Childhood undernutrition remains a public health problem in slums in Nairobi, yet little is known about current childcare practices, particularly child eating and maternal feeding behavior and their impact on child growth. Treatment options for malnutrition in this setting involve the use of sweet, high energy ready to use foods (RUF), which have the potential to displace home foods, but few studies have assessed this. This thesis therefore aimed to quantify high-risk caring practices in children aged 6-24 months and how these vary with nutrition status. The effects of RUF on meal frequency and eating and feeding behavior were also assessed. The programme of research was underpinned by the following research questions: • What are the commonest modifiable risk factors for undernutrition found in children and how does this pattern vary with nutrition status? • Do ready to use foods displace complementary foods in moderately undernourished children? • Do ready to use foods affect eating and feeding behaviour? Preliminary studies were carried out to test the feasibility of using observations to assess childcare practices. Caregivers of children aged between 6 and 24 months were recruited in Wagha town, a semi urban area in Lahore, Pakistan and in selected slums in Nairobi, Kenya. A structured observation guide was used to collect information on caregiver child interactions during mid-morning meals in Pakistan and lunch time meals in Kenya. A description of childcare practices in the household, specifically dietary practices, feeding behaviour and hygiene practices were assessed by asking the following questions: Who feeds the child? How is the child fed? What is the child fed and how often? What are the hygiene practices of caregivers? Thirty meal observations, 11 in Pakistan and 19 in Kenya, were carried out in homes, while 11 meals were observed in day-care centres in Nairobi. Eating and feeding behaviours varied between cultures. Compared to caregivers in Kenya, caregivers in Pakistan offered more encouragement during meals. In Kenya, encouragement was mainly in response to food refusal and undernourished children were more likely to show aversive eating behaviour. Caregivers would respond to this behaviour by either restraining the child or simply leaving them alone. In day-care centres, laissez faire feeding was common as children were left to feed themselves with little or no assistance. Poor hygiene practices were also common, especially in Kenya where caregivers did not wash their hands before feeding their children. Meal observations were not representative as only one meal could be observed and they were also not practical because of insecurity in the slums. Based on these findings, a cross sectional study carried out in seven health facilities was designed. Caregivers of children aged 6-24 months were recruited from health facilities in two stages. In the first stage, undernourished children (weight for age or weight for length below - 2 Z scores or length for age below -3 Z scores) were quota sampled either from outpatient therapeutic or supplementary feeding programs based on severity and supplementation status between February and August 2015. Undernourished children were recruited from well-baby clinics during growth monitoring. Between July and August 2016 healthy children (weight for age above-2 Z scores) were also recruited from well-baby clinics at the same health facilities. For both groups, child anthropometric measurements were taken and information on sociodemographic, hygiene breastfeeding frequency, meal frequency, dietary diversity, child eating and caregiver feeding behaviour collected using a structured interview guide. Among children receiving ready to use foods, information on child interest in food, food refusal and caregiver force-feeding was also collected for both family meals and ready to use food meals. We recruited 415 children (54.5% female), over half (58.6%) of whom were undernourished. Caregivers and their children came from disadvantaged backgrounds characterized by low parental education. They also lacked access to basic hygiene and sanitation facilities. There was no association between nutrition status and hygiene as nearly all children came from households that lacked piped water (83.6%) and shared toilets (82.9%). Compared to healthy children, undernourished children were more likely not to be breastfeeding (undernourished 11.5%; healthy 5.2% P=0.002) and to receive plated meals at a low frequency (undernourished 12.2%; healthy 26.2% P=0.002). Diets offered were mainly carbohydrate based and there was no association between dietary diversity and nutrition status. Close to one third of children showed low interest in food 25.8% (107) and high food refusal 22.5% (93). Force-feeding was also relatively common 38.5% (155). Compared to healthy children, undernourished children were more likely to show low interest in food (undernourished 34.2%; healthy 14.0% P < 0.001) and high food refusal (undernourished 30.9%; healthy 10.5% P < 0.001); and their mothers were more likely to be anxious about feeding them (undernourished 20.6%; healthy 6.4% P < 0.001). Within the undernourished group, 49.4% had either low interest in food or high food refusal or both. Force-feeding was common in both groups, with a non-significant trend towards more force-feeding in the undernourished infants (undernourished 41.4%; healthy 34.5% P=0.087). Children were more likely to be force-fed if they had low interest in food (odds ratio[95% CI] 3.72 [1.93 to 7.15] P < 0.001) or high food refusal (4.83[2.38 to 9.78] P < 0.001), after controlling for maternal anxiety and child nutrition status. Children appeared to prefer RUF to home foods which is good for treatment compliance, but it may have a negative impact on intake of home foods. Although a single sachet of RUF appeared not to displace family meals in moderately undernourished children, actual energy intake was not measured in this study and these findings are therefore inconclusive. Children in slum areas in Nairobi are exposed to many risk factors which puts them at risk of infection and undernutrition and provision of ready to use foods as a treatment option does not address the underlying problem. There is therefore a need for poverty alleviation strategies which will lead to improved access to hygiene facilities and better environmental conditions. Measures to improve access and utilization of safe nutritious foods as well as mother-child interactions during meals are also required. A better understanding of child care practices and underlying factors that influence them is also required for the design of effective and sustainable interventions in this setting.

