At a time when health literacy is emerging as a central concern in the health field, this thesis examines whether and how practitioners involved in the promotion of breastfeeding incorporate dimensions of health literacy as described in the current literature. Although there is little evidence that practitioners are familiar with specific definitions of health literacy, their description of practices reflected various facets of health literacy including functional health literacy, interactive and critical health literacy, and health literacy as composed of multiple literacies. This qualitative case study was set in a rural health district in the Canadian province of Nova Scotia where breastfeeding initiation and duration rates are lower than national averages and where health literacy was identified as a community health issue. In-depth face-to-face interviews were conducted with 30 professional and lay practitioners. Practices in one hospital-based and two community-based settings were observed. Data were analyzed for themes using an iterative process of constant comparison. Interview informants and mothers provided feedback on preliminary findings in focus group interviews. Findings reflect an emphasis on the transmission of information to persuade mothers to breastfeed, in contrast to strengthening their capacity to use information in making or acting on choices about how to feed their babies. Practitioners’ discomfort in identifying clients with low literacy skills raises fundamental concerns about the stigma associated with low literacy. A focus on the functional health literacy deficiencies of clients, not on their capacities, appears limiting in addressing the complexities of breastfeeding promotion. There is little evidence of practices which reflect critical health literacy or efforts to reduce structural barriers to breastfeeding. In conclusion, the study suggests that practitioners’ engagement in critical reflection of their breastfeeding promotion practices through the multidimensional frame of health literacy could help to further their practice and the conceptual development of health literacy.

No description available.

Background: Increasing breastfeeding rates is a longstanding goal of health policy in England. Rationale for this is premised upon the health benefits to both mother and child conferred by exclusive breastfeeding. Current UK Infant Feeding Policy (IFP) derives from international guidelines incorporating the Baby Friendly Initiative (BFI) that promote exclusive breastfeeding. Such ‘evidence informed policy formation’ is emblematic of the current context of health policymaking. However, the impact of current IFP upon women and healthcare professionals is under researched. Aim: This study explores the impact of IFP upon Women, Midwives and Heads of Midwifery services in England and considers the implications for maternity services. Methodology: A qualitative design used semi-structured interviews to determine the experiences and views of IFP with eight Heads of Midwifery and eight Midwives. Six women underwent three interviews exploring their infant feeding journeys at: 8 months pregnant, 1 month and 6 months’ post-partum. Data were analysed using Colaizzi’s phenomenological method. Findings: Three key themes arose contributing towards understanding the context of IFP: Being with IFP, Discourses of Self-Determination and The Emotion work of Compliance. For Midwives: The socio-political context of health and health-care system policy is multifarious but contains identifiable spheres relating to current IFP. Midwives do not appear to actively engage in the political process of this type of policy generation. For Mothers: Infant feeding remains emotionally fraught territory. Three key themes arose from the first interview: Adopting a Stance, Formulating a Vision and Processing the Dialogues of Infant Feeding. The second interview engendered three more key themes termed: Being with the Reality of Infant Feeding, Regaining Selfhood and Seeking Companions. Discussion and Conclusion: Foucault’s analyses of power and governmentality were used to explore the ‘Art of Midwifery’ vs the ‘Art of Governance’. Lack of holism and neoliberal agendas dominating current IFP may be detrimental to maternity service provision as they compromise decisional autonomy for women and clinical autonomy for midwives.

