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.

This research investigated physician and emergency room use among representative samples of children in the Dallas metropolitan area (N = 1606) and among patients who used Children's Medical Center of Dallas' First Care services (N = 612). Through telephone interviewing, caregivers to children under fifteen years of age were asked about an array of health service use behaviors, social-psychological issues related to acquiring health care for their children, and demographic characteristics as outlined by the Andersen & Newman model of health care service use. Children's use of physician services is best predicted by whether or not they have medical insurance, their level of income, and whether or not they have medical homes. Although having commercial managed care and fee-for-service Medicaid insurance consistently predicted increased physician use, neither independently reduced reliance on emergency rooms for non-emergent care. Managed care insurance and Medicaid did, however, significantly improve the odds that children would have medical homes, which significantly decreased emergency room use for non-emergent care. Further, increasing physician use and reducing reliance on hospital emergency rooms for non-emergent care will require ensuring that children have medical homeseither private physicians or community health centersat which they can readily and consistently receive sick and well care. Although some ethnic differences were observed, few of the broad array of factors in the Behavioral Model significantly predicted either physician or emergency room use. Moreover, educational levels and health beliefs rarely, and if significant negligibly, influenced physician and emergency room use. Health policy for children would best be served by focusing on programs that facilitate parent's ability to secure health insurance for their children and allocating children to medical homes where they can readily and consistently access sick and well care.

Research has shown that the reaction of the non-offending guardian following disclosure of child sexual abuse (CSA) is an important factor related to the adjustment of the victim. However, to date, comparatively little research has examined the characteristics of non-offending guardians, specifically factors related to their ability to support and protect their child in the aftermath of disclosure. A systematic review of the existing literature, specifically primary studies of intervening variables for guardian belief, support and protection, or various combinations thereof, is firstly presented. Here, the lack of consensus within the literature over definition of ‘guardian support’ is highlighted, a situation that has confounded the drawing of firm conclusions regarding associated factors. Secondly, an empirical study is presented where this area of research is broadened out to include a general population of mothers and female carers, and to specifically examine perception of future sex offending risk through the use of vignettes. It is postulated that risk perception is a mediating variable between a guardian’s belief in the occurrence of CSA and subsequent support and protection, a variable that has yet to be examined within the literature as it relates to non-offending guardians. Results showed that mothers tended to over-estimate risk of re-offending, although of concern was that, in general terms, younger offenders with male victims (rated as ‘high risk’ according to a widely-used actuarial measure of sex offender risk) were regarded to be the least risky. Finally, an existing measure of guardian support is critically appraised. It is hypothesised that this type of instrument, that only measures a narrow aspect of a non-offending guardian’s post-disclosure functioning, might be usefully employed within an overall ‘risk of failure to protect’ assessment framework. Drawing upon the current findings, a model upon which to base this type of assessment is outlined in the discussion.

This thesis explores policy and service delivery for adolescent and young adult or ‘transition age’ mental health service users aged 16-25 across different jurisdictions in the UK and Australia. The study explores the implications that policy formulation and implementation have for service delivery in these different contextual settings; and examines how young people (who are at a vulnerable stage developmentally in terms of mental health), have their access to services affected by the existing policy framework. A policy analysis was conducted along with qualitative interviews in six case sites (three in the UK and three in Australia). The thesis adopted a critical realist approach using a laminated cross-sectional interview strategy that was developed to include interviews with national policy makers; local policy makers and service managers; staff working within services; and the young people whom were accessing services as the recipients of policy. Findings from this thesis explore how young people use risk escalation as a way of managing delays to treatment and how practitioners identify particular difficulties for young people transitioning in services when they are due to ‘step up’ into more acute services, or ‘step down’ to a less intensive service. The thesis explores the implications and unintended consequences for young people of policy including processes of ‘cost-shunting’ and ‘resource envy’ at local and national levels. Finally, the thesis offers some learning for systems working to support 16-25 year olds through demonstrating the importance of the dual role of ‘curing’ and ‘caring’ in mental health services.

Objectives: To evaluate the effectiveness of a theory-based and culturally adapted community level behaviour change intervention to improve weaning-food preparation and handling in rural Gambia. Methods: (1) A systematic review of the literature on weaning-food hygiene interventions. (2) Mixed method formative research to identify critical control points (CCP) and motivational factors for mothers‟ behaviour on weaning-food, (3) Formulation of the weaning-food hygiene intervention including performing arts. (4) Implementation and evaluation of the intervention with a cluster randomized controlled trial (cRCT). Results: The systematic review found 4 RCTs on weaning-food hygiene interventions. Formative research prioritized 5 CCPs with 6 corrective messages and 5 motivational factors. For the intervention compared to the control arm the composite behaviour score primary outcome was 72% in the intervention versus 19% respectively (p < 0.001). Each individual behaviour was significantly improved except washing of pots dried on clean surface. There was a significant reduction of contamination of weaning-food immediately after cooking and before second feeding, of children's drinking water, of diarrhoea and respiratory symptoms reported for the past 7 days, and hospital admission for diarrhoea. Conclusion: Our public health, community level intervention for mother's hygienic preparation and handling of weaning-food was effective in rural Gambia.

