Two central themes were assessed in this thesis involving children with cancer. First, the relationship between the child's medical functioning and their overall quality of life (QOL). Second, how the child's illness and subsequent QOL related to parental mental health and parenting behaviours. These themes were explored using the Risk and Resilience model developed by Wallander et al. (1989b). Study one involved children diagnosed with acute lymphoblastic leukaemia (ALL), the most common form of childhood cancer. Results showed that the child's medical functioning (e.g., time since diagnosis) did not relate to the child's QOL, but did relate to parental mental health. Furthermore, child QOL was significantly related to both parental mental health (depression) and parenting behaviours (endorsement of force). In an attempt to explore these themes in greater detail, Study two involved two groups of cancer survivors, those with ALL or tumours of the central nervous system (CNS). Medically, these groups have different prognoses, treatments, and long-term consequences. Results showed that those with poorer medical functioning, i.e., CNS tumours, had poorer QOL than both the ALL group and population norms, confirming the relationship between the child's medical and psychological adaptation. Furthermore, the child's adaptation was strongly related to both parental mental health and parenting behaviours, again providing evidence for the relationship between child and parent functioning. The results of both studies in this thesis go some way to demonstrate the wide-ranging effects that cancer can have on both the child and family. The child's QOL can be compromised by the illness. Moreover, cancer has a detrimental effect on the family life, from pervasive feelings of depression and worry, to longterm concerns about child-rearing. This thesis has shown that those children with CNS involvement, and their families, are particularly at-risk. To conclude, a section outlining clinical interventions which can help reduced the impact of childhood cancer on the family are discussed.

Online social support is reported to be used by a number of people to obtain social interaction and exchange communication as a way to buffer stressful situations. Breastfeeding women experience a significant change in their lives and routine which a number of women find it stressful for various reasons. Research shows that breastfeeding women use the Internet to obtain support, however little is known about how breastfeeding women use online social support and their perceptions, concerns and expectations about using it. An interpretive approach using qualitative methods was adopted in this research to obtain and analyse the data acquired through interviews and observations. The framework proposed by the Social Cognitive theory was used to conduct this research and to provide insights into online social support in a breastfeeding peer support context. The results in this research indicate that in spite of face-to-face interventions being favoured, online social support is perceived as a helpful alternative support with the potential to positively influence breastfeeding self-efficacy. A number of similar characteristics of face-to-face support were found to be present in online social support, such as emotional and informational support, empathy and empowerment. Online social support was perceived as offering additional features to traditional support including convenience of use, connection with peers and supporters at any time of the day, and the opportunity to express emotions and issues textually. Certain concerns were also associated to using online social support to support breastfeeding women, which need to be taken into consideration by providers of online social support. These included the need for training volunteers in this type of media, confidentiality and trustworthiness of the information available online and issues related to digital divide. These findings are useful to further the understanding of the implications of online social support in self-efficacy and the associated outcomes. Policy makers, social scientists and breastfeeding support organisations can use the findings in this research to develop future breastfeeding promotion strategies and interventions. Ultimately, breastfeeding women benefit from the findings of this research, through the implementation of online social support interventions addressing the issues raised in this research. These women will consequently have access to more services and applications, as well as engage with volunteers or clinicians trained to fulfil their needs over an alternative channel.

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.