Objective: The present study aims to develop a better understanding of how different feeding methods impact upon the psychological health of mothers. Background: Initiation of breastfeeding in Scotland is 74% (exclusive or partial) with prevalence of breastfeeding falling to 47% at 10 days and to 37% at six weeks. The chosen feeding method a mother uses for feeding her infant can impact upon her psychologically but studies have reported inconsistently as to whether breastfeeding or formula-feeding is associated with psychological distress. Methodological limitations, including classification of feeding method, the use of unsuitable measures and assessing psychological health at wide ranging time-points preclude any definite conclusions being made. Methods: This cross-sectional study recruited 58 mothers with a biological child aged between eight weeks and six months. Twenty-six mothers were self-reported as breastfeeding exclusively, 10 formula-feeding exclusively and 22 formula-feeding following weaning from breast. Participants completed five self-reported psychological health and distress measures, with scores being compared between feeding groups. Results & Conclusions: Mothers who weaned onto formula, after initially trying to breastfeed, experienced higher depression and negative affect compared to mothers who exclusively formula-fed. Mothers who were unable to feed as intended appeared to be more psychologically vulnerable. This has implications for clinicians and policy makers who need to be aware that support may be needed for this group.

This doctoral submission draws on a range of published material to pursue meandering lines of enquiry into the study of children’s play. At its heart is a claim that playing is quintessentially the process of life going on in an affirmative manner (Lester, 2015a); not merely an outcome or activity but the grounding of life itself, a force productive of creative novelty that precedes its classification. In developing this account, the writings of Gilles Deleuze, including collaborations with Felix Guattari, and contemporary iterations of what might be termed ‘new materialisms’, take centre stage. it is a geo-philosophical quest that seeks to overcome the individualisation of life and its accompanying categorisation of playing as a subordinate state, something that can only be tolerated if it contributes to furthering the progress of a subject. The intention here is to go beyond such value, to re-position playing alongside life itself and by doing so to question the ways in which childhood, adulthood and space are constructed and practised. This it is not merely carried out at a level of abstraction: true to Deleuzian process philosophy this thesis is not concerned with the meaning of play but questions how does it work and how might it be worked differently? In response, it develops an ‘exemplary method’ (Massumi, 2002, p. 17) by drawing on a series of singular examples from playwork practice, everyday life, research projects and more remote sources. These are designed to be generative and bring forth new concepts rather than reducing things to more of the same. Above all it is an ethico-political manoeuvre, a tentative and modest experiment in (re)thinking and thinking anew what constitutes a ‘good life’ and how we might increase capacities to create a more just and equitable world.

There has been considerable debate over the optimum age of introduction of solid foods in infants and particularly its association with nutrient and iron adequacy for growth and development as well as its impact on eating behaviours, such as feeding difficulties, dietary variety and food preferences. Since infants and toddlers are at a higher risk of developing iron deficiency anaemia, a non-invasive method of measuring haemoglobin could be a useful tool in identifying low haemoglobin levels early and prevent further deterioration of iron status. Since the adoption of the World Health Organisation (WHO) recommendations for exclusive breastfeeding for 6 months, there has been limited data in the UK about how the new guidelines have affected the growth, eating behaviours, dietary intake and iron status. This thesis aimed to address these gaps in the literature in 3 studies: the Brighton’s Breast-fed Babies Study, the Haemospect® Validation Study and the GO-CHILD Study.