Background: Childsmile, the national oral health improvement programme for children in Scotland, aims to reduce oral health inequalities and improve access to dental services. Childsmile is delivered, in part, by a new category of lay or community-based worker known as a Dental Health Support Worker (DHSW) who supports families to improve oral health behaviours and attend a dental practice. Findings from Childsmile’s national process evaluation indicated there was widespread variation in delivery of the DHSW role and additional research was required to further understand and develop programme theory for the DHSW role; and clarify areas of variation which were adaptive and which were a risk to the programme meeting its desired objectives. Aims: The overarching aim was to gain further understanding of which factors and variants (contextual and those associated with programme delivery) impact on effectiveness of the DHSW role within Childsmile Practice. This research is a component study of the national Childsmile evaluation strategy. Findings will be fed back to the Childsmile programme to optimise delivery of the role and to enable future evaluation of the role’s impact. Methods: Learning and evidence generation was triangulated from two phases of research, comprising three component studies. Phase 1 comprised the sensitising study and comparative case studies: both provided learning from within Childsmile. The sensitising study was designed as a scoping exercise using qualitative data collection methods. The aim was to establish existing programme theory and explicate delivery of the DHSW role, while uncovering deviation (from programme theory) and variation within and between NHS boards. Findings were used to design three comparative case studies, comprising one DHSW and key stakeholders involved in delivery of the role from three NHS boards. The comparative case studies employed qualitative data collection methods; and were designed to address the overarching aim, and explore the casual links between context, delivery, and outcomes in delivery of the role using Realist-inspired analysis. Phase 2 comprised a Realist Review to provide learning from out with Childsmile. The aim was to gain an understanding of which components of child health interventions, delivered by lay health workers to parents, could influence ‘child health parenting behaviours’. Findings and Conclusions: Findings indicated that in terms of motivational readiness to engage with positive oral health parenting behaviours (POHPBs) there were three types of families referred to the DHSW for support: low, moderate, and high-risk. It was established that to address programme aims DHSWs ought to support moderate-high risk families, yet DHSWs only had capacity to support low-moderate risk families. Findings demonstrated that the Public Health Nurses/Health Visitors were best placed to triage families according to their needs and motivational readiness. The peer-ness of the DHSW role was found to positively influence parental engagement with the programme and facilitate person-centred support. However, an embedded ‘sweetie culture’ and health damaging environments were found to negatively impact on parents’ self-efficacy and perceived locus of control to engage with POHPBs. Learning indicated that: delivery over a prolonged period of time; incorporation of the programme into the Early Years Pathway and GIRFEC policy; and recent changes to the Children and Young Person (Scotland) Act (2014), served to embed Childsmile within the NHS boards and facilitated stakeholder buy-in, which positively impacted on delivery of the role. From the learning derived within and out with Childsmile the recommendations for the DHSW role included: (1) DHSW support should move away from a primarily information provision and facilitation of families into dental practice role, and incorporate socio-emotional and person-centred support; (2) The DHSW role should be redefined to support moderate-high risk families; and interpretation and application of referral criteria should be addressed to ensure continuity with who is referred for support; and (3) Programme theory for the DHSW role should be refined and future evaluative effort should concentrate on assessing impact.

