Rozprawy doktorskie na temat „Child health services”

Child maltreatment, and recurrent maltreatment in particular, occurs at an alarmingly high rate. Frequency of reports to Child Protective Services (CPS) is associated with negative psychological outcomes, and children whose reports are unsubstantiated experience similar risk of behavioral, emotional, and substance use disorders as those whose reports are substantiated. Prior research has demonstrated that children with no CPS reports and children with one CPS report showed no significant differences in rates of maltreatment perpetration or substance use in adulthood, suggesting that prevention efforts after one report may have strong merit in reducing negative outcomes in adulthood. However, patterns and risk factors of unsubstantiated reports have been only minimally explored thus far, despite having been found to predict subsequent maltreatment. The current study extends upon previous research by (a) examining both substantiated and unsubstantiated reports to identify longitudinal patterns of timing and recurrence and (b) assessing the extent to which service provision mediates long-term recurrence after each type of report. Analyses were conducted using subsamples of a longitudinal national dataset from 2011-2015 containing data from CPS reports for 3,655,951 children. Measures included child, caregiver, and CPS case characteristics obtained at the time of first report in 2011. Latent class analysis of referral patterns indicated four classes of recurrence patterns: (1) 2011 unsubstantiation followed by moderate recurrence, (2) 2011 unsubstantiation followed by low recurrence, (3) 2011 substantiation followed by moderate recurrence, and (4) 2011 substantiation followed by low recurrence. Multinomial logistic regression with most likely class membership as the outcome variable indicated that domestic violence, caregiver substance abuse, and poverty were better predictors of initial substantiation status than of long-term recurrence. Prior victimization was predictive of initial substantiation status as well as long-term recurrence. Asian American race predicted low rates of recurrence. Latent class analysis of service provision revealed only two classes: a class of children who received services and a class of children who did not. Service provision partially mediated associations between initial substantiation status and five-year maltreatment recurrence, as measured by number of subsequent reports, number of subsequent substantiated reports, and number of subsequent years in foster care. Limitations are considered and implications of using predictive modeling to drive service prioritization are discussed.

The purpose of this study was to identify to what degree specific factors influence the level of satisfaction experienced by foster parents whose foster children are recieving mental health services from agencies that they have been referred to by a Coming of Age Foster Family Agency.

There is a sound evidence base on the effects of the therapeutic alliance on outcome in psychotherapy for adults. In comparison, there is a smaller amount of literature on the effects of the therapeutic alliance on outcomes for adolescents. Adolescents rarely are seen individually for therapy and instead are often seen by family therapists as part of a system with other members of the family. At present, it is uncertain what the effects of the therapeutic alliance on outcome for adolescents in family therapy are. This paper presents a systematic review that aims to investigate the effects of the therapeutic alliance on outcome in adolescents in family therapy and what factors influence the therapeutic alliance with adolescents in family therapy. A systematic review of electronic databases was carried out using a quality assurance checklist adapted from the American Academy of Neurology Clinical Practice Guidelines (2004). This checklist was used as it assessed aspects of the studies’ theoretical basis, design, measures, analysis and results. Eleven studies met the inclusion criteria and were reviewed. The findings of this review suggest that the therapeutic alliance affects outcome for adolescents in family therapy. The presence of identifiable features of the therapeutic alliance, such as task, goal and bond can strengthen the therapeutic alliance with adolescents. Research into this area is still in its preliminary stages. However, important factors have been identified that affect outcome. Further research is necessary before more substantial claims of the therapeutic alliance on outcome can be made. The limitations of this review are presented, followed by clinical, training and supervision implications and suggestions for future research.

Background This work in child population medicine describes child health problems, increases knowledge of health services, systems, and wider determinants, and makes recommendations for improvements. Aims To explore trends in UK child health and health service quality and highlight policy lessons from the UK and other European countries To study child health and health services in western Europe and derive lessons from different approaches to common challenges To enhance knowledge on child to adult transition care To describe trends in UK and EU15+ child and adolescent mortality and seek explanations for deteriorating UK health system performance, and make recommendations for improving survival Methods Population level measures of health status and system performance; primary and secondary research on policies and practice for health system assessments. Quantitative: mortality rate trends, excess deaths, DALYs, healthcare processes Qualitative: case reports, system descriptions, analyses  Results European child survival has improved, but variably between countries. The UK has not matched recent EU mortality gains. There are 6,000 excess deaths annually in children under 15 years in EU14 countries. There are child survival inequities; countries investing in social protection have lower mortality. Children in the UK, compared with other EU countries, are more likely to be poor than adults. Non-communicable diseases are now dominant causes of child death, disease, and disability. Mortality, processes, and outcomes of healthcare amenable conditions varies between countries. Better outcomes seem to be associated with flexible health care models promoting cooperation, team working, and transition. Conclusions Child health in Europe is improving, but unevenly. Child health systems are not adapting sufficiently to meet needs. Recommendations are made for improving health systems and services.
How do European countries compare when it comes to child health statistics? How do different child health services, systems, and wider determinants impact long term influences for good or harm? Why do some countries seem to do better than others in safeguarding their children’s and young people’s health and wellbeing? And what can we  do to make things better for children? This thesis explores some of these difficult but important issues, and despite describing some serious signals of concern about child health, offers recommendations and clear ways forward for countries to ensure healthier futures for children.

The robustness and responsiveness of a country's health system predict access to a range of health services, including maternal and child health (MCH) services. The purpose of this cross-sectional study was to examine the influence of 5 health system characteristics on access to MCH services in Sierra Leone. This study was guided by Bryce, Victora, Boerma, Peters, and Black's framework for evaluating the scaleup to millennium development goals for maternal and child survival. The study was a secondary analysis of the Sierra Leone 2017 Service Availability and Readiness Assessment dataset, which comprised 100% (1, 284) of the country's health facilities. Data analysis included bivariate and multivariate logistic regressions. In the bivariate analysis, all the independent variables showed statistically significant association with access to MCH services and achieved a p-value < .001. In the multivariate analysis; however, only 3 predictors explained 38% of the variance (R� = .380, F (5, 1263) = 154.667, p <.001). The type of health provider significantly predicted access to MCH services (β =.549, p <.001), as did the availability of essential medicines (β= .255, p <.001) and the availability of basic equipment (β= .258, p <.001). According to the study findings, the availability of the right mix of health providers, essential medicines, and basic equipment significantly influenced access to MCH services, regardless of the level and type of health facility. The findings of this study might contribute to positive social change by helping the authorities of the Sierra Leone health sector to identify critical health system considerations for increased access to MCH services and improved maternal and child health outcomes.

Thesis (M. S.)--Public Policy, Georgia Institute of Technology, 2010.
Committee Chair: Susan E. Cozzens; Committee Member: Barbara D. Lynch; Committee Member: Marilyn A. Brown. Part of the SMARTech Electronic Thesis and Dissertation Collection.

Thesis (Ph.D.)--Aberdeen University, 2009.
With: Health status and health needs of the orphan children of Kathmandu Nepal : the findings of the pilot study / S. Sing, Edwin R. Van Teijlingen, P. Simkhada. Stupa Journal of health services. 2007: 3, 1-2. With: Health status and health needs of orphan children of Kathmandu Nepal / S. Sing, P. Simkhada, Edwin R. Van Teijlingen. Journal of Nepal Heath Research Council. 2007: 5, 2. Includes bibliographical references.

Thesis (MCur)--Stellenbosch University, 2012.
ENGLISH ABSTRACT: Member states of the United Nations accepted eight Millennium Development Goals in 2000. Millennium Development Goal number four addresses the improvement of child health. The purpose of goal number four is to decrease the child mortality rate by 60% for the period 1990 to 2015. South Africa is one of twelve countries where the incidence of child mortality increased during this period. Guided by the research question “What are the experiences and perceptions of mothers utilizing child health services”, a study was done. A qualitative, descriptive phenomenological methodology was applied to explore the experiences and perceptions of mothers utilizing child health services for children younger than two years. The goal of this study was to determine the experiences and perceptions of mothers utilizing child health services. The objectives were to explore their experiences and perceptions, with specific reference to the service they receive regarding: - immunization - nutrition assessment - the growth of the child - the growth chart - other underlying illnesses Ethical approval was obtained from Stellenbosch University and various health authorities. Validity was assured by adhering to the principles of trustworthiness, namely credibility, transferability, dependability, and conformability. The population for this study was mothers who utilized ten clinics in a demarcated area of Cape Town for child health services. Purposive sampling was utilized to consciously select three clinics (N =10), and at each of the clinics four mothers were purposively selected to participate. A total of seventeen mothers participated in the study. An interview guide was used to conduct interviews with participants. The researcher conducted and recorded the interviews after obtaining written informed consent from each participant. A field diary was kept for notation of observations. Data analysis involved the transcribing of digitally recorded interviews, the coding of the data, the generating of themes and sub-themes, interpretation and organization of data and the drawing of conclusions. The Modeling Role-Modeling Nursing theory of Erickson, Tomlin and Swain were utilized as conceptual theoretical framework to facilitate application to the broad population. Findings of the study indicated varied experiences. All mothers did not receive information about the RtHB or RTHC. Not all mothers developed a relationship of trust with caregivers or were afforded the respect of becoming part of the child’s health care team. According to the mothers integrated child health care services were not practised. The consequences were missed opportunities in immunization, provision of Vitamin A, absence of growth monitoring, feeding assessment and provision of nutritional advice. Hospitals and private practitioners equally did not provide immunization services or offered holistic care. Simple interventions such as oral rehydration, early recognition and treatment of diseases, immunization, growth monitoring and appropriate nutrition are not diligently offered; that could reduce the incidence of child morbidity and mortality. The following recommendations are made: determine why hospitals do not immunize children. The root causes must be addressed to change practice. Rendering of child services must happen in an integrated approach. Staff must be empowered with skills regarding procurement, in particular regarding vaccines.
AFRIKAANSE OPSOMMING: In 2000 het die lidlande van die Verenigde Volke Organisasie die Millenium Ontwikkelingsdoelwitte aanvaar. Die Millenium Ontwikkelingsdoelwit nommer vier roer die kwessie van kindergesondheid aan. Die strategie om die voorkoms van kindersterftes met 60% te verminder vanaf 1990 tot 2015 is die vierde millenium doelwit. Suid Afrika is een van twaalf lande in die wêreld waar die kindersterftes vir hierdie tydperk toegeneem het. ‘n Studie is gedoen om te bepaal “Wat die ervaring en persepsies van moeders is wat van kindergesondheidsdienste gebruik maak. ‘n Kwalitatiewe, beskrywende, fenomenologiese studie is gedoen,om die ervaring en persepsies van moeders wat kinders jonger as twee jaar na klinieke geneem het, te bepaal. Die doel van die studie was om die ervaring en persepsies van moeders ten opsigte van kindergesondheidsdienste vas te stel. Spesifieke doelwitte was die bepaling van die ervaring en persepsies rondom: - immunisasiedienste - groeimonitering - voedingsvoorligting - die groeikaart - behandeling van siektes Etiese goedkeuring was verkry vanaf die Universiteit van Stellenbosch en die verskeie gesondheidsowerhede. Geldigheid van die studie is verseker deur die beginsels van geloofwaardigheid na te kom naamlik, aaneemlikheid, betroubaarheid, oordraagbaarheid en inskiklikheid. Die bevolking betreffende die studie was moeders wat kliniekdienste gebruik het vir hulle kinders in ‘n spesieke area van Kaapstad, bestaande uit tien klinieke. Drie klinieke (N=10) is doelgerig geselekter vir deelname. Vier moeders is doelgerig by elk van die drie klinieke geselekteer vir deelname. Onderhoude is met sewentien deelnemers gevoer. ‘n Onderhoudsgids is gebruik en die navorser het rekord gehou van waarnemings. Die navorser het onderhoude gevoer en opgeneem na skriftelike toestemming daarvoor van elke deelnemer verkry is. ’n Veldwerkdagboek is gehou van alle waarnemings. Data-analise het behels: digitale opnames wat woordeliks beskryf , tematies ontleed en geïnterpreteer is en volgens temas georganiseer is. Toepassing na die breër populasie is bevorder deur die gebruik van die verpleegteorie van Erickson, Tomlin en Swain. Bevindinge van die studie het getoon dat moeders verskillende ervaringe gehad het. Nie alle moeders het inligting ontvang omtrent die RtHB of RTHC nie. Nie alle moeders het vertroue in die kliniek nie en moeders word nie erken as bepalende faktore in die sorgspan nie. . Volgens die moeders is geïntegreerde gesondheidssorg nie beoefen nie. Die gevolge is dat geleenthede nie benut word om te immuniseer nie, vitamien A te verskaf, groei te kontroleer, voeding te bepaal en voedingsadvies te verskaf. Die voorraadvlakke van entstof word nie oral doeltreffend beheer nie. Hospitale en dokters beoefen nie altyd immunisering en holistiese kindergesondheidsdienste nie. Eenvoudige intervensies, wat die voorkoms van kindermorbiditeit en kindermortaliteit kan bestry, word nie verskaf nie. Voorbeelde van sulke intervensies is mondelinge rehidrasie, vroeë diagnose en behandeling van siektes, immunisering, groeimonitering en geskikte voedingsinligting. Daar word aanbeveel dat daar indringend bepaal word hoekom hospitale nie kinders immuniseer nie en dat die oorsake aangespreek word. Integrasie van dienste by klinieke moet as prioriteit gesien en geïmplimenteer word. Personeel se vaardighede betreffende beheer van voorraad moet verbeter word, veral t.o.v. entstof voorraad.