This thesis contains three chapters that each study the spillover effects of two aspects of the child's household environment, Domestic Violence (chapter one and two) and Maternal Working Hours (chapter three). The first chapter looks at Children's Health, the second at Education Outcomes and the third looks at children's Well-Being. Understanding what influences a child's early development is of paramount importance as it explains future job market performance and success in life in general. All chapters exploit the data set UK Millennium Cohort Study (MCS), a longitudinal survey following around 19,000 children born in the UK in 2000-01. The first chapter studies the effect of Domestic Violence on children's health production function. We use waves 4 and 5 of the MCS, when children are aged 7 and 11, respectively. We find that there is a strong negative externality of living in a household where there is violence on children's parental-assessed health outcomes. Simultaneity between the child's health and the existence of Domestic Violence in the household makes it diffcult to establish a causal relationship, so we use an instrumental approach to address the potential bias caused by this. In particular, our results show that children exposed to Domestic Violence appear to be between 55% and 61% less likely to have their health rated as Excellent. Our results are robust and statistically significant across all specifications. Our paper not only sheds light on the negative impact of Domestic Violence on children's health but provides a robust quantification of this effect. This chapter is co-authored with Prof. Jofre-Bonet and Dr. Serra-Sastre. The second chapter studies the spillover effect on children's educational attainment of living in a household in which mothers are subject to Domestic Violence. To do so, we exploit measurements of the child's educational performance in English, Science, Mathematics, Physical Education, Creativity, and Information and Technology by the age of 7 and 11, available in the MCS. Our results suggest that growing up in a household where there is Domestic Violence has a negative impact on all educational outcomes. Our results are robust and hold when addressing several potential sources of sample selection bias. Children from domestically abused mothers lose around 0.20 standard deviations in English and 0.30 standard deviations in Mathematics scores at an age as early as 11 years. The cumulative negative effect is heterogenous across academic areas, being more pronounced for those subjects where past knowledge acquisition is essential (i.e., Mathematics and Science). This chapter is co-authored with Prof. Jofre-Bonet and Dr. Serra-Sastre. The third chapter investigates how maternal working status is connected to children's well-being at ages 7 and 11. The rapid increase of female participation in the labour market, along with the impact that well-being levels during childhood has on their psychological development and labour market outcomes later in adulthood, calls for a closer examination of this topic. To do so, we also exploit the MCS, which contains a very complete set of children's well-being outcomes and the intensity of the engagement of mothers with the labour market. To our knowledge, this is the first paper to use such a full array of children's well-being indicators and relate it to maternal labour supply. Our results show that in households in which mothers work fulltime, children are, on average, happier, less worried, as well as less likely to lose their temper. Further, we investigate whether child obesity, which has been related to children's well-being, is associated to the mother's working hours, the mother's commuting time and the father's employment status. We find that higher the number of working hours of the mother increases the likelihood of the child being obese at 7 and 11 years of age, in line with previous literature. This chapter is co-authored with Prof. Jofre-Bonet and Dr. Serra-Sastre.