A high prevalence of malnutrition has been reported in paediatric inpatients both in developed and developing countries, using various methodology and criteria. According to national and international guidelines, all inpatients should be screened for risk of malnutrition on admission using a validated screening tool. However, because of the lack of universally accepted definition for malnutrition, there is no consensus on the measures and methods to use for nutritional screening. There is controversy concerning the validity, reliability and practicality of existing paediatric nutrition screening tools. Moreover, current paediatric screening tools have not been designed and validated for infants. The study aimed to: 1) Validate a novel malnutrition screening scheme for infants - the Infant Paediatric Yorkhill Malnutrition Score (iPYMS) and compare its utility in different hospital settings, in UK and Middle East, Iran. 2) Compare the usefulness of various anthropometric measures to predict malnutrition in infants. 3) Determine the factors that correlated with malnutrition in hospitalised infants. 4) Explore the use of body composition measures in sick infants. The Paediatric Yorkhill Malnutrition Score (PYMS) had already been developed in Glasgow for use in children admitted to hospital. It utilized four elements that were reported as recognized predictors of the past, present or future nutrition risk. An audit was carried out at the beginning of the PhD course and aimed to evaluate the effect of PYMS on collection of anthropometric measurements in the wards. Findings suggested that introduction of a screening tool improved the acquisition of anthropometry by nursing staff, but their utilization by medical staff remained poor. Method: The Infant Paediatric Yorkhill Malnutrition Score (iPYMS) was developed by the research team. The score encompasses 4 rated steps that similar to those used for older children: weight < 2nd and 9th centile was used as opposed to BMI, and 3 elements concerning the history of nutritional issues. A score of 1 classifies a patient at medium risk and ≥2 or ≥3 indicates high risk. Infants were studied at admission to two tertiary children's hospital, 210 (0-12 months) in Glasgow, UK and 187 (1-12 months) in Tabriz, Iran. Convenience sampling was used to recruit equal number of patients in each risk group. Four researchers recruited the samples for the UK cohort and one for the Iran cohort. The diagnostic accuracy and validity of iPYMS in both cohorts were assessed by comparing the iPYMS nutritional risk with the Paediatric Subjective Global Nutritional Assessment (SGNA) that determine malnutrition risk and mean skinfolds z-scores (triceps and subscapular) below <-2SD as the benchmark for low fat stores and acute/chronic malnutrition. Discriminant validity was assessed using body composition and anthropometry measurements, with the hypothesis that infants at high risk of malnutrition will have lower fat and possibly lean mass compared with those at low risk. Results: More infants in Iran (32%) were rated as high risk for undernutrition than UK (7%). The diagnostic performance of iPYMS improved with the cut-off ≥ 3, more so in Iran than the UK. In Iran, only, infants who were classified as being at high risk of malnutrition had longer hospital stay. Infants in the iPYMS moderate and high risk groups all had significantly lower mean SD-score for anthropometry. After excluding patients scored high risk based only on low weight z-score (≤-2 SD), the differences in weight and BMI z-scores remained significant. In Iran 76% infants with raised iPYMS had mean skinfolds <-2SD, but only 5% in the UK. The UK infants may thus not actually be malnourished. They may be ill and just at risk of malnutrition. The first step of iPYMS (weight below <9th or 2nd centile) was a strong predictor of malnutrition risk, more so in Iran; in the Iranian cohort, 91% and in the UK 70% of infants above the high risk threshold of ≥ 3 scored as high risk due to the weight below <9th or 2nd centile. ROC Analysis either with SGNA or sum skinfolds z-score as the main outcomes illustrated that admission weight and growth velocity had almost the same predictive value in predicting malnutrition risk. This suggests that weight velocity is no improvement on weight alone as a predictor of malnutrition. Current breast feeding was found to be an independent predictor of malnutrition in Iran. Socioeconomic factors were weak predictors of malnutrition in this population. There is a lack of validated and suitable methods to assess body composition in infants. To determine whether analysing bio-electrical impedance data is practical in our young age range population, this was compared to skinfolds thicknesses and how the two measures of body composition varied relative to SGNA. The WHO standard for skinfolds only starts at 3 months, excluding nearly one third of infants in the Iran cohort and half in the UK. An iPYMS skinfold reference was thus generated using the iPYMS dataset for the UK cohort, as this was a population with low rates of malnutrition risk who had skinfolds levels mainly within the WHO range beyond age 3 months. In Iran, most high SGNA risk infants (72%) had low skinfolds, but in UK there was no association. Iranian infants had much lower mean lean and fat than the UK infants. Fat measured by BIA varied by SGNA rating risk group with both cohorts, but lean differed between risk groups only for Iran cohort. Conclusion: Malnutrition was common in this tertiary children's hospital in Iran. iPYMS might perform well in this setting and could be used by health professionals to identify infants with malnutrition. In contrast, in the UK, iPYMS would mainly identify infants at risk of malnutrition, because of the low prevalence of under-nutrition. On the other hand, we found that weight alone (the first component of iPYMS) is a robust predictor of malnutrition risk. Therefore iPYMS may not add any advantage over the simple measurement of weight alone to identify infants at risk of malnutrition. This is essential where there are limited resources. Studies should be continued to explore a suitable and appropriate gold standard to test the validity of the tools particularly in low prevalence settings as well as the resources and cost of the introducing the tool in clinical practice. Any screening tool for malnutrition can only be considered effective if it results in early intervention and improved clinical outcomes, so the effectiveness of iPYMS needs to be explored in future intervention studies.