Research shows that the integration of physical and mental healthcare in paediatric settings is beneficial in terms of clinical and cost effectiveness (Kahana, Drotar, & Frazier, 2008; Douglas & Benson 2008, Griffin & Christie, 2008). Due to the high rates of mental health problems within this population, several studies have shown that referral to paediatric psychology should be increased (e.g. Wagner & Smith, 2007). However, there are few studies investigating factors influencing healthcare professionals’ referral behaviour. The current study used theory of planned behaviour (Ajzen, 1988; 1991) to develop a questionnaire which explores factors influencing the referral of children and families to paediatric psychology. Psychometric properties of the questionnaire were examined. Findings indicate that the questionnaire holds good reliability and validity and that the main constructs of theory of planned behaviour are useful in predicting intention to refer to paediatric psychology. Specific beliefs about referral were also shown to influence intention to refer. Findings that individual referrer factors such as attitudes and beliefs can impact healthcare professionals’ referral behaviour indicates that multidisciplinary interventions and inter-professional education relating to the psychological aspects of illness are required. Recommendations for future research are discussed.

Despite significant evidence of the importance of the early years of life, to date limited research has evaluated how health services best support and assist families during this crucial time. One important service through which infant and children's health are promoted and monitored in Australia are the government-based community child health nursing services (CCHNS). Traditionally, child health surveillance and health promotion are provided through CCHNS via individual appointment-based clinics. In recent years, resource allocation and workload within CCHNS has changed, requiring the development of contemporary approaches to service delivery. One novel approach, which was examined in this study, was an Open Access Clinic (OAC), which provided a group-based, appointment-free clinic where parents could attend with their infant for child health nurse support and health care, based on parental needs and convenience. The objective of this research study was to investigate the efficacy, quality and perceived value of the OAC approach to universal child health surveillance in one urban community child health service. A three-phase study, using method triangulation was conducted. It comprised a retrospective documentary analysis of pre- and post-OAC healthcare outcomes; a phenomenological inquiry into the lived experience of those directly involved with the OAC; and an 18-month prospective cohort study, tracking health care-seeking behaviours and child care practices of families who accessed the OAC.;There was also a statistically significant increase in families receiving unemployment benefits (thus were from a relatively low socio-economic demographic) in the OAC cohort, when compared with the individual appointment approach. However, a statistically significant decrease was noted in the developmental assessment documentation in the OAC cohort when compared with the individual appointment cohort, which was further investigated in the prospective cohort study (phase three). The second phase of the overall study was a phenomenological inquiry into the everyday experience of the OAC. The purpose of phase two was to understand what the OAC meant to those involved with it, and to gain insight into the everyday experience of the OAC. The methodology used for this phase was a North American phenomenological inquiry approach, which sought to describe and interpret the everyday experience of multiple participants' lived experiences of the phenomenon - the OAC. New knowledge and understanding has been generated through this inquiry. According to the participants the OAC represented a place where support and reassurance could be accessed flexibly and provided in a non-judgemental manner. The emerging themes described a busy and bustling clinic. It was a place where parents felt safe and supported. They enjoyed the flexibility, the appointment-free structure and valued the accessible location of the both the urban clinics, where shops were close by and public transport available. However, for working parents, services offered in extended hours would be of benefit. The service had a clear role definition and according to the participants achieved this purpose through the working of the OAC, in conjunction with other support services (such as the breastfeeding clinic and the early intervention specialists). Furthermore, parents often shared experiences of feeling lonely and socially isolated.;They valued the consistency of seeing the same child health nurse within the OAC, and the child health nurses valued this for reasons of continuity. The parents reported the benefits of the group approach, and overall preferred it to individual appointments. The mothers identified their use of other service providers, for example their general practitioner if sensitive or confidential issues required attention. The information discussed during the clinics was offered in a non-judgemental way, however the findings indicate that it is essential that the child health nurse's advice and practice is consistent with the latest evidence-based guidelines. The child health nurses sometimes found the clinic stressful and busy, without enough time to perform thorough family assessments.;More specifically, clear trends of usage, such as increased visit frequency and use of breastfeeding clinics in the early weeks, provided helpful evidence to assist in service planning. Through understanding where parents access information, such as family and friends, health services may target these sources with health promotion activities. 'The real challenge lies in ensuring sustained policy effort to achieve long-term measurable change in outcomes for children - to improve their health and well being, to modify the effects of social determinants, and to minimise the inequalities already apparent in early childhood' (Goldfeld & Oberklaid, 2005, p. 209). This final phase affirmed that parents have varied patterns of attendance within the OAC, based on their immediate needs, and that these change with the age of the infant. Important data was also found detailing patterns of usage for other child health service providers, such as access of general practitioners and child health nurses for routine well-baby assessments. Potentially, parents could be provided with clearer service pathways prior to discharge from maternity units, informing them regarding which services are helpful for specific infant health issues. There is also potential for increased collaboration between Queensland Health and general practitioners and practice nurses, to ensure that services are streamlined and thus reduce unnecessary burden on the health care system. This may also be helpful in ensuring consistency of health care information provided to parents between different providers. Whilst this phase was limited by the small sample size, and a context specific group of families, it does provide new information in key areas, such as why parents introduce solids early, when they consider prevention for childhood obesity, where they are attending for their infants' developmental assessments, and health care needs at different stages between 0-eighteen months.;These findings will provide Child Health Services, with valuable information to more efficiently and effectively plan services to meet parental and infant health needs. Overall, the key findings from the combined phases found the OAC compared favourably to the traditional individual-appointment method of child health surveillance in the areas of parent and health care professional satisfaction, infant growth and nutrition, immunisation status and key health promotion areas such as Sudden Infant Death Syndrome prevention. However, areas for quality improvement were also found, specifically in the areas of consistent evidence-based information, documentation in areas such as developmental assessment attendance, health care provider duplication and collaboration and timely discussion of parent-infant attachment. This study has generated new knowledge and understanding regarding the effectiveness and quality of an OAC approach to community child health nursing services, specifically in the delivery of group-based, appointment-free universal child health surveillance services.

Over six million insured children belong to families where the parents in their household lack health insurance. Studies have indicated insured low-income children with uninsured parents are less likely to have physician visits and well-child visits than their counterparts with insured parents. However, self-selection may be responsible for the relationship found between parental insurance and well-child visits. No studies have been undertaken to examine the impact of parental insurance on the utilization of children with chronic conditions. Social Cognitive Theory was used to model children's health care utilization and explain the relationship between parental insurance and that utilization. The objectives of the study are to estimate the effect of health insurance for the primary parent on (1) insured children's well-child visits and (2) physician visits for asthma in insured children. This study used a cross-sectional design. The data source was the 2007 Medical Expenditure Panel Survey-Household Component. The sample consisted of children 17 years or less who were insured through the same source(s) for the entire year and had a primary parent who was either insured or uninsured the entire year. The dependent variable for the entire sample was whether or not the child had at least one well-child visit during the year. The dependent variables for the subsample of children with asthma were (1) whether or not the child had at least one asthma-related physician visit and (2) whether or not the child had at least two asthma-related physician visits. The independent variables were the same for the three analyses and were selected to represent the Social Cognitive Theory determinants. These included parent (insurance, sex, worry, education, language, employment, health use, health, risk aversion, and self care expectation), child (source of coverage, age, health, race, and oldest child), and household (Metropolitan Statistical Area, region, number of children, number of parents, and income) variables. Probit and bivariate probit models were estimated for each dependent variable. The percentage of children with insured parents that had a well-child visit during the year was significantly higher than the percentage of children with uninsured parents that had a well-child visit (50.6% vs. 42.8%, respectively). However, multivariate analyses revealed no significant relationship between parental insurance and well-child visits. The percentages of children with insured and uninsured parents that had an asthma-related physician visit were 29.6% and 32.6%, respectively. The percentages that had at least two asthma-related visits were 14.9% and 14.6%, respectively. No significant relationship was found between parental insurance and asthma-related physician visits. The region of the United States where the child lived and whether the child's parent was employed were associated with each type of utilization. Other determinants were also associated with children's utilization, but these varied with the type of utilization. In conclusion, insured children with insured parents are no more likely to have a well-child or asthma-related physician visit during the year than insured children with uninsured parents.