With the increased number of childcare centres in Thailand, the role of nursery workers has become pivotal to promoting optimal child development. The importance of learning though play is generally not recognised as an important factor in promoting child growth by nursery workers in Thailand. This aim of this study was to enhance the knowledge and attitudes of Thai nursery workers towards play and the play environment by using a multimedia teaching package (MMTP). Based on a pragmatic paradigm using mixed methods approach, this study was broken down into two phases: 1) the design of the MMTP based on a content analysis of UK and Thai curricula for training Thai nursery workers, and 2) evaluating the effectiveness of the MMTP by comparing knowledge and attitudes among three sample groups of Thai nursery workers. Three sample groups consisted of a total of 226 Thai nursery workers: 1) those who received the MMTP training, 2) those who received no training and 3) those who only received official government training. Data collection was conducted over three periods: before training, immediately after training and four weeks after training. Nursery workers from the first group, who had received the MMTP training, were found to have a significant improvement in knowledge and attitudes towards the importance of play and the play environment immediately after training. The improvements increased even further after four weeks. On the other hand, there were no comparable changes in the other two groups (those who did not have any training or had only official government training). Five weeks after training, semi-structured interviews were carried out with eight participants from the first sample group. These provided insights into lessons learned from three main areas: 1) participating in the MMTP training, 2) applying the MMTP to work at childcare centres and 3) barriers that occurred as a result of using the MMTP. The findings indicated that the MMTP had a positive effect on the knowledge and attitudes of Thai nursery workers towards the importance of play and the play environment as a means to promote child development. It was concluded that using the MMTP training package to train all nursery workers in Thailand may improve knowledge and attitudes towards play and the play environment and would have the potential to enhance child development in the future.

When children with cerebral palsy attend a mainstream school, their physical functioning may impact on day-to-day school activities and on their active participation. The Special Educational Needs Code of Practice (DfES 2001b) advocates a multi-agency approach to enable children with SEN to be included within the mainstream school system. Physiotherapists often work with school staff to manage the child’s physical needs within this environment and to deliver therapeutic interventions. Despite numerous government policies endorsing the inclusion of children with SEN within mainstream school, there has been little research into the detail of how this might be achieved for children with physical impairments. This qualitative study explores the physical management of children with cerebral palsy within mainstream school. In the first phase I conducted focus groups and semi-structured interviews exploring the views and experiences of parents of children with cerebral palsy, physiotherapists and school staff regarding the management of the child’s physiotherapy needs. The second phase utilised a case study approach to generate in-depth contextual knowledge of the issues faced when managing the child’s physical needs by exploring individual cases within three mainstream schools using observation, interviews and documents. Thematic analysis was used to analyse these data. Three main themes emerged from the findings of the study: how therapy and education services work together; the delicate balance to achieving participation; and how views of difference impact on the child’s management. I found that the way physical impairments were viewed within the current SEN framework, inhibited a holistic view of the child with physical impairments. It impacted on collaborative practice between agencies affecting how the child’s needs were met. I conclude that a more interactional model of viewing disability is required to ensure that the child’s needs are considered within the context of not only school but the child’s life as a whole.

Childhood sleep problems are highly prevalent and the importance of adequate sleep quantity and quality in child development has been well documented. The most common area of difficulty associated with young school-age children is bedtime resistance, where the child typically refuses to go to bed or attempts to delay bedtime with repeated requests. Current behavioural approaches used to address such difficulties typically involve the use of extinction techniques, which aim to minimise parental attention after bedtime. Research has shown that these techniques have led to a reduction in problem behaviours, but the emotional difficulties that parents face during the initial phase of the intervention have led to the exploration of alternative techniques. This review explored the potential use of a Social Story™ intervention (a short personalised story designed to teach a child how to manage their own behaviour during a specific situation) to help children with their bedtime problems. Current literature has shown that Social Story™ interventions have a good level of treatment acceptability, with supporting evidence provided for their use with both typically developing children and those with an Autistic Spectrum Disorder (ASD). Only 2 studies however have investigated the use of Social Stories™ within the specific area of children’s bedtime problems (Burke, Kuhn & Peterson, 2004; Moore, 2004). The empirical paper reports a study that investigated the use of a Social Story™ intervention with a community sample of 6 children who found it difficult to settle at bedtime. Results replicated previous findings, demonstrating a reduction in the frequency of disruptive bedtime behaviours for all 6 children associated with the introduction of the Social Story™. Treatment effects, however, were not maintained on all measures at the 6-month follow-up and results from an objective measure of sleep behaviours (actigraphy) produced mixed findings.

