendix 15 Confirmation of Group Allocation Letter (Control) – Yoga Intervention Appendix 16 Confirmation of Group Allocation Letter (Yoga) – Yoga Intervention Appendix 17 Thank you letter/Debrief (Baseline) – Yoga intervention Appendix 18 Follow-up Sheet (Control) – Yoga intervention Appendix 19 Thank you letter/Debrief (Control) – Yoga intervention Appendix 20 Thank you letter/Debrief (Yoga) – Yoga intervention Appendix 21 4 Month Follow-up Letter – Yoga intervention Appendix 22 4 Month Thank you letter/Debrief – Yoga Intervention Appendix 23 Your Diary – Yoga intervention Appendix 24 Yoga and Quality of Life Study Questionnaire Booklet – Yoga intervention Appendix 25 R&D Approval Letter – Yoga intervention