In chapter 1, bone structure, bone growth and development, osteoporosis in children and skeletal morbidities in children with acute lymphoblastic leukaemia (ALL) are discussed. After that, the mechanostat and the effect of whole body vibration (WBV) on bone health are considered. Finally, I examine diagnostic approaches to assess the musculoskeletal system. In chapter 2, the incidence and risk factors for skeletal morbidity in ALL children are determined. The medical records of all (n,186, male,110) children presenting with ALL between 1997 and 2007 and treated on UKALL97, UKALL97/01 or UKALL2003 were studied. Skeletal morbidity included musculoskeletal pain (MSP), fractures and osteonecrosis (ON). MSP was classified as any event of limb pain, muscle pain, joint symptoms or back pain that required radiological examination. Fractures and ON were confirmed by X-rays and MRI respectively. We found that skeletal morbidity, presenting as MSP, fractures or ON were reported in 88(47%) children of whom 56(63%) were boys. Of 88 children, 49(55%), 27(30%) and 18(20%) had MSP, fracture(s) or ON, respectively. Six (7%) had both fractures and ON. The median(10th,90thcentiles) age at diagnosis of ALL children without skeletal morbidity was 3.9years(1.4,12), which was lower than in those with skeletal morbidity at 8.2years(2.2,14.3) (p<0.00001,95%CI:1.7,4.4). Children with ALL diagnosed over 8years of age were at increased risk of developing fracture(s) (p=0.01,odds ratio(OR)=2.9,95%CI:1.3,6.5), whereas the risk of ON was higher in those who were diagnosed after 9years of age (p<0.0001,OR=15,95%CI:4.1,54.4). There was no gender-difference in the incidence of skeletal morbidity. Children who received dexamethasone had a higher incidence of skeletal morbidity than those who were treated with prednisolone (p=0.027,OR=2.6,95%CI:1.1,5.9). We concluded that the occurrence of skeletal morbidity in ALL children may be influenced by age and the type of glucocorticoids (GCs). These findings may facilitate the development of effective bone protective intervention. In chapter 3, the aim is to investigate the influence of physical activity, age and mineral homeostasis over the first 12months of chemotherapy on subsequent skeletal morbidity. We reviewed 56 children who presented with ALL between 2003 and 2007 and treated only on iv UKALL2003. The number of in-patient days over the first 12months of chemotherapy was collected and used as a surrogate marker of inactivity and lack of well-being. Data for serum calcium (Ca), phosphate (Pho), magnesium (Mg) and albumin were also collected over this period. Skeletal morbidity was defined as any episode MSP or fractures. We found that the median duration of in-patient days over the first 12months of treatment in children with no skeletal morbidity was 58days(40,100), whereas the median number of in-patient days during the first 12months in those children with any skeletal morbidity, MSP only or fractures only was 83days(54,131), 81days(52,119) and 91days(59,158), respectively (p=0.003). Children with skeletal morbidity and fractures particularly had lower levels of serum Ca, Mg and Pho compared with those without skeletal morbidity over the first 12 months of chemotherapy. There was a higher risk of skeletal morbidity in those who were diagnosed after the age of 8years (p=0.001,OR=16,CI:3,80). Multiple regression analysis showed that the incidence of skeletal morbidity only had a significant independent association with age at diagnosis (p=0.001) and the number of inpatient days (p=0.03) over the first 12months (r=23). All children who were diagnosed after the age of 8years with an inpatient stay of greater than 75 days in the first 12 months of the chemotherapy (n,14) had some form of skeletal morbidity (OR=64). The conclusion was that the incidence of skeletal morbidity in children receiving chemotherapy for UKALL2003 is associated with a higher likelihood of being older and having longer periods of inpatient stay. The close link between age and changes in bone mineral status may be one explanation for the increased bone morbidity in ALL children In chapter 4, the effects of two WBV regimens on endocrine status, muscle function and markers of bone turnover are compared. We recruited 10adult men with a median age of 33years(29,49), who were randomly assigned to stand on the Galileo platform (GP) (frequency (f)=18-22Hz, peak to peak displacement (D)=4mm, peak acceleration (apeak) =2.6-3.8g) or Juvent1000 (f=32-37Hz, 0.085mm,0.3g) platform (JP) three times/week for a period of eight weeks. The measurements were performed at five time points (T0, T1, T2, T3, T4) and performed in a four week period of run-in (No WBV), eight weeks of WBV and a four-week period of washout (No WBV). The measurements included anthropometries, body composition measured by Tanita, muscle function measured by Leonardo mechanography and biochemical markers of endocrine status and bone turnover. The immediate term effect of WBV at 22Hz was associated with an increase in serum growth hormone (GH), increasing v from 0.07μg/l(0.04,0.69) to 0.52μg/l(0.06,2.4) (p=0.06),0.63μg/l(0.1,1.18)(p=0.03) ,0.21μg/l (0.07,0.65) (p=0.2) at 5minutes, 20minutes and 60minutes after WBV, respectively in the GP group. The immediate term effect of GP at 18Hz was associated with a reduction in serum cortisol from 316nmol/l (247,442) at 60minutes pre-WBV to 173nmol/l(123,245)(p=0.01), 165nmol/l(139,276)(p=0.02) and 198nmol/l(106,294)(p=0.04) at 5minutes, 20minutes and 60minutes post-WBV, respectively. At 22 Hz, GP was associated with a reduction in serum cortisol from 269nmol/l(115,323) at 60minutes before WBV to 214nmol/l(139,394)(p=0.5), 200nmol/l(125,337)(p=0.08) and 181nmol/l(104,306)(p=0.04) at 5minutes, 20minutes and 60minutes post-WBV, respectively. Median serum cortisol decreased after eight weeks of WBV from 333nmol/l(242,445) to 270nmol/l(115,323)(p=0.04). Median serum of the carboxy-terminal telopeptide (CTX, bore resorption marker) reduced significantly after eight weeks of WBV from 0.42ng/ml(0.29,0.90) to 0.29ng/ml(0.18,0.44)(p=0.03). None of these changes were observed in the JP group. Therefore, WBV at a certain magnitude can stimulate GH secretion, reduce circulating cortisol and reduce bone resorption. These effects are independent of clear changes in muscle function and depend on the type of WBV that is administered. In chapter 5, the effect of WBV using GP on the bone health of children receiving chemotherapy for ALL was assessed. We recruited 16children with ALL with a median age of 7.8years(5-13.8; 9males), who were randomized either to receive side-alternating WBV (f=16-20Hz,D=2mm, apeak =1-1.6g)(n,9) or to stand on a still platform as a control group (n,7) for 9minutes, once/week for four months. Measurements were performed at baseline, two-month and four-month assessing bone health (DXA and p.QCT), body composition and muscle function by imaging and biochemical assessment. DXA BMC data were corrected for bone area and presented as BMC z-score. We found that the median compliance rate measured as a ratio of actual completed minutes and expected minutes of WBV was 55%(17,100). The median percentage change of total body BMC z score in the WBV group from baseline to four months dropped by 10%(-25,10)(p=0.1), whereas it was 87%(-203,4)(p=0.07) in the control group. The median lumbar spine BMC z-score (L2-L4) in the WBV group was -0.4(-1.3,0.3) and -0.3(-1.4,1.5) at baseline and four months, whereas the respective data in the control group were 0.04(-0.6,2.4) and -0.1(-1.1,1), respectively. The median percentage change in LS-BMC z-score declined from baseline to four-month by19%(-349,365)(p=0.1) vi and 75%(-1016,178)(p=0.1) in the WBV and control groups, respectively. We concluded that WBV is tolerated by children receiving chemotherapy.

The Cognitive Abilities Profile (CAP) (Deutsch and Mohammed, 2010) is a collaborative tool for psychologists and teachers. The CAP is based on principles of Dynamic Assessment (DA) and uses a consultative model for rating pupils' cognitive abilities in various cognitive domains and for planning interventions to facilitate pupils' progress accordingly. The CAP was developed in response to a perceived need for educational psychologists (EPs) to have access to alternative assessments to standardised psychological tests, particularly in the case of learning disadvantaged and ethnic minority pupils. Using DA as one possible approach creates a need for EPs to have access to training and to receive support with the implementation of DA-based intervention methods within local services. However, surveys of EP use of DA indicate limitations in training, inadequate support and difficulties in wider application of DA. In the present work, a quantitative methodology has been used to examine the validity and reliability of the CAP in overcoming the above-noted difficulties in the implementation of DA by EPs. The methodology involved the collection and analysis of data from three groups of EPs, two of which conducted consultations with teachers using the CAP and the third group of EPs used its own choice of consultation methodology and functioned as a control group. The findings of the present work provide evidence of good construct validity of the CAP cognitive domains, adequate inter-rater reliability between CAP users and evidence of advantage for pupils in some areas of functioning between pre- and post-use of the CAP, as validated by independent standardised tests. Analysis of perceptions of EPs of the utility of the CAP, based on the results of feedback questionnaires, addresses issues of user friendliness of the CAP. CAP users agreed on the need for initial training for psychologists and support for practitioners. The findings have implications for adoption of a novel approach in EP and teacher related work.

Exclusive breastfeeding (EBF) for 6 months is recommended as the most cost-effective public health intervention to improve child survival particularly in Sub-Saharan Africa and is central to achieving Millennium Development Goal number 4 for child health. However, despite the benefits of EBF to infants and mothers, the rates continue to decrease as the age of the infant increases in an African cultural context including Malawi. There is increasing literature on the effectiveness of community-based peer counselling on EBF promotion in resource-poor settings but its effectiveness in the context of HIV and experiences of HIV positive women with the intervention remains a gap. The purpose of this thesis was to explore determinants of EBF using MaiMwana infant feeding peer-counselling intervention conducted in Mchinji, Malawi as a case study. Specifically, in this study I explored the effectiveness of the intervention to help HIV positive women to overcome the barriers and examine people’s experiences and perceptions towards the intervention with respect to HIV and poverty. I adopted qualitative in-depth interviews with 39 informants, including breastfeeding mothers, peer counsellors and key informants who were purposely selected. The data was analysed using a framework approach. I found that despite having good knowledge, women from rural communities face considerable challenges while practicing EBF. Cultural beliefs, economic constraints, lack of power and support, and fear of transmitting the virus to their infants were cited as major barriers that prevented them from practicing EBF. Overall, the findings from this study suggest that peer counsellors are well accepted by service-users and other community members as they positively viewed their frequent visits as providing additional support, reinforcing infant feeding messages and provide psychological support to women resulting in improved EBF rates. Furthermore, the presence of peer counsellors was viewed as “bringing services at their door step” which reduced time and cost to travel to the health facility. Nevertheless, the findings suggest that voluntary work in resource-poor settings presents considerable challenges such as: poor motivation due to lack of incentives, overworking, lack of knowledge and time to handle HIV positive cases and poor supervision. In order to effectively promote EBF in resource-poor settings, public health programme designers and implementers need to consider these barriers so as to design community-based interventions that suit the local context and create an enabling environment.

Background – Physical activity (PA) has been shown to have numerous physical (e.g., reduced risk of cardiovascular disease, type-2 diabetes and obesity) and psychological (e.g., improved mental well-being, and reduction in levels of stress and depression) benefits for childhood health. Despite the known benefits, childhood PA levels are low in Scotland, where less than 20% of children achieve the recommended daily guidelines. Evidence suggests that time spent outside is positively associated with achieving higher PA levels. Understanding what might encourage children to spend time outside in their neighbourhood could inform the development of interventions aimed at encouraging children to be more active. Children from different socio-spatial neighbourhoods may perceive and utilise their neighbourhood differently, influencing how they spend their free time. This PhD thesis examines how children from diverse settings perceive their neighbourhood in relation to their outdoor activity behaviours. Methods – This thesis takes a qualitative, multi-methodological approach, towards understanding 10-11 year old children’s perceptions of their environment in relation to their time spent outside through the lens of Gibson’s theory of affordances. A pilot study (n=15, 5 boys, 10 girls) was conducted to test the feasibility of the methods. For the main study, the children (n=25, 12 boys, 13 girls) were from different levels of area deprivation and from varying levels of urbanicity. Data collection methods included photo voice, drawings, focus groups or interviews. The participants were asked to document features within their environment (via photographs and drawings) that they felt influenced their time outside. They were then asked to participate in either a focus group or a one-to-one interview. The data collection process took place between May and September 2015. Findings – Children’s perceptions of their neighbourhood environments are complex, and numerous differences were found to be dependent on area of residence. Children from rural areas appeared to be influenced more by physical affordances whereas children living in urban settings were influenced more by social affordances, specifically their friends. Children living in more deprived neighbourhoods spoke of needing more PA opportunities in their neighbourhood compared to children living in more affluent neighbourhoods, suggesting that inequalities may still exist between higher and lower area deprivation. Many of the children considered current play equipment too boring, and lacked challenge or risk. The children desired equipment that better suited their perceived capabilities. This thesis found that children were more likely to spend time outside for psychological reasons, such as relaxation. Conclusion – Through the use of novel methodology in this subject area, this thesis adds an original contribution to the literature by exploring children’s environmental perceptions in relation to PA, and by looking at how setting might influence these perceptions. This thesis found that children perceive their environment differently dependent on the context of their lives, suggesting that initiatives to increase childhood PA could differ depending on residential setting. Additionally, policy may emphasize the psychological benefits to children as opposed to the physical benefits. Highlighting benefits such as relaxation, happiness and excitement may be more conducive to increasing PA among this age group than focusing on benefits such as weight management and cardiovascular health.