Introduction: Acute lymphoblastic leukaemia (ALL) is the commonest childhood cancer. In the early trials of ALL treatment, central nervous system (CNS) relapse was a common occurrence - the introduction of CNS-directed therapy in the 1970s was associated with the largest single improvement in outcome for childhood ALL. Today, despite universal intensive CNS-directed therapy - with significant associated toxicity - the CNS is involved in around 50% of ALL relapses, with approximately 50% of these being isolated CNS (iCNS) relapse. Whilst many factors increase risk of CNS relapse, few are specific for CNS relapse. Discovery of specific risk factors for CNS relapse would allow increased therapy for children at high risk, and potentially less CNS-directed therapy for those at low risk. Relatively little is known about the biological differences between systemic and CNS ALL. In the CNS, leukaemic cells form plaques adherent to the leptomeninges, bathed in low-nutrient, low-oxygen cerebrospinal fluid (CSF). It was hypothesised that leukaemic cells adapt metabolically to this nutritionally poor CNS microenvironment, and these metabolic adaptations may be targets for specific therapy and/or specific biomarkers for CNS relapse. Findings: Transcriptional analysis of ALL cell lines from CNS and spleen in a mouse xenograft model, and of ALL cells retrieved from the CSF at CNS relapse of ALL, have shown the upregulation of cholesterol biosynthesis as a key adaptation to the CNS niche. Analysis of transcriptomic data from the bone marrow or peripheral blood from children with ALL at diagnosis have shown the potential for upregulated cholesterol biosynthesis (and, independently, upregulated IL7R) as a significant risk factor for CNS relapse of ALL. To support this finding, metabolomic analysis found evidence of changes in CSF cholesterol in the presence of CNS leukaemia, and of increased mevalonate (a cholesterol precursor) and cholesterol in ALL cells retrieved from the CNS in a xenograft model. Therapeutic targeting of CNS ALL in vivo with statins resulted in a CNS-specific increase ALL disease burden. Untargeted metabolomic analysis of CSF shows differences between children with ALL (either at diagnosis or on maintenance therapy) and non-ALL controls, and between children with ALL at diagnosis and the same children on maintenance therapy. Creatine abundance was significantly different in children with ALL at diagnosis compared with both other groups (1/3 lower at diagnosis than either on maintenance or non-ALL controls). This change in creatine and persisted on analysis of CSF from mice with and without leukaemia. On analysis of CSF from children at CNS relapse with ALL there is evidence of increased reduced creatine at time of CNS relapse in 3 of 4 patients. Conclusions: There is evidence to confirm the hypothesis that ALL cell adapt metabolically to the CNS niche. Cholesterol biosynthesis was identified as a key pathway upregulated in CNS ALL, and upregulated cholesterol biosynthesis in ALL cells at diagnosis was found to be a key risk factor for CNS relapse of ALL. In addition, clear changes in the CSF metabolome related to both ALL and ALL therapy were shown, and a new potential marker for the presence of CNS ALL identified. Prospective analyses in independent cohorts are required to determine the clinical utility of these novel strategies for prediction of CNS relapse risk.

Esta pesquisa se propôs a conhecer a experiência materna no cotidiano de cuidados dos bebês de risco no domicilio, considerando que esses cuidados são determinantes para o desenvolvimento infantil. Foram realizadas histórias orais temáticas com três mães de bebês atendidos em um núcleo de reabilitação da periferia da zona leste de São Paulo, selecionadas por conveniência. As entrevistas foram gravadas, transcritas, textualizadas e transcriadas e posteriormente analisadas segundo método da hermenêutica-crítica. Por meio de análise temática foram identificadas duas categorias como resultado: Tornando-se mãe de um bebê de risco em meio às durezas do cuidado especializado e O cotidiano de cuidados de um bebê de risco, cada qual subdividida em quatro temas. O nascimento dos bebês veio acompanhado da notícia de sua condição de risco e da necessidade de internação hospitalar, o que gerou sofrimento para as mulheres. A interação com os bebês de risco não se configurou de forma espontânea, o que trouxe marcas no processo de tornar-se mãe das mulheres. O período de internação hospitalar dos bebês se configurou para as mães como um vazio, resultando em seu investimento para a concretização da alta, de modo a poderem dar continuidade à vida e à maternidade. As mulheres assumiram o papel de acompanhantes de suas bebês durante o período de hospitalização e passaram a se apropriar de informações acerca dos cuidados envolvidos, vivendo também uma expectativa pela alta. A chegada dos bebês ao domicílio no pós-alta hospitalar configurou-se como um momento que as mães assumiram o papel de cuidadora quase exclusiva, lidando com a instabilidade da condição de saúde do bebê. A ineficiência da rede de assistência tornou essa experiência solitária, frente à descontinuidade do cuidado oferecido. Mesmo com a sensação de insegurança, as mães assumiram o cuidado rotineiro, os procedimentos especializados e o acompanhamento ambulatorial dos bebês. Com a precária oferta de programas e políticas que garantissem a continuidade dos cuidados, as mães empreenderam a construção pessoal de uma rede de cuidados. A investigação do diagnóstico das bebês constituiu-se como um processo longo, com realização de exames e encaminhamentos em serviços diversos de saúde e de reabilitação. A preocupação com o futuro das filhas, o cuidado de si e os projetos pessoais passaram a se configurar como temas para as mulheres. Com muitas tarefas a cumprir e com tempo escasso para cuidar de si, as mulheres vivenciaram desgaste físico e emocional resultante dos cuidados requeridos por seus bebês, mas em geral também referiram a experiência como prazerosa, intensa e vivida com muito afeto e interesse nesse cuidado. O fato das mães colaboradoras serem todas primíparas contribuiu para a compreensão da experiência de vivenciar a maternidade pela primeira vez na condição de torna-se mãe de um bebê de risco. Contudo, outros estudos são necessários para se conhecer as diferenças nas experiencias de mães que tiveram outros filhos anteriormente / This research aimed to know the maternal experience in the daily care of babies at risk at home, considering that a good care is determinant for child development. Thematic oral histories were carried out with three mothers of babies attended in a rehabilitation nucleus of the periphery of the east zone of São Paulo, selected by convenience. The interviews were recorded, transcribed, textualized and transcreated and later analyzed according to the method of critical hermeneutics. By means of thematic analysis, two categories were identified as a result: Becoming the mother of a baby at risk amidst the hardships of specialized care and The daily care of a baby at risk, each subdivided into four themes. The birth of the babies was accompanied by the news of their risk condition and the need for hospitalization, which caused suffering for the women. Interaction with at-risk babies did not develop spontaneously, which has impacted the process of becoming a mother. The period of the hospitalization of the babies was experienced by the mothers as an emptiness, making them to invest their strength in the babies\' discharge, to give continuity to life and motherhood. The women assumed the role of supporting their babies during the hospitalization period and began to get information about the care involved, also living an expectation of discharge. The arrival of the babies at home after hospital discharge was set up as a time when mothers assumed almost exclusively the role of caregiver, dealing with the instability of the baby\'s health condition. The inefficiency of the assistance network made this experience solitary, in the face of the discontinuity of care offered. Even with the feeling of insecurity, the mothers took on the routine care, the specialized procedures, and the out-patients follow-up of the babies. With the precarious supply of programs and policies that could ensure the continuity of healthcare, the mothers undertook a personal construction of a support network. The investigation of the diagnosis of the babies constituted a long process, with examinations and referrals in various health and rehabilitation services. The concern for the future of the daughters, the care of themselves and the personal projects began to be configured as themes for the women. With many tasks to accomplish and with limited time to take care of themselves, the women experienced physical and emotional exhaustion resultant of the care required by their babies, but in general they also referred the experience as pleasant, intense, and lived with great affection and interest. The fact that the participants were all primiparous contributed to the understanding of this experience of experiencing motherhood for the first time under the condition of becoming a mother of a baby at risk. However, other studies are necessary to understand the differences of experiences regarding mothers who had other children previously