This study explored the factors which affect the feeding and weaning practices of Emirati mothers as well as the experiences and perceptions which influence their breastfeeding decisions. It used both quantitative and qualitative methods to examine Emirati mothers’ understanding of infant feeding and to identify the factors which appeared to have a relevant effect and locate them in their cultural context. n the survey, a convenientce sample of 593 mothers with infants aged up to 2 years was interviewed face to face in the maternal and child healthcare centers in Al Ain, Dubai and Abu Dhabi. The interview was based on a pretested structured questionnaire. The results of multiple logistic analysis showed that the time of initiation of the first breastfeed was significantly associated with the infant’s birth weight (OR=2.007; P<0.023), parity (OR=2.139; P<0.001) and rooming in (OR=21.70; P<0.001). As for the feeding patterns, the results of the multiple logistic analysis revealed that rooming in (OR=4.485; P<0.001), feeding on demand (OR=2.290; P<0.005) and feeding more frequently at night (P<0.001) emerged as significant factors associated with exclusive or almost exclusive breastfeeding practices. The duration of breastfeeding rate was significantly influenced by many variables. Concerning the duration of lactational amenorrhea, the, the multiple logistic analysis showed that mother's age, breastfeeding duration and the early introduction of formula milk and solid food emerged as significant variables. Among the 593 infants in the study, 24.1% were predominantly breastfed,25% of the infants were exclusively breastfed, and 49.4% were almost exclusively breastfed since birth. Fifteen Emirati mothers from each city were interviewed about their breastfeeding practices, beliefs and perceptions. The following themes emerged: the influence of others, the sources of information, infants’ behavior, knowledge of and attitudes towards current WHO recommendations and mothers’ perception of the benefits of breastfeeding. Health promotions and healthcare facilities failed to deliver the message of the importance of exclusive breastfeeding. Grandmothers and mothers-in-law appeared to influence the mother's breastfeeding practices. In conclusion, there is a need for a national community-based breastfeeding intervention programme for the promoting exclusive breastfeeding practices as part of a primary public health strategy.

There is a wealth of literature suggesting that breastfeeding for 6 months offers the ideal balance of nutrients for complete infant growth, and that all infants should be: “exclusively breastfed from birth to six months of age” (WHO 2003). However, although 98 percent of new mothers are capable of breastfeeding, only a minority of infants continue to be breastfed at six months following birth. In addition, breastfeeding rates are socially patterned whereby women living in the most affluent neighbourhoods are three times more likely to breastfeed their infants than women living in the least affluent areas (Bolling et al 2007). This thesis set out to address a range of research questions in relation to women’s lived experiences of breastfeeding in private and public spaces throughout the first 6 months of motherhood within a sample of mothers from the most and least affluent neighbourhoods. Given that breastfeeding is an embodied health behaviour, the epistemology adopted a position of interpretivism as a means of capturing the meaning and lived experiences of women’s breastfeeding. Breastfeeding women were recruited at 2 days following birth from the most and least affluent areas of Glasgow south and 41 in-depth interviews were conducted over 3 time periods following birth: 4 weeks (n18), 10 weeks (n12) and 26 weeks (n11). The results from this public policy health service research study suggest that breastfeeding is a learnt skill and women work hard to develop their skills and confidence in order to breastfeed comfortably and discreetly in private and public spaces. Breastfeeding is commonly discussed as a private domestic activity, and home is generally considered the most appropriate place for breastfeeding to take place. However, with the constant flow of visitors a new baby attracts, the boundaries between what are considered private and public space breaks down. As a result, women develop an awareness of appropriate and inappropriate spaces for breastfeeding both at home and outside the home. Women suggest, at times, they feel a greater degree of privacy breastfeeding within public spaces than they do in the private space of their own home.