Introduction: In recent years the idea of inequality has been revitalised in the global discourse of development. Despite experiencing significant achievements in addressing the Millennium Development Goal, the fight against inequality remained an unfinished agenda. Disparities in child and maternal health & nutrition exist in almost every low and middle-income country. The global community is increasingly recognising the fact that while a country may be on track to achieve specific targets, the situation concerning some subgroups of the population may remain the same or even worsen over time. To address inequalities within a country, it is thus critical to understand the determinants of inequalities. Social determinants of health, which denote the economic and social conditions and their distribution among the population, have significant influences on individual health conditions. To reduce inequalities in maternal and child health and undernutrition in Bangladesh, it is thus imperative we take proper action on the social determinants of health. But the foremost task is to understand the specific role of social determinants of inequalities in the health and nutrition of the mother and the child. Objectives: Overall the research aims to examine the role of social determinants of health in explaining the inequalities in child health, child under-nutrition and maternal health services in Bangladesh. The specific objectives are to examine the role of social determinants in explaining the inequalities in childhood mortality, childhood malnutrition and maternal health services in Bangladesh. The research also aims to assess the feasibility of monitoring social determinants of health in Bangladesh and testing innovative approached to address inequality in child undernutrition. Methods: Data for Chapter 3, 4, 5 and 6, data were derived from Bangladesh Demographic and Health Surveys, while data for Chapter 7 and 8 were derived from Bangladesh Maternal Mortality and Health Care Survey 2010. Multilevel logistic regression analysis was used in Chapters 3 and 8. The study used decomposition of concentration index method to assess the contribution of social-determinants to the inequality in Chapters 4, 5, 6 and 7. The study also used horizontal inequity index (HII) to measure the horizontal inequity. For measuring the feasibility of monitoring social determinants of health and testing of a mobile-based integrated package to improve maternal and child nutrition among low-income families, the study undertook a mixed method approach. Results: Chapter 3 reported the current situation of universal health coverage in Bangladesh based on priority indicators from a suggested UHC framework. For several priority public-health interventions, the country has reached relatively high levels of coverage with greater equity. For example, Bangladesh has achieved high vaccine coverage while reducing disparities significantly between different wealth quintiles. The primary treatment coverage for diarrhoea and acute respiratory infections (ARI) has also improved. In 2011 81% of under-five children with diarrhoea were treated with ORS. Among children with ARI, 35% were taken to a health facility or a health care provider, and 71% received an antibiotic. Bangladesh’s progress with interventions to combat malnutrition has been mixed. According to the latest DHS, 90% of children are breastfed until the age two years and 64% of children less than age 6 months are exclusively breastfed. However, a mere 21% of children age 6-23 months are appropriately fed based on recommended infant and young child feeding practices. The country has done less well with specific interventions that require relatively higher clinical care, For example, the rate of delivery assisted by skilled birth attendants is only 32%. Chapter 4 examined the mortality differentials in children of different age groups by key social determinants of health (SDH). Our study reported that the mother’s age, parental education, the mother’s autonomy to make decisions about matters linked to the health of her child, the household socio-economic conditions, the geographical region of residence, and the condition of the roads were significantly associated with higher risks of neonatal, infant, and under-five mortality in Bangladesh. Chapter 5 measured the extent of socioeconomic‐related inequalities in childhood stunting and identified the key social determinants that potentially explain these inequalities in Bangladesh. The study reported significant inequality in stunting prevalence in Bangladesh. The negative concentration index of stunting indicated that stunting was more concentrated among the poor than among the well‐off. Our results suggest that inequalities in stunting increased between 2004 and 2014. Household economic status, maternal and paternal education, the health‐seeking behaviour of the mothers, sanitation, fertility, and maternal stature were the significant contributors to the disparity in stunting prevalence in Bangladesh. Chapters 6, 7 and 8 examined the inequities in access to maternal health services (facility delivery and caesarean section) and identified the key social determinants that can potentially explain such inequities. Chapter 6 reported that the use of caesarean sections for delivery is mainly driven by the social determinants of health. Household economic status; women’s education, and neighbourhood prevalence of caesarean sections contributed the most to this socioeconomic inequality. Chapter 7 reported that facility delivery in Bangladesh Nepal and Pakistan is driven mostly by the social determinants of health rather than individual health risks. Household socioeconomic condition, parental education, place of residence and parity emerged as the most critical factors. Chapter 8 reported that there is a substantial amount of variation at the community level in the use of facility delivery services. Among the community level factors place of residence, low concentration of poverty in the community, the high concentration of use of antenatal care services in the community, the high concentration of media exposure and high concentration of educated women in the community were found to be significantly associated with facility delivery. Among other individual and household level factors maternal age, educational status of the mother, religion, parity, delivery complications, individual exposure to media, individual access to antenatal care and household socioeconomic status showed strong association with facility delivery. Chapter 9 reported the relevance of a set of indicators of social determinants of health in tracking progress in universal health coverage and population health in Bangladesh and three other countries. For most countries, monitoring is possible. However, a qualitative assessment showed that technical feasibility, reliability, and validity varied across indicators and countries. Producing understandable and useful information proved challenging, and particularly so in translating indicator definitions and data into meaningful lay and managerial narratives, and efficiently communicating links to health and ways in which the information could improve decision-making. Chapter 10 tested an intervention package of voice messaging, direct counselling through mobile phones and an unconditional cash transfer for changing perceptions on nutrition during pregnancy and first year of the child’s life. The study aims to assess the feasibility and acceptability of an integrated package of nutrition counselling, and unconditional cash transfers all on a mobile platform for changing perceptions on nutrition during pregnancy and the first year of the child’s life. The study was a mixed method pilot study with 340 women. The women were either pregnant or lactating. The intervention consisted of an unconditional cash transfer combined with nutrition counselling both delivered on a mobile platform. The participants received BDT 787 per month and a mobile phone. The nutrition messages were delivered by a voice messaging service. Additional nutrition counselling were provided by a nutrition counsellor from a call centre. The poor rural women were interested both in voice messages and direct counselling. Most women reported that they had no problem in operating the mobile phones and listen to the voice messages. There were also able to interact freely with the counsellor. Charging of the mobile handsets posed some challenges. No significant barriers were identified with the use of mobile banking for cash transfers. Regarding the use of cash, our study reported that one of the highest priorities for low-income families was purchasing food. Chapter 11 describes the study protocol of a cluster randomised controlled trial that aims to assess the impact of a cash and nutrition counselling based interventions, randomised among villages with an objective of improving the nutritional status of children less than two years of age to reduce stunting. The proposed trial will provide high-level evidence of the efficacy and cost-effectiveness of a behaviour change communication intervention combined with unconditional cash transfers in reducing child undernutrition in rural Bangladesh. This trial of an innovative approach to enhancing the impact of cash transfers on child nutrition will be a leading study to guide future policies about how to reduce inequalities in child undernutrition in low income and food insecure populations. Conclusions: Health equity is considered as a critical component of progressive achievement of universal health coverage as part of the Sustainable Development Goals (SDG 3). The results of the research presented in this thesis demonstrate the importance of reducing the inequalities in social determinants of health to reduce socioeconomic inequalities in health and nutrition outcomes. There is no simple solution to tackle inequalities in the social determinants of health. The mechanisms producing social hierarchy are different in different settings so there is no strategy that will be effective for every socio-political context. It is now well established that contextual factors that produce the social hierarchy or social stratification are within people’s control. There are evidence-based actions that can address the determinants of health inequities adequately, and such steps are politically achievable. Policymakers should not limit their focus towards intermediary determinants but also try to tackle the underlying structural determinants of health inequalities. A coordinated multi-sectoral approach will be needed to combat the inequalities in the social determinant of health.

Objectives: This study sought to determine whether a computerised cognitive bias modification programme could be effective within a waiting-room setting for parents accompanying their children to CAMHS appointments. The primary objectives were to determine whether detectable changes to participants' emotion recognition could be observed in this setting, and whether this approach would be acceptable to the population. Secondary measures investigated whether the programme would lead to changes in participants' affect or changes in parents' appraisals of difficulties with children. Methods: A computerised emotion recognition training task was delivered to all participants during four weekly sessions. Participants in the experimental condition (n=17) received feedback aiming to shift their detection of positive facial emotions, while those in the control condition (n=14) received feedback which was not designed to elicit any shift in emotion detection. Results: Positive shifts in emotion recognition were observed in the experimental group, although no changes were observed in secondary measures in either control or experimental groups. Qualitative data indicated that the programme was acceptable and appropriately constructed. Conclusion: This study demonstrates that cognitive bias modification is possible within a waiting-room setting, although the extent to which this can lead to clinically significant improvements in mood or relationships remains uncertain. This work has implications for emotion recognition interventions for clinical populations known to present with negative emotional biases (e.g. anxiety and depression) and represents an important first research step towards developing interventions to improve parent-child relationships.

Thesis M. Med.(Family Medicine))University of Limpopo (Medunsa Campus), 2010.
The experience of child birth occurs in all cultures and is important for the continuation of a community. Beliefs related to pregnancy and child birth though usually harmless may at times be detrimental to the health and well being of women that may practice them. The adherence to such beliefs depends on the socio cultural background of individuals and the importance they place on their cultural practices. Aim and objectives The study aimed to explore the health beliefs regarding pregnancy and childbirth of women attending the antenatal clinic at Chawama Health Center in Lusaka Zambia. The main study objectives were to determine the demographic characteristics of the women and ascertain their beliefs regarding diet, behaviour and belief in the use of herbs during pregnancy, delivery and the post natal period. Methods A descriptive, cross-sectional survey was conducted. A 32 item questionnaire was administered to 294 women over a four week period by two research assistants, after obtaining informed consent. Results Results indicate that traditional beliefs were wide spread among the participants though few significant associations were demonstrated. Dietary beliefs that what is eaten could ix affect the progress of labor or the unborn child’s appearance or behaviour were popular. Negative behaviour such as quarrelling or infidelity was believed could lead to difficult labour or adverse outcomes. Herbs were generally believed to be useful for certain indications such as to assist labour or for ‘cleansing’ after miscarriage. Conclusion Health beliefs regarding pregnancy and child birth are an integral part of the community and to be discussed in order to have some influence on them. Continued dialogue is recommended though current clinic health education sessions and qualitative studies to explore other beliefs and myths that are arising out of new health concerns such as HIV.

This study is a qualitative, cross-cultural research on advice giving for mothers in maternity and child health services in Scotland and Finland. It has been accomplished through local case studies using ethnographic methods. The main objective is to analyse how in these service systems motherhood, women's daily life, and their responsibilities for children's welfare and health are defined and organised, and how these definitions vary across social and cultural contexts. Methodologically, referring to the feminist methodology by Dorothy E. Smith, it is emphasised that beginning from the local and particular, from the everyday practices of health professionals, can provide more general understanding of the social relations that organise motherhood in the two societies. Empirical results of the study are presented under six substantial themes: The first theme discusses different professional groups as service providers and the relationships between them. Second theme concentrates on the clinic and the home as the physical settings of service provision and their professional and cultural meanings. Third section discusses the relationship and interaction between health professionals and their clients. Next two themes are related to the standards of motherhood: expectations for proper motherhood, child care, and family relations of the mothers. The last theme analyses possible conflicts between women's everyday experience and professional expertise in motherhood. The general conclusions drawn from the research suggest that motherhood is socially organised at four different but interrelated levels, named in this study as interactional level, institutional level, welfare state level, and socio-cultural leveL. Advice giving for mothers in maternity and child health care is related to family policy measures, social class and gender systems, historical and cultural tradition, customs, and ways of thinking in a certain society. This complexity underlines the relevance of qualitative approach in comparative research.

This research comprises three linked projects stemming from the first project which aimed to define “long-term” pupil absence from school and discover the principal reasons for such absence. The second project focussed on the area of Child and Adolescent Mental Health Services (CAMHS), an issue emerging from the first project. The CAMHS 4-Tier Strategic Framework (or “CAMHS Concept”), including links between CAMHS providers were examined and referral pathways investigated and measured against published criteria. The third project explored the new CAMHS Strategic Framework and considered whether implementation problems were to blame for its lack of transformational impact.