Thesis (M.Sc. (Statistics)) -- University of Limpopo, 2014 / The health and survival of children are important measures of the social wellbeing and health status of the community. The World Community made a commitment to reduce under-five mortality by two-thirds between 1990 and 2015. The purpose of this study was to identify factors that have influence on child survival. The Dikgale Health and Demographic Surveillance System (HDSS) data for children born between 01 January 1996 and 31 December 2010 were analysed using cross-tabulation, logistic regression and survival analysis to determine factors that have influence on child survival. The findings revealed that mother’s survival status and child birth weight are significantly associated with child survival. The results showed that the odds that children born to mothers who are alive survive beyond five years are almost four times the odds that children born to mothers who are not alive survive beyond five years. The study also found that the odds that children born with birth weight 2.5kg or more survive beyond five years are almost two times that of children born with birth weight less than 2.5kg. The results of this study may help in formulating strategies and interventions that improve the lifespan of children and assist in the reduction of child mortality. KEY CONCEPTS Child survival, Health Demographic Surveillance System, Cross-tabulation, Logistic regression, Survival analysis, Mother’s survival status, Birth weight.

Child Health Services (CHS) in Sweden are offered free of charge to all Swedish parents with children 0-5 years of age.  The regular service schedule includes home visits, health examinations, vaccinations and participation in parenting groups. The CHS should pay extra attention to disadvantaged families. The aim of this thesis was to investigate to what extent the CHS reaches groups of families with special needs, e.g. immigrant families, low income families, young and single mothers, with universal or selective measures, as well as to investigate the variation of two determinants of child health, second hand smoke and breastfeeding, in these groups of families. The thesis also aimed at investigating validity of data in the county CHS quality database (Basta). The thesis is based on data from Basta together with several national registers. The CHS equally reached all families with infants with the universal program except for participation in parenting group. Foreign born, young, single and low-income mothers had lower participation rates. Smoking rates were lower in foreign-born than in Swedish-born mothers and higher for foreign-born than in Swedish-born fathers. Smoking was more common among single and low income parents and young mothers. Young and single mothers had lower breastfeeding rates at 6 months. At 12 months the breastfeeding rates were higher among foreign-born mothers. The validity test of data in the Basta database showed sensitivity values for immunizations, breastfeeding and smoking at 90-100 % and for any home visit, participation in parenting group at any time, a minimum number of 6 visits at the Child Health Centre (CHC) and a minimum number of 11 visits at the CHC at 88 - 96 %. The sensitivity value for the exact match of number of CHC visits (+/- 3 visits) was 88 %. Conclusions: The universal programme was equally distributed in different immigrant and socio-demographic populations. However, the results did not indicate equality according to the assumption that some families need more input than others in order to achieve equity of outcome. Individual data routinely collected from CHS records to a quality database provides data of good quality that can be used for both quality surveillance and research.