Breastfeeding is widely considered the healthiest way to feed an infant. Promoting breastfeeding and increasing breastfeeding rates has become a global strategy to improve children’s health. However the latest rate of exclusive breastfeeding at six months in 2014 in China was 30% in rural areas and 16% in urban areas. Support from skilled practitioners can positively influence breastfeeding initiation rates, duration and women’s breastfeeding experience. This research aims to develop and evaluate a new breastfeeding training programme for professionals to improve support for breastfeeding mothers in China. Mixed research methods were used in the research which included qualitative and quantitative studies. Two qualitative studies provided the evidence for the importance of training professionals in two essential skills of positioning and attachment (P & A) and hand expression (HE). This study further applied a 15-minute breastfeeding DVD training intervention to train Chinese professionals in P & A and HE. At the meantime, the research developed two valid breastfeeding assessment tools, including knowledge assessment tool and confidence assessment tool. Two quantitative studies of the pilot study and RCT study evaluated the effectiveness of DVD training intervention on improving professionals’ knowledge and confidence before and after DVD training by the two breastfeeding assessment tools. The findings in both studies indicated that the DVD training intervention significantly improve the professionals’ knowledge and confidence in P & A and HE with a big effect size. The semi-structured interviews conducted after the RCT study showed the feasibility and applicability of DVD training for professionals in China. This first evidence-based new training programme is likely to be widely implemented in China due to its effectiveness, convenience and ease of access. However, the long-term effectiveness of the DVD training at improving professionals’ knowledge, confidence and breastfeeding outcome needs to be further examined in the future.

No description available.

The evidence that breastfeeding reduces mortality and short and long-term morbidity among premature and small babies is well established but breastfeeding rates in neonatal units in the UK remain low. The aim of this study was to develop and evaluate an eLearning module that addresses the learning needs of neonatal clinicians to support breastfeeding on Neonatal Intensive Care Units (NICU). The module focussed on the knowledge areas of anatomy and physiology of lactation and expression. Mixed methodology was used to evaluate the eLearning module and inform its iterative development. This consisted of quasi-experimental pre-test/post-test studies using The Neonatal Unit Clinical Assessment Tool (NUCAT), an on-line objective knowledge test with self ratings of confidence to test the effects of the eLearning module on knowledge, confidence in knowledge and confidence in practice. Semi-structured interviews explored neonatal clinicians’ experiences of undertaking the eLearning module and their perceptions of the feasibility and applicability of the eLearning module as well as their opinions and experiences of breastfeeding support and training. In total 101 neonatal clinicians, including neonatal nurses, doctors, Advanced Neonatal Nurse Practitioners (ANNPs), nursery nurses and students undertook the initial NUCAT assessment of knowledge and confidence. A further 90 clinicians went on to complete the training and post intervention assessment, 60 repeated the post intervention assessment at 6-8 weeks. Baseline knowledge was greater in the area of breast milk expression than in the anatomy and physiology of lactation. Neonatal nurses were found to have greater baseline knowledge of breast milk expression than doctors or nursery nurses. Doctors/ANNPs were more knowledgeable about the anatomy and physiology of lactation. Following the training intervention doctors/ANNPs showed the greatest improvement in knowledge scores and nursery nurses the least. Knowledge and confidence was significantly increased immediately following the intervention and at 6-8 weeks in all groups. The semi-structured interviews conducted after the study showed the feasibility and applicability of the eLearning module for clinicians in NICU. On-line assessment and training provide a potentially effective multidisciplinary training method to improve breastfeeding knowledge and confidence. Nursery nurse may have differing learning needs and require further support and training.