Introduction Randomised controlled trials administering probiotic supplements to preterm infants to prevent sepsis and necrotising enterocolitis are already underway, despite the lack of a robust evidence base of normative values for gut microbiota, bacterial metabolites, and markers of inflammation and immunity. There are increasing calls for observational studies to establish baseline data in these infants. Most of these studies to date have involved the measurement of these analytes individually. In the studies presented in this thesis, we measured a range of stool markers collectively in a cohort of preterm infants in health and disease. Design 56 infants at <32 week gestation and less than 1500g birth weight were sequentially recruited from all three Glasgow Neonatal Units within week one of life after commencement of enteral feeds. Anthropometric, dietary and treatment data were collected. Stool samples were taken once weekly for the first four weeks, testing: short chain fatty acids; calprotectin, secretory immunoglobulin A; and microbial diversity by temporal temperature gel electrophoresis. Results Out of 61 live births meeting the study criteria, 56 infants were enrolled in the study, 62.5% of whom were female. 19.6% were between 24-26 weeks gestation, 28% were 26-28 weeks, 30% were 28-30 weeks, and 21% were 30-32 weeks. 5.3% were between 490-600g in birth weight, 17.8% were 600-800g, 21.4% were 801-1000g, 39.2% 1001-1250g, and 16% were between 1251-1500g. Feed regimen was heterogeneous, comprising 5 combinations of maternal, donor and formula milks. The highest social deprivation level as measured by the Carlisle ‘Depcat’ scoring system of level 7 was significantly higher in the study group than Glasgow or Scotland-wide averages. Sepsis rates were low, with a group median of only 1 per infant. Overall mortality: 7%. 32 with any NEC (56%), 20 with Bells’ ≥2a NEC. 8 (14%) with surgically treated NEC, 5 (8%) underwent ileostomy. SCFAs: (n=56) there were no correlations between gestation, weekly totals, feed type, or NEC and SCFA concentration. Acetate and lactate dominated each sample. Few significant changes were noted with respect to NEC, and these were in the less dominant SCFAs: stage 2a NEC showed higher concentrations of propionate in week 4 than week 3, and lower valerate in week 4 than 2. Stage 3b levels of isobutyrate and heptanoate were significantly lower in week 4 than 3. FC: (n=56) there were no significant differences in FC levels between each week in infants with or without NEC, although the former illustrated a trend to lower levels by week 4. There were no significant differences in NEC before and after clinical signs were apparent, or in those before NEC and after stoma formation for stage 3b NEC. However, significantly lower FC levels were noted in stage 3b NEC requiring ileostomy compared to the immediate pre-operative sample. SIgA: (n=34) Levels rose significantly week on week, and were considerably higher in weeks three and four than week one. There were no significant differences in stool SIgA concentration between infants with and without NEC. A significant increase in mean stool SIgA concentration appeared from week 2 to week 3 in NEC infants, and from week 1 to week 2 for those without. For all breastfed preterm neonates (n=6), the level of milk SIgA was significant higher on week 1 (colostrum) than week 2 and week 3. TTGE: (n=22) There was large variability between number (1-17) and species diversity (25-36 different species). Bacterial composition varied largely between the 2 sample points. No difference in species richness or similarity within the 2 feeding groups was observed. 4 bands were identified in >50% of infants. Intra-individual similarity varied greatly and ranged from a similarity index (Cs) of 0% to 66.8%. There was no statistical difference between the similarity indices of the feeding groups or between those with and without NEC. There were no significant correlations between any of the analytes. Conclusions Only extreme prematurity and extremely low birth weight were associated with NEC, which was at a strikingly high incidence. A limitation was therefore the unexpected onset of severe NEC resulting in prolonged paralytic ileus with low stool production. No correlations were found between analytes, indicating that each set of stool investigations may signify independent physiological, biochemical and immunological gut processes. Despite the severity of NEC, the levels of each analyte were remarkably consistent. High levels of deprivation within the study population may provide the constellation for an as of yet undefined genetic and epigenetic predisposition to NEC in this cohort, similar to that of other illnesses endemic to different geographical areas – notably Multiple Sclerosis in the North East of Scotland – and both follow up of these infants into childhood as well as further analysis of future inborn infants with NEC is planned.

Through the Colombian Institute for Family Welfare (ICBF), the Colombian government aims to provide comprehensive reintegration for children demobilized from the country’s various armed groups. The reestablishment of rights, including the right to health (guaranteed by the Colombian constitution), is a key factor in successful reintegration. This thesis explores the topic of access to health care and health seeking behavior among former child soldiers in Manizales, Colombia who are over the age of 18 and were previously in the Hogar Tutor program (foster care-based youth reintegration) in Manizales. This thesis utilizes semi-structured interviews (n=9) and body mapping (n=9) with former child soldiers, key-informant interviews, participant observation, and a review of archival and secondary sources, including survey data, which is used to complement this research. This research is focused on understanding the barriers participants are experiencing in accessing health care, how participants understand and experience health and the health care system, and how health is handled within reintegration programs. Findings illustrate the incompatibility of transitional justice and the right to health within a neoliberal health system. This research suggests that former child soldiers face significant barriers in access to health care, experience persistent health conditions related to the conflict, and may be insufficiently aware of their rights as both citizens and victims of the armed conflict. These challenges likely affect the ability of former child soldiers to successfully reintegrate. This thesis provides recommendations for future research, as well as for the implementation of- and changes to- health education efforts within the ICBF and the Colombia Agency for Reintegration (ACR).

The objectives of this study are to provide a comprehensive assessment of inequalities in infant and under-five years' child survival, access to and utilisations of child health services among different socio-economic groups in Ethiopia; and identify issues for policies and programmes at national and sub-national levels. This thesis examines the effect of parental socioeconomic status, maternal and delivery care services, mothers' bio-demographic and background characteristics on the level of differences in infant and under-five years' child survival and access to and utilisation of child health services. Descriptive and multivariate analyses were carried out for selected variables in the literature which were consider as the major determinants of infant mortality rate (IMR) and under-five years' child mortality rate (U5MR); access to and utilisations of child health services based on data from Ethiopian demographic and health survey (EDHS), covering the years 2000-2005. In the multivariate analysis a logit regression model was used to estimates inequalities in infant and under-five years' child survival, and inequalities in access to and utilisation of child health services. In Ethiopia, little was known about inequalities in IMR and U5MR, and inequalities in access to and utilisation of child health services. Besides, there is no systematic analysis of health inequalities and into its determinants using logistic regression. According to the available literature, this is the first comprehensive and systematic analysis of inequality of health in Ethiopia. The findings show that compared to under-five years' children of mothers' partners with no work, mothers' partners in professional, technical and managerial occupations had 13 times more chance of under-five years child survival for 2000 weighted observations. In addition, compared to infants of mothers who were gave birth to one child in last 5 years preceding the survey, infants of mothers who were gave birth to 2 children in last 5 years preceding the survey had 70% less chance of infant survival while infants of mothers who were gave birth to 3 or more children had 89% less chance of infant survival for 2000 weighted observations. Moreover, this study finding also indicates that inequalities increased significantly in the five years period between 2000 and 2005 among mothers with different birth interval. Most of the relations between birth interval and receiving childhood immunisation for vaccine-preventable diseases were statistically significant. Moreover compared to non-educated mothers, mothers who completed secondary and higher education were nearly 10 times more likely to receive DPT3 immunisation for their young children. This study concludes that policy measures that tackle health inequalities will have a positive impact in the implementation of health sector strategy of Ethiopia. Health inequalities studies in Ethiopia and Sub-Saharan Africa (SSA) countries should focus on systematic analysis of different socio-economic groups. The finding of this study support investing in the Ethiopia's health extension package (HEP) is a necessary but not sufficient condition for addressing rural poor health problem. HEP is successful in increasing primary health care coverage in rural Ethiopia to 89.6% (FMOH, 2009) but unable to reduce Ethiopia's higher level of IMR and U5MR. HEP is one of the success stories that address the rural poor health problem and can also be adapted to developing countries of SSA. The finding also shows that the success stories such as health insurance programs like Rwanda (World Bank, 2008a) and Ethiopia (FMOH, 2009/10) will play a key role in achieving country's health care financing goal of universal coverage. This can also be replicated in the developing SSA countries.

The HIV/AIDS prevalence rate in the Caribbean is second only to Sub-Saharan Africa and higher than the global rate. HIV/AIDS presents a real threat to children as they account for one in six global AIDS-related deaths and one in seven new global HIV infections. Furthermore, the number of new cases of children in the region is growing. Despite the impact of HIV/AIDS on Caribbean children, few research studies have been undertaken on the psychosocial issues that affect them and studies that include children’s perspectives seem to be even more lacking. This thesis is based on original research carried out in the Republic of Trinidad and Tobago. This study has examined the psychosocial issues that exist for children living with HIV in Trinidad and Tobago and has explored, from the perspectives of both children and their mothers, the types of supports that are available or accessed. The aims of the research were to 1) examine the psychosocial issues that affect children with acquired HIV/AIDS in Trinidad (the children in this research acquired HIV from their mothers) and 2) to explore the support that exists and gaps that may be necessary for their improved quality of life. It is hoped that intervention strategies will be gleaned from this research to assist future interdisciplinary teams that interact with this population. The methodology was based on a grounded theory approach (Strauss & Corbin 1990), and consisted of theoretical sampling and constant comparison throughout data analysis (open, axial, and selective coding) using a case triad (triad refers here to perspectives of three different actors). Four cases were purposively selected, each ‘case’ comprising a mother who was HIV positive, an “HIV Friend” (primary support figure, 4 in total) identified by the mother, and a child living with HIV (there were two children in one family, making five children in total, aged between five and thirteen years) – each of whom was interviewed. In addition, three mothers who did not tell their children of their status were also interviewed. These additional interviews were the result of theoretical sampling to explore two themes that emerged as significant in the first stage of analysis: 1) How “secrecy” was manifested in the lives of families coping with HIV and 2) The role of mothering. In total sixteen persons were interviewed. The findings produced three core categories, namely 1) the cyclical and complex nature of secrecy as a strategy to protect children from stigma and discrimination, 2) the impact on children of living with HIV-AIDS, including their role as protectors of HIV-positive mothers and 3) Mothering with HIV-AIDS. The study showed that these families, though impacted by uncertainty about the future, fear of dying and societal rejection, and for the large part financially and materially disadvantaged, were in-tact and functioned well. Furthermore these families had created a ‘new normal’ in which the secrecy about HIV was central and around which a range of behaviours, social codes and perceived consequences for breaches (of the secret) shaped relationships in both explicit and implicit ways. This indicates a high level of resourcefulness and resilience on the part of the women and their children. However the pressure to maintain the secret created additional challenges for women and children already impacted by a high level of stress because of HIV. Additionally, the rules of secrecy meant that women were unable to talk about their circumstances or needs and consequently had very little support either for themselves or their children. From the child’s point of view, the secret required them to be conscious of what they said and to whom and although not able to talk about HIV, paradoxically the secret had the effect of making HIV more dominant in their lives. This was despite the fact that children themselves did not seem to regard HIV as central in their everyday worlds. Mothering was also a significant theme to emerge from the study and it appeared that such was the importance of the role of mother, as a primary signifier of Caribbean womanhood, that the decision to have children was more important than the risk of passing on HIV. Two of the mothers had gone on to have more children even though their first child had been born with the virus. The study showed that being a good mother in a family affected by HIV means being able to protect children from the implications of the virus being known about outside the family and thus mothering was intertwined with the creation and maintenance of the secret. New understandings about the effects of HIV/AIDS on children and several recommendations aimed at improving services and resources for these children and their families have emerged from the study. Implementation of these recommendations would auger well for improved quality of life in the future, as children continue to live with the chronic illness of HIV/AIDS. The sample was small (16 participants in all) and as a qualitative study, no claims are made about with respect to any generalisations of the findings.

Background: Despite the growing evidence about acute pain management in children and the availability of practice guidelines, children still experience unnecessary pain when in hospital. Involving parents in their child’s pain care has been identified as being central to the pain management in children. However, little is known about how parents and nurses work in partnership in acute children’s wards to care for the child experiencing pain. This thesis explored the experiences and perceptions of parents and nurses and the extent to which parents are involved and partners in the child’s pain care, and the factors that influence parental involvement in care. The family-centred care practice continuum was the theoretical framework that underpinned the study. Methods: A qualitative ethnographical study using non-participant observation and follow up interviews was undertaken. Fourteen nurses and 44 parents/grandparents participated, recruited from the children’s wards of two district general hospitals. The framework approach underpinned data analysis. Findings: While some evidence of parental involvement was identified, the study revealed variations in the way parents are involved in their child’s pain care. A range of challenges were highlighted in relation to the implementation of family-centred care as an approach to promote parental involvement in care. Parents wanted to be more involved in their child’s pain care, and act as an advocate for their child, particularly when they perceived their child’s pain care to be sub-optimal. At times nurses created barriers to parental involvement in pain care, for example, by not communicating effectively with parents and planning pain care without involving parents. The ‘Pillars of Partnership in Pain Care Model’ is offered as an alternative approach to engaging with parents, to address the barriers to involvement and assist nurses shift from a paternalistic approach to involvement to one of working collaboratively with parents in the context of the care of child in pain. Conclusions and implications for practice: Parental involvement in their child’s acute pain care can improve the child’s pain experience, increase parents’ satisfaction in care and reduce parental anxiety. The challenge for nurses is to embrace parental contribution to care and develop the confidence to support parents to advocate for their child.

Background: Safeguarding children is a priority area, yet the experiences of those statutorily charged with offering strategic direction and clinical leadership in health organisations has received little research attention. This study focuses on the experiences of Designated nurses and doctors as they transition from working as an organisation’s sole expert to sharing tasks and responsibilities across many organisations as part of a countywide clinically-led Network. Method: This qualitative study used a participatory action research methodology that allowed the author – a participant Designated nurse – together with colleagues to address concerns and ensure improvements during the course of the study. Data was collected at two points: during the consultation on the Network’s form; and 12-18 months after its implementation. Results: The first data, gathered when Designates were working as sole practitioners, illustrated their isolation, difficulties in accessing knowledge and anxieties about their capacity to respond to changing demands. Further analysis demonstrated that participants’ experiences were shaped by local circumstances and the concerns raised by the newly announced NHS reforms. The second data set, gathered a year after the Network’s launch and contemporaneous with the implementation of the NHS reforms, showed that team working had addressed most of their earlier concerns. The Network had legitimised sharing tasks, combatted isolation, improved access to new knowledge, and benefitted the professionals’ authority through the reputation the Network had achieved for innovation in safeguarding. However, professionals raised concerns regarding collective responsibilities and individuals’ accountability to the team. Conclusion: The study’s inability to completely separate the effects of this change in working practice from the NHS reforms limits its generalisability. The research offers insights into whether small groups of practitioners endeavouring to deliver scarce expertise to multiple organisations would benefit from a team approach, and whether voluntary participation and shared objectives are enough to sustain such teams.