Breast milk is acknowledged and recommended as the best food for babies by the World Health Organization. However, globally the proportion of mothers who breastfeed is still low and this is particularly the case in Thailand. The aim of this study is to improve women’s ability to breastfeed. A two phase study was designed. Phase I was to better understand women’s experiences and breastfeeding support needs, which formed the development of the ‘Breastfeeding Support Package’. The package, which consisted of the tool and leaflets, was to be administered by the nurses with the postpartum women. Phase II aimed to explore mother’s and nurses’ experiences following the use of the package. A pragmatic qualitative approach was used throughout. A government hospital in Bangkok, Thailand, was the setting for this research. Purposive sampling was used to recruit the participants for both phases of the study. In Phase I, semi-structured interviews of 17 mothers who visited the Family Planning Clinical, post-delivery, were undertaken. Thematic analysis was used to examine the data. For phase II, three groups of participants were involved: five participants from phase 1, five postpartum women and five nurses working on the postpartum ward. Telephone interviews were used to assess face validity to the tool while semi-structured interviews were used to investigate mothers’ and nurses’ experiences regarding the use of the package. Three themes that contributed to women’s experience of breastfeeding were ‘knowledge and attitude towards breastfeeding’, ‘practicality’ and ‘support’. Three themes that contributed to ‘women’s needs of breastfeeding support’ were ‘knowledge’, ‘attitude’, and ‘practice’. The use of the package could open a ‘platform to communication’ regarding women’s needs and act as a ‘platform to support’ for nurses. The postpartum women were able to better communicate their needs regarding breastfeeding support with the nurses, as well as receiving the support they required. The packaged worked well with present conditions and environment at the postpartum ward of the hospital.

Earlier studies have shown that individuals whose mothers were diabetic when they were in utero, have an increased risk of early obesity, and impaired glucose tolerance (lGT) and type 2 diabetes in adult life. This study was designed to test whether adiposity, glucose tolerance and insulin concentrations are altered in Indian children born to mothers with gestational diabetes (GDM), and are related to maternal glucose and insulin concentrations in pregnancy even in the absence of GDM. 830 pregnant women attending the antenatal clinics of the Holdsworth Memorial Hospital (HMH), Mysore, India underwent an Oral Glucose Tolerance Test (OGTT) at 30+/-2 weeks. 674 of these women delivered at HMH. Detailed anthropometry was performed on the offspring at birth, and annually thereafter. 585 mothers returned with their offspring at 5 years of age for detailed investigations including OGTT for glucose and insulin concentrations, bio-impedance for fat estimation and blood pressure measurement. OGTT was administered to mothers and fasting plasma glucose and insulin concentrations were measured in fathers. The Mysore babies were small compared to UK neonates, but the deficit varied for different body measurements. While birthweight (-1.1 SD) was considerably lower, crown-heel length (-0.3 SD) and subscapular skinfold thickness (-0.2 SD) were relatively spared. At five years, subscapular skinfold thickness was larger than the UK standards (+0.23 SD, p<O.OOl) despite all other body measurements being significantly smaller. Findings at 5 years were similar in comparison with another standard, based on Dutch children. At 5 years, girls in the cohort had higher insulin concentrations and were more insulin resistant. Body fat was the strongest predictor of glucose and insulin concentrations independent of other body components and parental characteristics. Newborns of the mothers with gestational diabetes were larger in all body measurements than control neonates (born to non-GDM mothers and non-diabetic fathers). At one year, these differences had diminished and were not statistically significant. At five years, female, but not male offspring of diabetic mothers had larger subscapular and triceps skinfolds (P=O.Ol) and higher 30- and 120-minute insulin concentrations (P<0.05) than control females. Even in the control offspring maternal insulin area-under-the-curve was positively associated with 30-minute insulin concentrations, after adjusting for sex and maternal skinfolds (P<O.OOl). Offspring of diabetic fathers (n=41) were lighter at birth than controls; they showed no differences in anthropometry at five years. In conclusion, Maternal GDM is associated with adiposity and higher insulin concentrations in female offspring at 5 years. The absence of similar associations in offspring of diabetic fathers suggests a programming effect of the diabetic intra-uterine environment. With increasing levels of obesity and IGT among Indian mothers, these effects may be contributing to the rise of type 2 diabetes in India. Our continuing follow-up aims to study the long-term effects of higher maternal glucose concentrations in the absence of GDM.