Crohn’s disease (CD) is a chronic inflammatory bowel disease. Once considered rare in the paediatric population, it is recognized with increasing frequency among children of all ages. Approximately 20-30% of all patients with CD present when they are younger than 20 years. With its increasing recognition, CD has become one of the most important chronic diseases that affect children and adolescents. In addition to the common gastrointestinal (GI) symptoms (diarrhoea, rectal bleeding, and abdominal pain) children often experience growth retardation, pubertal delay, and bone demineralization. In these children, maintenance of skeletal health is a complex process that is influenced by a number of different mechanisms including steroid therapy, the disease process, nutritional status, endocrine status and the response of the body to inflammatory mediators. The recent introduction of biologic therapy that targets specific mediators of the proinflammatory process is a promising adjunct in the therapeutic management of the child with chronic inflammation. These drugs may also exert beneficial effects on the adverse effects of inflammation on growth and skeletal development. It is unclear whether these beneficial effects are due to improvement in overall disease or due to a direct ‘anti-cytokine’ effect at the level of the target tissue involved in growth and skeletal development. The hypothesis of this study was that the biologic therapy improves linear growth, puberty, bone health, body composition and muscle function in children with CD and this is associated with changes in the IGF-1 axis and markers of bone formation and bone resorption. Chapter 1 is an extensive literature review about the effects of biologic therapy on growth and skeletal development in paediatric patients with chronic inflammatory conditions particularly inflammatory bowel disease (IBD). The main aim of this review was to summarize and evaluate effects of inflammation and biologic therapy on growth and skeletal development in children with chronic inflammatory conditions and to explore the areas of interest for further research. Chapter 2 is the study about the growth in children receiving contemporary disease specific therapy in children with CD. The aim of this study was to assess the frequency of short stature and poor growth and their relationship to disease course and therapy in children with CD. Clinical records of all children with a confirmed diagnosis of CD, who were between 2yrs and 18yrs at the Royal Hospital for Sick Children, Glasgow were examined retrospectively. Data were collected at diagnosis, 1-yr, 2-yr and 3-yr after diagnosis and at maximum follow-up. The relationship of a number of factors including therapeutic modalities to two commonly used anthropometric markers of growth height velocity standard deviation scores (HVSDS) and change in height standard deviation scores (∆HtSDS) was examined. This study suggested that ∆HtSDS may be a more valid method of assessing and reporting longitudinal growth in children with chronic disease, particularly when there is a high prevalence of children of a peri-pubertal age. This study provides clear evidence that despite advances in therapy, short stature and slow growth continue to be encountered in a sub-group of children with CD. Chapter 3 is about the effect of Infliximab therapy on growth, puberty and disease activity in children with CD. The aim of this study was to assess growth, puberty, markers of disease and concomitant therapy over the six months prior to starting Infliximab and for the 6 and 12 months following treatment. Clinical records of all children with IBD who were started on Infliximab therapy between 2003 and 2008 at the Royal Hospital for Sick Children were examined retrospectively. This study has shown an average improvement of approximately 50% in HV in the 6 months after the initiation of Infliximab therapy which was further sustained for a further 6 months. Improvement in growth was found to be better in those children who were responders as compared to non-responders suggests that growth improved as a result of disease control. Improvement in growth was also observed in children who remained pre-pubertal and those who had never been on glucocorticoids (GC) compared to those who had been on GC. This study suggests that increase in height may not be simply due to progress in pubertal status or reduction in glucocorticoid dose. Chapter 4 is about the effect of Adalimumab therapy on growth in paediatric patients with CD. This is the one and only world wide multicentre study that adequately assess the effect of Adalimumab on linear growth in children with CD. The aim of this study was to assess the effect of Adalimumab therapy on growth, puberty and disease activity over the 6 months prior to and 6 months after starting Adalimumab treatment in children with CD. This study provides evidence that Adalimumab is associated with improvement in short term linear growth in children with CD who enter remission but not in those who do not. It is also more likely to happen in children who are on immunosuppression and those in early puberty but seems to be relatively independent of steroid use. These findings suggest that growth improves as a result of several interrelated factors, including improved disease control. It was also interesting to note that the growth response to Adalimumab varied dependent on the reason for discontinuing Infliximab; those who had an allergic reaction to Infliximab fared best. Chapter 5 is Longitudinal observational prospective study of changes in physical growth, IGF-1 axis, bone health, body composition, muscle function and disease activity at baseline (BL), 2 weeks (2wk), 6 weeks (6wk), 6 and 12 months (6M & 12M) following biologic therapy in paediatric patients with CD. The aim of this longitudinal observational prospective study was to assess changes in physical growth, puberty, IGF-1 axis, bone health; body composition and muscle function following biologic therapy in paediatric patients with CD. Patients either newly diagnosed or patients with long-lasting disease in clinical relapse, who started treatment with biologic therapy as part of their standard clinical management, were recruited. A non significant improvement was observed in both ∆HtSDS and HVcms/yr at 12M as compared to BL. Individually, the majority of the children experienced improvement in clinical activity and improvement of the systemic inflammatory markers. A significant increase in biomarker of bone formation bone specific alkaline phosphatase (BALP) and a non-significant increase in a biomarker of bone resorption cross-linked c-terminal telopeptides (CTX-1) was observed from BL to 12M. This observation suggests the beneficial effect of biologic therapy on bone formation. This study showed a significant change in fat mass (FM (kg) in paediatric patients with CD following biologic therapy an effect that has not been reported extensively in previously published studies. A significant change in both fat free mass (FFM (kg) and fat free mass index (FFMI(kg/m²) shows that the treatment with anti-TNF-α therapy also had a significant impact on fat mass accrual. This is the first study that charts the effect of biologic therapy on changes in lower limb muscle function using jumping mechanography in paediatric patients with CD. A non significant change was observed in jump height (m), V-max (m/s), EFI (%), efficiency % from BL to 12M following biologic therapy and a significant increase in both F-max (kN), and P-max (kW) at 12M. Despite the fact that the increase in efficiency % of the movement was not significant but however, the change was likely to be through improvements in jump height and velocity thereby indicating higher muscular flexibility. These data are suggestive of an effect of biologic therapy on lower limb muscle function through improvements in the mechanical efficiency of the muscle.

Introduction: Insulin Pump Therapy has gained worldwide acceptance for the treatment of Type 1 diabetes mellitus (T1D), offering a new method of insulin delivery, which circumvents the need for Multiple Daily Injections (MDI). It is thought to improve quality of life (QoL) by facilitating an increase in lifestyle flexibility, independence and glycaemic control (Scottish Intercollegiate Guidelines Network, 2010; National Institute for Clinical Excellence, 2008). These benefits have resulted in the National Health Service (NHS) Scotland pledging funding of at least £1million to deliver insulin pumps to under 18s (Scottish Government, 2012). Currently, investigations regarding the impact of Insulin Pump Therapy on QoL have resulted in conflicting findings (Barnard et al., 2007). This study aims to explore the impact of Insulin Pump Therapy on the QoL of children and adolescents, using Interpretative Phenomenological Analysis. Method: Eight participants with T1D, aged between 8 and 13 years and using an insulin pump, were recruited from the Glasgow Royal Hospital for Sick Children Diabetes Clinic. Each participant completed an in-depth interview, which explored their beliefs and attitudes towards Insulin Pump Therapy including its impact on their QoL. Results: Analysis of the transcripts led to the identification of six super-ordinate themes: ‘Physical Impact’, ‘Mood and Behaviour’, ‘Lifestyle Flexibility’, ‘Practicalities’, ‘Peer Reactions’, and ‘Support’. It is suggested that these six factors are not mutually exclusive and together inform the complexity of individuals’ experiences and the impact that the insulin pump has had on many aspects of their lives. These findings suggest a framework to help clinicians understand how young people with T1D perceive and conceptualise their treatment regimes. Conclusions: There was general agreement amongst participants that switching to Insulin Pump Therapy resulted in improvements to their QoL. Additional concerns were outlined but reportedly none of the participants regretted switching to an insulin pump.

The majority of children attending ophthalmology clinics require a visual acuity assessment. The optimal technique depends on age as well as the ability to cooperate with testing. Most acuity assessments are performed subjectively by an orthoptist. Objective acuity assessment by Visual Evoked Potential (VEP) provides a complementary assessment in those subjects who cannot complete subjective tests. The aim of this study was to develop and evaluate a rapid, objective visual acuity assessment. The technique was named the step_ VEP and is based on the real-time analysis of steady-state VEPs (ssVEP). It presents high contrast checkerboard stimuli of sizes 0.4 to 3.0 LogMAR with a successive approximation algorithm. Speed of response detection, specificity and sensitivity were optimised by investigation of recording montage and analysis techniques in a group of normal children and adults (N=102). The success, duration and outcome of step_ VEP acuity assessment was compared to transient VEP (t-VEP) acuity assessment and subjective acuity assessment in a group of paediatric patients (N=218). I-D Laplacian analysis of three occipital electrodes was significantly faster than conventional recording and analysis (Oz-Fz) at detecting ssVEP responses near visual acuity threshold (3' checks) from three years upwards, and at detecting responses to 6' and 9' checks in the 7-9 year age group. A lateral electrode site at 15% of the half-head circumference was fastest most often in adults. Step_ VEPs were 16% more successful than t-VEPs and 9% more successful than subjective tests in providing a complete acuity assessment. Subjective acuity scores were systematically higher than VEP acuity scores in subjects who successfully completed both assessments. A closer agreement with subjective acuity scores was found for step_ VEPs than t-VEPs. The disparity between step_ VEP acuity score and subjective acuity score was shown to reduce with age.

Objective: to examine the effects of work on health and pyschosocial status among boys aged 10-16 years in Jordan. Study design: This is a comparative cross-sectional study, comparing working and non-working with respect to health and psycho-social outcomes, taking account of confounding due socio-economical factors. Results. Bivariate analysis showed that child's work was a strong significant predictor for eight z score, height z score, PCV, morbidity, skinfold thickness percentile and PEFR. This significant effect persisted in the full regression models after controlling for socio-economic and smoking status. Working children had significant lower weight z score (B=-0.31), height z score (B=-0.51), PCV (B=-2.96), skinfold thickness percentile (B=-6.85) compared to non-working subjects. Pyschosocial score tended to be reduced by 13 points (better pyschosocial status) when the child was non-working (B=-12.7). The significant negative relationship between work and PEFR in the bivariate model disappeared in the full regression model. In multiple regression modelling work status explained 3% of the 6.5% of variance explained in the weight z-score model, 6.7% of 9.8% for height z-score, 12.5% of 14.9% for PCV, 15% of 21% for skinfold thickness, 115 of 24% for PEFR, 9.4% of 30.9% for morbidity and 46% of 50% for pyschosocial status. Mean height and weight z-scores and packed cell volume among working children were significantly lower than those of their siblings; 5% and 9.6% of working children respectively were wasted and stunted (z score<-2 SD) compared to none of the siblings. No statistically significant correlation was also found between weight z-scores, height z-scores, packed cell volume and skinfold thickness of siblings and the proportion of household income contributed by the working child. Duration of work, child's monthly income, household per capita income and maternal height, were significant predictors of the growth of working children expressed by weight and height z score.

Weight monitoring is an integral part of routine community child health care in the United Kingdom. An intensive focus on fluctuations in charted weight of young babies has been charged by some breastfeeding advocates with undermining continued breastfeeding. Concern has also been expressed by clinicians and women about the applicability of current growth charts to breastfed babies - a concern echoed by the World Health Organisation. This ethnographic study involved two phases. Six months' participant observation in a child health clinic in the Northwest of England was followed by longitudinal interviews with 14 breastfeeding women. Equal numbers of first and second-time mothers were included; they were interviewed two to three times in the first six months. Data were analysed using grounded theory, allowing an in-depth examination of the lived experiences of weighing and how these shaped on-going feeding decisions and the course of breastfeeding. Weighing babies was the major focus of clinic visits for women and for health visitors. Interactions centred on the concern that the baby's weight should 'follow the line' of the centiles on the chart. Mothers and health visitors also collaborated in efforts to achieve prescriptive routines of baby feeding and sleeping. Breastfeeding was treated as a milk production system, and required to measure up. If weight gain caused concern a variety of strategies were used, including formula supplements and 'worrying'. Techniques to improve the physical effectiveness of breastfeeding were not part of the routine approach to any feeding difficulty on the part of either mothers or health visitors. Using anthropological theory, the character of weighing as a ritual occasion is explored. Weighing sessions are shown to provide occasions to mark the rite of passage through the liminal time of early motherhood. Building on the observation of this ritual experience, it is suggested that the experience of breastfeeding is 'even more liminal', as our society treats formula feeding routines and growth as the implied norm for infants. Weight gain which conforms to chart centiles has become the measure and arbiter of breastfeeding adequacy. Minor fluctuations in weight were treated as potentially serious threats to infant health, while the maintenance of breastfeeding was considered secondary. Recommendations are offered for improving the practical conduct of routine weight monitoring to improve its ability to identify growth which should genuinely spark concern. At the same time, the need for rituals to ease women through their early months of motherhood and the experience of breastfeeding is highlighted. Currently breastfeeding as a method of feeding milk to babies is poorly supported with suggestions for improving physical effectiveness, while at the same time, breastfeeding as a social practice is pushed to the margins of normal everyday experience. This lived dilemma for women and the health visitors who support them deserves attention at national policy level and serious consideration in overall planning of services.

Hypoglycaemia is an unavoidable consequence of treatment of Type 1 Diabetes Mellitus (T1DM). Symptoms are often embarrassing and distressing and can lead to the development of fear of hypoglycaemia (FoH). This fear can have a negative impact on diabetes management and can lead to further medical complications. 210 children and young people (CYP), aged 3-17 years and 190 parents from diabetes paediatric clinics across the West Midlands, UK, completed questionnaires exploring the prevalence of hypoglycaemia, FoH and links to hypoglycaemia awareness, self-care, quality of life and anxiety. Demographic information and HbA1c data were also collected. Results indicated that hypoglycaemia and severe hypoglycaemia (SH) are a problem for CYP in the UK. Hypoglycaemia Fear Survey (HFS) scores were higher in parents than in CYP (Total HFS 37.1±14.9 vs. 50.2±17.8 vs. 45.2±18.0, CYP vs. mother vs. father, respectively, p < 0.01). Adolescents with prior experience of severe hypoglycaemia (SH) had higher HFS scores compared to those without (t=-3.61, p < 0.001). Trait anxiety and SH explained 23% of the variance in HFS scores in adolescents. Trait anxiety explained 37% of the variance in HFS scores in under 11 year olds, 18% in mothers of under 11 year olds, 6% in mothers of adolescent and 10% in fathers of adolescents. There was no correlation between HFS and HbA1c. Qualitative analyses identified ‘Burden’ as an overarching theme from CYP and parent interviews. ‘Negative emotions’ and ‘Living with diabetes’ emerged as the key themes of analysis. This research study adds to existing findings on the prevalence of hypoglycaemia, severe hypoglycaemia, FoH and possible related factors, by focusing on the paediatric population and their parents, in the UK, for which there is limited research. Qualitative analyses also provided novel reports of the experience of T1DM for CYP and their mothers. Implications of this research could lead to the development of an FoH and anxiety managementprogramme for CYP and their parents. The findings of this study also help to raise awareness of this very real and current issue in diabetes management.

The effects of androgens reach far and wide and can be physiological as well as pathological. They are not limited to males and involve almost every system in the human body. Their influence on reproductive development and behaviours is well studied, but more recently, attention has turned to the wider reaching consequences of androgen exposure. Disorders of sex development (DSD) are rare conditions in which individuals may be deficient in, or resistant to, the effects of androgens. The long-term health and quality of life for these individuals is not well reported, but where there are reports, there are descriptions of increased depressive like behaviours, anxiety and poor social functioning. Lack of androgens has been linked to poorer neurocognitive outcomes in some studies and there is a concern that more aggressive hormone replacement should be considered in early life for those individuals lacking in androgens. These disorders can be difficult to study for many reasons. Firstly, they are rare conditions. Secondly, adults with DSD do not tend to visit hospital regularly and can therefore be challenging to engage in research. Thirdly, studying the effects of early life exposure to steroid hormones and relating these to later life behaviours is incredibly complex. Animal models have been used for many years to study the hormonal environment. For my first study, I used a model of rodent neonatal androgen blockade by treating pups with the anti-androgen flutamide for the first five days of life. The animals were studied again in adolescence (6 weeks of age) and early adulthood (10 weeks of age). There were no significant differences found in testosterone, dihydrotestosterone and androstenedione levels in either age group, demonstrating that the androgen blockade was transient. The anogenital index (AGI) was significantly shorter in the treated animals when compared to controls at 6 weeks of age and 10 weeks of age. Phallus length was significantly shorter in treated males when compared to the healthy males at 6 weeks of age and at 10 weeks of age. Phallus weight was significantly lower in the treated animals at 10 weeks of age when compared to the healthy animals. This work demonstrated that my rodent model of neonatal androgen blockade was an effective one. My next study used the same rodent model and aimed to link the perinatal hormonal environment with in vivo brain chemistry using a painless, non-invasive technique known as Magnetic Resonance Spectroscopy. Using a mixed effects model, I analysed the effects of sex, gender, treatment with flutamide and age on the metabolite pattern of the rodent brain. Ɣ-aminobutyric acid (GABA), glucose, glutamine, glutamate, phosphocholine and myo-inositol all changed over time. The combined peaks of glutamate and glutamine also demonstrated a significant change over time. GABA, glutamate, phosphocholine and myo-inositol showed significant sex differences as did the combined peaks of glycerophosphocholine and phosphocholine, N-acetylaspartate (NAA) and N-acetylaspartylglutamate (NAAG) and glutamate and glutamine. Aspartate, GABA and myo-inositol were all significantly changed by treatment of the animals with flutamide and GABA and myo-inositol levels in treated males were similar to control females at both 6 and 10 weeks. My final study using the rodent model of androgen blockade looked at the histological changes in the brain. Brains were sectioned and stained for neuronal cell counts and microglial cell counts, and PCR for the Androgen Receptor (AR) was performed. I demonstrated significant, sexually dimorphic changes in neuronal cell counts, microglial cell counts and androgen receptor expression in two clearly defined areas in the rodent brain. In summary, my rodent work demonstrated a link between the neonatal hormonal environment and the sexually dimorphic chemistry and histology of the in vivo brain, and supports the hypothesis that the microglial cell plays a critical role in brain masculinisation. To include a translational aspect to this thesis I extended my work to a population of undermasculinised boys, who were attending hospital for an hCG stimulation test as part of their investigations for 46 XY DSD. The hCG stimulation test is a valuable method for assessing androgen production but there is a need to explore its utility in assessing androgen responsiveness and long-term prognosis. I aimed to assess the effects of the hCG test on the in vivo brain chemistry using MRS, and the peripheral transcriptome using microarray. I reliably demonstrated metabolites in the brains of healthy male infants, healthy female infants and affected male infants. Healthy male infants had significantly lower levels of N-acetylaspartate than affected males in the hypothalamus and lower levels of the phosphocholines in the frontal cortex. In my transcriptomic study of DSD patients, I demonstrated the existence of an androgen responsive group of small RNAs that are measurable in peripheral mononuclear blood cells, and that change over the short duration of an hCG stimulation test, raising the prospect of combining the biochemical assessment of testosterone production with an objective molecular assessment of androgen sufficiency. In summary, in this thesis I have successfully linked the early hormonal environment with later life in vivo brain chemistry, confirmed by histological studies. I have also identified a novel marker, which could potentially be used as an assessment of androgen sufficiency in the future.

NHS reforms have sought to ensure that children and young people who are ill receive timely, high quality and effective care as close to home as possible (DH, 2004). This study examined the experience and impact of introducing new, ‘closer to home’ community-based paediatric outpatient clinics from the perspectives of NHS service-users and providers. Twenty-seven interviews conducted with parents and patients (aged 8-16), were analysed using a descriptive phenomenological approach. Thirty-seven interviews conducted with healthcare professionals, were analysed using a thematic framework method. Findings reveal that paediatric outpatient ‘care close to home’ is experienced in ways that go beyond concerns about location and proximity. For families it means care that ‘fits into their lives’ spatially, temporally and emotionally; facilitating a sense of ‘at-homeness’ within the self and within the place, through the creation of a warm and welcoming environment, and by providing timely consultations which attend to aspects of the families’ lifeworld. For service-providers, place and professional identity were closely related, with implicit assumptions made about where high quality of care and clinical expertise were located. Place, time and human relations were thus shown to be meaningful constituents of the experience of paediatric outpatient care. These previously ‘taken-for-granted’ nuances of healthcare delivery have implications for the design and implementation of effective ‘closer to home’ services.

Children are uniquely placed in a context where external influences are likely to determine their food consumption. Evidence regarding the immediate food environment’s influence on dietary quality and/or weight status in children is limited. This thesis uses data from the West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study to explore patterns of dietary intake in children aged 5-9 years (n=1467), some of the determinants of children's dietary consumption and their associations with child weight status. Findings suggest that children’s dietary consumption needs to be more healthful, and aspects of children's school and home life may have the potential to influence dietary quality and weight status. Specifically, a healthy home food environment was associated with increased fruit and vegetable intake and a lower weight status. Certain parental feeding practices, such as using food as a reward or to regulate emotion, were also associated with increased energy intake from free sugar and weight status. In conclusion, various environmental and behavioural factors are associated with children’s dietary intake and as such, coordinated efforts in a variety of settings are required to affect the ‘what’, ‘how’ and ‘in what context’ of children’s dietary consumption and consequently childhood obesity prevalence.

The World Health Organization (WHO) recommends exclusive breast-feeding until 6 months of age, where exclusive breast-feeding is defined as giving human breast milk only with no other foods or fluids. This recommendation has since been adopted by many countries. A systematic review of studies in exclusively breast-fed infants by Reilly and colleagues found a mean milk intake at 6 months of age that seemed too low to cover infant energy requirements. However, the evidence was relatively scarce, only from cross-sectional studies and based on the method of test-weighing, which has been criticised for under-estimating milk intake. Furthermore, longitudinal studies indicated no marked increase in milk intake over time, but these studies did not include measurements at 6 months of age. Reilly and Wells proposed the hypothesis that for exclusive breast-feeding to adequately cover infant energy requirements to 6 months of age, either 1) infants had to be unusually small, or 2) breast milk energy content had to be unusually high, or 3) milk intake had to be unusually high. The Reilly-Wells hypothesis was backed up by evidence of a world-wide low prevalence of exclusive breast-feeding to 6 months, and by studies consistently reporting a maternally perceived insufficient milk supply as a major reason for mothers to cease exclusive breast-feeding and introduce either formula supplementation or complementary foods. Based on the Reilly-Wells hypothesis, the research question for the First-Feed study was: To explore how exclusive breast-feeding to 6 months of age is achievable – mainly from an energy balance point of view. The First-Feed study tested the hypothesis that successful exclusive breast-feeding to 6 months of age would include 1) infants that were small and/or growing slowly, 2) milk intakes and/or milk energy content that were higher than literature values and increasing over time, 3) infant energy requirements that were lower than reference values, and/or 4) infant feeding practices that were strained by very frequent and/or very time consuming breast-feeds. The study was designed as the first longitudinal observational study to use an isotopic method to measure milk intake and energy balance in exclusively breast-fed infants to 6 months of age, and it evaluated parts of the methodology employed in the study, in order to appreciate the results in light of the methodological strengths and limitations. The First-Feed study found that infants were overall of normal size and growing well relative to WHO Child Growth Standards. Metabolisable milk intakes were significantly higher than the values obtained by Reilly and colleagues at both 3½ and 6 months of age, and increased significantly over time. Infant energy requirements, determined as metabolisable energy intake, was significantly higher than references for mean energy requirements at 3½ months of age, while it was appropriate at 6 months of age. Breast-feeding practices showed no change over time in feeding frequency, but a significant decrease in time spent on breast-feeds. The First-Feed study had several limitations. Firstly, due to the inclusion criteria of exclusive breast-feeding, the participants were characterised as an affluent and well-supported sample of mother-infant pairs, who were highly motivated to breast-feed. Therefore, the generalisability of the present study to other populations should be accepted with caution. Secondly, the anthropometric measurements were prone to imprecision, as is often the case in field studies. Thirdly, the imprecision of the dose-to-infant procedure for administration of doubly-labelled water considerably reduced the precision of the doubly-labelled water method. This, in addition to the biological variation, increased the variation in some outcome variables. However, the First-Feed study is unique as it is the first to use a more objective method to measure milk intake in a longitudinal design, and on a sample of infants with a very high success rate of exclusive breast-feeding to 6 months of age. The WHO changed the recommendation on exclusive breast-feeding from 4 – 6 months to 6 months (exactly) in 2001. Since then, many resources have been invested in breast-feeding promotion, but rates of initiation, duration and exclusivity is only slowly improving. The present study supports that exclusive breast-feeding can adequately cover infant energy requirements to 6 months of age - even without undue strain on breast-feeding practices and even in mothers where initial breast-feeding problems were very common. However, the present study found a wide variation in both infant size, milk intake and energy requirements. It therefore begs the question if a recommendation based on one age-point (6 months exactly) is appropriate given the vast biological variation in variables that are important for the adequacy of exclusive breast-feeding, or if the recommendation should be adapted to include developmental milestones (e.g. oral motor skills) indicative of readiness for complementary foods.