This study explores the role of a specialist centre in responding to actual or suspected childhood sexual abuse. Children, families and professionals from several agencies are required to navigate an intricate journey when abuse is suspected to have occurred. Through the application of case study research methods in which a specialist centre forms ‘the case’, the complexities of the journey are explored. The literature review highlights the emergent nature of ‘knowledge’ about specialist children’s centres. To inform the research study, papers that focus on children and families’ experience of the multiagency response, the rate of positive medical findings on examination and their relationship with criminal justice outcomes are examined. The available literature relating to the nursing role in responding to child sexual abuse is also reviewed. This case study comprises three data sets: 1) Sixty children (0-17 years) who attended the Centre following suspected sexual abuse were ‘tracked’ to ascertain reasons for referral, type of examination undertaken and outcomes in terms of health status, social care input and criminal justice actions. 2) Semi structured interviews with 16 professionals (paediatricians, nurses, police officers and social workers) in which their perceptions of the centre were explored. 3) Analysis of patient and parent/carer satisfaction questionnaires. Medical examination rarely confirmed abuse had occurred and only 13% of cases were pursued within criminal justice systems. However, 66% of children had an identified health need that required professional follow up. Interviews demonstrated that professionals believed the Centre provided a ‘child friendly’ facility that enhanced multiagency co-operation, but challenges associated with the principles of multiagency working were identified. Patient questionnaires demonstrated positive views of the care received by those who completed them. Findings from the three data sets are presented as the child’s journey through a complex series of events in a case study ‘story’. The study demonstrates the way in which professionals may be distracted by the medico-legal demands of the ‘system’. Children’s active participation in decision making should be promoted when actual or suspected abuse has occurred and a combined approach by multi-agency professionals, based on the individual needs of each child, is advocated not only during attendance at the specialist centre but also during a follow up period. Where abuse is not confirmed, children may benefit from continued care from health professionals. Nursing has the potential to adopt a greater leadership role in achieving the required change.

Aims: To examine the interaction of maternal factors (body composition, physical activity, diet and cigarette consumption) with childhood factors (body composition, diet & physical activity) in the determination of bone mineral accrual by aged 6 years, assessed by a) bone densitometry b) hip structural analysis c) pQCT measurement of the tibia in children born to mothers from the Southampton Women‟s Survey. Methods: Children were recruited at 6 years old from the Southampton Women's Survey. Their mothers‟ diet, lifestyle and anthropometry had previously been characterised before and during pregnancy. The children underwent measurement of bone mass by DXA, including hip structure analysis (HSA), and by pQCT at the tibia. Physical activity was assessed by accelerometry (Actiheart) for 7 continuous days. Diet was assessed using a validated food frequency questionnaire and detailed anthropometric data was also collected. Results: There were 530 children who attended for a DXA scan. Of these, 148 also underwent pQCT assessment. Increased childhood height, weight and milk intake were associated with increased measures of bone size; increased physical activity levels and greater lean mass were positively associated with increased volumetric BMD. Fat mass was negatively associated with volumetric BMD. Whilst maternal height, weight, exercise in late pregnancy and pre pregnancy calcium intake were associated with increased bone size in the offspring, this association was removed after adjusting for childhood factors suggesting that maternal body composition and lifestyle may predict the child‟s body composition and lifestyle. On assessment of growth patterns in this cohort, children were who born small tended to remain small at aged 6 years. Increased catch up growth was associated with increased maternal height and total milk intake at aged 3 years. Rapid weight gain during childhood was associated with maternal smoking during pregnancy. Conclusions: We have demonstrated that maternal and childhood factors influence bone mineral accrual and bone strength, in the developing child. Whilst many important maternal determinants measured (such as physical activity levels) were shown to influence the corresponding determinants in the offspring, other factors such as maternal cigarette smoking were shown to have persistent independent effects on post-natal growth and body composition.

Attention-Deficit/Hyperactivity Disorder (ADHD) is the most common psychiatric disorder of childhood and manifests as symptoms of developmentally inappropriate inattention, impulsivity and hyperactivity. Although numerous deficits have been identified in ADHD, one of the most consistent findings is that patients with ADHD are more variable in the speed of their reaction time (RT) responses on neuropsychological tasks than control children. In 2008, the default-mode interference hypothesis of ADHD was introduced by Sonuga-Barke and Castellanos as a biologically plausible account of this increased within-subject variability in ADHD. This hypothesis suggests that some patients with ADHD might not effectively attenuate low frequency resting brain activity from rest to task and that these low frequency oscillations may then intrude onto task performance and cause periodic attention lapses. These periodic attention lapses would manifest as increased variability in RT data. The present thesis provided the first test of this hypothesis using DC-EEG. We assessed the power in very low frequency EEG bands (< .1 Hz) during rest and during goal-directed task performance in two samples. First was a sample of adults who self-reported either high- or low-ADHD scores, and second was a clinic referred sample of adolescent boys with ADHD and age- and gender-matched controls. We found that in both samples, low frequency EEG was generally attenuated from rest to task, but the degree of this attenuation was lower in ADHD or inattentive participants compared to controls. We also found that periodicity was evident in RT data, and that there was synchrony between low frequency fluctuations in RT data and low frequency EEG. These findings provide some initial support for the default mode interference hypothesis. The findings also highlight the potential involvement of low frequency electrodynamics in attentional processes and in the pathophysiology of ADHD.