The World Health Organization estimates that 22 million children worldwide aged <5 years are overweight and highlights tackling childhood obesity as an urgent priority. Childhood obesity is rising to epidemic proportions in the developing world, reflecting changing physical activity levels and dietary intakes, adding a significant public health burden to countries where undernutrition remains common. Interventions to prevent childhood obesity have had disappointing results, because the science and aetiology of obesity is poorly understood and prevention programmes have not targeted appropriate behaviours nor adequately engaged communities being studied. The origins of obesity appear simple, excess energy intake and/or low energy levels expended on physical activity, leading to chronic energy imbalance. However, the problem is more complex with underlying societal, behavioural and genetic causes of energy imbalance remaining unclear. Obesity is driven by individual, household and community factors: research to date has concentrated on individual factors with almost no significant focus on higher level influences on obesity. Findings from studies in developed countries are unlikely to be applicable to rural African settings where there is an increasing transition from a state of undernutrition to that of overnutrition. Few data exist on the prevalence of child and adolescent obesity from low and middle income countries like South Africa. This thesis aimed to determine the prevalence of overweight and obesity in children and adolescents (aged 7-15 years) within this population and to identify possible risk factors. Participants and Methods The study was cross-sectional and involved collecting primary data in local schools. A total of 1,519 subjects were recruited from three age groups (approximately 500 from each age group 7, 11 and 15 years). Participants were recruited from school grades 1, 5 and 9 corresponding to the ages 7, 11 and 15 years respectively. The study comprised two parts, a main cross-sectional study and a further study including a sub-sample of the participants. In the main cross-sectional study anthropometric measurements (height, weight, mid-upper arm circumference and body fat) were performed on all the participants and a lifestyle questionnaire administered (questions related to water collection, travel to school, TV watching and sport participation). The study took place in a demographic surveillance area and data collected from participants was linked with their household/community data to allow analysis of variables associated with overweight/overfat status. 150 participants were randomly selected from the main study (50 from each age group 7, 11 and 15 years) and invited to take part in a sub-sample study which included objective measurement of physical activity (7 days accelerometry) and dietary assessment (2 x 24 hour multiple pass recall assessments) on each participant. Main Findings Prevalence of overweight and obesity was higher in girls than boys and was highest in the oldest age groups for females. Using the Cole/IOTF BMI for age reference combined overweight and obesity was 23% in grade 9 females compared to only 6% in boys in the same grade (p<0.01). The lifestyle questionnaire revealed high levels of water collection, active commuting and TV watching.

Domestic abuse puts children at risk. There is evidence that the health of these children is compromised. This thesis aims to explore whether specific health services to children living in refuges with their mothers who have fled domestic abuse should be targeted at this group. Method The epidemiological, comparative and corporate methods of health care needs assessment were used. Evidence for effective interventions to address the key health issues for this group of children was sought. Few other service models could be found against which to directly benchmark. Guidance for services to children in these circumstances was thus included in the review as a comparator. Professionals and Mothers were interviewed to explore their perspective on the needs of these children. Results Children in refuge have an increased risk of mental health problems and poor access to health services. They are more likely to have suffered maltreatment themselves. Refuges in Cardiff provide assessment and a programme of work and support for children. The specialist health visitor role uncovers unmet health needs in the under 5s. Professionals working with these children and their mothers are concerned about their mental health and are looking for more specialist CAMHS (Child and Adolescent Mental Health Service) help. A number of barriers stand between children and the health services they need. Referral criteria are not clear and timeliness of services and continuity of care is an issue for mobile families. Conclusions A model for health service is suggested for children in refuge using the logic model method. The Primary Mental Health Worker role should provide the advice and expertise Tier 1 workers require and demystify the referral criterion for specialist CAMHS. Timing and continuity of care for appointments requires joint decision making and a flexible service. Health staff requires training to provide an acceptable and accessible service to vulnerable families.

Children with Autism Spectrum Disorder (ASD) have difficulties with social interaction that affect their early learning through play. Systematic reviews were conducted on the effectiveness of Social Stories™ (SS™), Self Video Modelling (SVM) and Peer Video Modelling (PVM) to teach social behaviour to such children. Study 1 compared their effectiveness for teaching three core play skills to 18 young children with ASD: initiating play, turn taking and finishing play; using a counterbalancing design across skills and play materials so that each participant received each intervention. At intake, participants’ ages, Vineland Adaptive Behavior Scale and PLS-3 scores were assessed. The three core skills were observed with good interobserver (97.3%) and procedural (100%) reliability and quantified using a specifically designed scale. The social validity of target skills and interventions was assessed using a Likert scale. All interventions showed evidence of significant improvement. Non-parametric repeated measures ANOVA and post-hoc Wilcoxon tests showed that SVM was superior to SS™ and PVM. Such superiority was evident for initiating play and turn taking but not for finishing play. There was no significant association between the intake variables and either the degree of change between baseline and post-intervention or the post-intervention scores themselves for SS™. Change following SVM was positively related to the Vineland composite score and its motor skills domain score. Post-intervention scores for SVM were positively related to the Vineland composite scores and its communication, daily living and motor skills domain scores as well as all three PLS-3 scores. Change following PVM was related to the Vineland maladaptive score. The target skills and interventions had high social validity. Study 2 showed that more sustained intervention over time resulted in improvement for those who did less well initially. Overall, the research provides encouraging evidence that these interventions are effective in teaching play behaviours to young children with ASD.

Most mutations in SCN1A-related epilepsies are novel and when an infant presents with febrile seizures (FS) it is uncertain if they will have simple FS, FS+ or develop a severe epilepsy such as Dravet Syndrome. The main aim of this work has been to translate specific genetic findings in SCN1A related epilepsies not only to the phenotype, but to examine the implications this has on treatment and quality of life in children and their families. Clinical and genetic data were collected from 273 individuals with SCN1A mutations identified in our laboratory between November 2005 and February 2010. I examined whether the mutation class, distribution or nature of amino acid substitution correlated with the epilepsy phenotype, using the Grantham Score (GS) as a measure of physicochemical difference between amino acids. From structured referral data I analysed a range of clinical characteristics including epilepsy phenotype, seizure precipitants, EEG data, imaging studies, mutation class and response to medication and determined predictors of developmental outcome. I developed novel ideas on how to characterise mutations in SCN1A related epilepsies, showing that phenotypes are not determined by chance, but are in part determined by defined physico-chemical changes affecting a specific location in the protein structure. I was able to demonstrate that these principles not only apply to the SCN1A gene but also to the wider voltage gated sodium channel family and related diseases. This study has been the largest to date to systematically examine the prognostic, clinical and demographic features of Dravet syndrome. The overall incidence of Dravet syndrome was found to be at least one in every 28,600 UK births. Clinical features predicting a worse developmental outcome included status epilepticus, interictal EEG abnormalities in the first year of life and a motor disorder. No significant effect was seen for seizure precipitants, MRI abnormalities or mutation class (truncating vs. missense). Sodium valproate, benzodiazepines and topiramate were reported the most helpful medications and aggravation of seizures was reported for carbamazepine and lamotrigine. Health related quality of life (HRQOL) has emerged as a widely accepted measure to evaluate how chronic disease impacts on an individual’s well-being and I examined in detail the comorbidities and predictors of health related quality of life in Dravet syndrome. HRQOL was evaluated with two epilepsy-specific instruments, the Impact of Pediatric Epilepsy Scale (IPES) and the Epilepsy & Learning Disabilities Quality of Life Questionnaire (ELDQOL), a generic HRQOL instrument the Pediatric Quality of Life Inventory (PedsQL) and a behavioural screening tool, the Strength and Difficulties Questionnaire (SDQ). 163 individuals with Dravet syndrome and their families participated in the questionnaire study. HRQOL was significantly lower for children with Dravet syndrome compared to normative data. One third of children had conduct problems and two thirds had hyperactive or inattentive behaviour. Regression analysis revealed that behavioural problems were the strongest predictors of poorer HRQOL. Identification of specific comorbidities will help us to better recognise and understand the needs of children and families with Dravet syndrome and facilitate a distinct multi-disciplinary approach to management. Genetic testing in the epilepsies has become an increasingly accessible clinical tool and this is the first study to assess the impact of SCN1A testing on patient management from both carer and physician perspectives. The vast majority of parents whose children tested positive for a mutation reported genetic testing helpful, leading to treatment changes resulting in fewer seizures, and improved access to therapies and respite care. Nearly half of the physicians reported that a positive test facilitated diagnosis earlier than with clinical and EEG data alone. In two thirds it prevented additional investigations and altered the treatment approach; it influenced medication choice in three quarters of cases and through medication change improved seizure control in forty percent. In addition to confirming a clinical diagnosis, a positive SCN1A test enabled early diagnosis, influenced treatment choice and facilitated improvements in clinical management, especially in the very young. Finally I hope that this work will contribute to a better understanding of the causes of SCN1A related epilepsies. Furthermore I hope that it will provide evidence to aid earlier diagnosis and treatment of children with severe infantile epilepsies and that it will offer more information for genetic counselling. These improvements in epilepsy care and seizure control could help prevent or reduce the disability associated with SCN1A related epilepsies such as learning and behaviour problems and would improve the quality of life for children and families.

Recent years have seen an increase in self-harm behaviours amongst children and young people. In tandem, the amount of research on the phenomenon has also grown. However, despite the evident importance of care staff attitudes in the treatment of those who self-harm, an examination of the literature indicated a limited number of studies on how clinicians view such behaviour in the young. The aim of this thesis was to examine the attitudes of health care staff toward child self-harm. Within the study, it is argued that factors pertaining to both patients (age, gender and rate of admission) and care staff (role and clinical experience), will influence how an incidence of child self-harm is viewed. To answer the question, both quantitative and qualitative methods were employed. Within the former, a questionnaire was developed that contained hypothetical case vignettes of child self-harm. Once constructed, the instrument was distributed to the care staff of four Accident and Emergency departments, each of which treated self-harming children. Examination of the completed questionnaires (n = 152), showed significant differences in both staff and patient variables, confirming that attitudes toward child self-harm should not be viewed as a single entity but rather as constituent parts of a whole phenomena, each worthy of examination in its own right. In order to explore these issues in more detail, a series of focus groups were undertaken amongst care staff. Use was made of a Foucauldian discourse analysis framework devised by Kendall and Wickham (1999). This revealed intrinsic differences in the way clinicians view self-harm in children and the constituent parts therein. Comparison of both experienced and inexperienced nurses and physicians produceda raft of reasonsw hy child self-harm elicited responsesp articular to each group, ranging from personal experiences to the use of medical jargon. In conclusion, this thesis has explored a particular aspect of the self-harm spectrum, touching on topics that appear to have been neglected by the literature. The dissemination of its results to a wider audience, it is hoped, will generate debate aroundt his sensitiveto pic andt husi ncreasea n understandinogf the needso f those clinicians who deal with such vulnerable patients.