Principles of Realist Evaluation (Pawson & Tilley, 1997) were used alongside a framework based on Realist Social Theory (Archer, 1995; De Souza, 2013) in order to explore and explain the nature of the local parenting context in which the Holding Hands Parenting Programme (HHPP) was both embedded and functioned. The research identified particular mechanisms that were pre-existing in the local context in its structural, cultural, agential and relational aspects which were activated by the introduction of a parenting programme. It was carried out in a large shire county where the researcher worked as a Trainee Educational Psychologist. Stakeholders in the HHPP from various system levels, ranging from those with service and commissioning responsibilities to recipients of parenting support, participated in the study, providing a rich insight into the multi-layered local context. Thematic analysis (Braun & Clarke, 2006) was used as a grounding framework for the analysis of data which followed a realist analytical process culminating in retroduction (Crinson, 2001) and six overarching themes were developed: (i) forward thinking; (ii) one size fits; (iii) collaboration; (iv) involvement; (v) barriers and (vi) perceptions and expectations. Network patterns (or configurations) were created which mapped out the relationship between aspects of the context, pre-existing mechanisms and the outcomes potentially generated as a result of a parenting programme. Existing literature was explored and findings formed a key part of the theorisation and retroductive phases of data analysis. Two overarching theories were constructed in order to summarise the concluding thoughts in this study on the relationship between the HHPP and its context. These were presented and can form the basis of future realist evaluation research. This research contributes to the further development of the HHPP as it seeks to use innovative and creative ways to support a wider range of parents within a complex and changing local context. Implications for future research and links to the practice of educational psychologists are discussed and the potential value principles of realist evaluation may have for an educational psychology service is outlined.

Low-intensity parenting programmes play a key role in a public health approach to parenting support and are designed to be a cost-effective intervention for child conduct problems. Several studies that have evaluated a single topic-specific Triple P–Positive Parenting Program Discussion Group, an example of a low-intensity parenting programme, have found promising results for improving child and parent outcomes among parents with young children. This thesis aimed to examine ways to enhance the intervention outcomes of low-intensity topic-specific parenting groups for parents with young children. In study one, the effects of generalisation promotion strategies, such as teaching multiple exemplars, were examined. As a single training exemplar may not be sufficient for parents to effectively generalise parenting skills, multiple exemplars may assist parents to flexibly apply skills across a range of behaviours and settings leading to greater change in child behaviour, parenting practices, and parenting self-efficacy. This study also sought to extend the literature by examining the effects of low-intensity parenting groups with parents of primary school aged children using topics relevant to this development phase and investigating outcomes for mothers and fathers separately. A two arm randomised control trial design was used to compare the two conditions (single exemplar vs. multiple exemplar). Participants were 75 mothers and 58 fathers with a 5-8 year old child displaying at least a mild level of conduct problems. They represented 78 families: 66 two-parent families and 12 single parent families. Among two-parent families, there were 55 mother-father pairs, nine mothers who participated alone, and two fathers who participated alone. The majority of the single parent families were mothers (n = 11). Self-report measures of child behaviour, parenting practices, parenting self-efficacy, parent’s perceptions of their parenting role experience, parental mental health, inter-parental conflict, partner support, and partner relationship satisfaction were completed by parents at pre-intervention, post-intervention, and 6-month follow-up. Satisfaction with each intervention condition and the individual sessions was also examined. Low-intensity topic-specific parenting groups led to improvements on a range of child and parent outcomes for both mothers and fathers of primary school aged children. Receiving multiple exemplars resulted in more robust change in mother- and father-rated child behaviour, mothers’ parenting practices, and mothers’ behavioural parenting self-efficacy at post-intervention. For mothers in the multiple exemplar condition, superior improvements in child behaviour, parenting practices, and behavioural parenting self-efficacy were maintained at 6-month follow-up. Greater improvements in mothers’ setting parenting self-efficacy, mental health, and perceptions of partner support were also found at 6-month follow-up among the multiple exemplar condition. The second study in this thesis added to the literature on low-intensity parenting programmes by exploring whether addressing parental mental health, in addition to parenting, was beneficial for parents with young children. As poor parental mental health is linked with child conduct problems, negative parenting practices, and can negatively impact the effects of parenting programmes for families, simultaneously addressing parental mental health when delivering low-intensity parenting programmes may be advantageous. A mixed-method quasi-experimental evaluation of a combined low-intensity parenting and mental health programme was conducted. Thirteen families with a 3-8 year old child took part in the study. Self-report symptoms of anxiety, depression, and stress and ineffective parenting practices were obtained at pre-intervention, mid-intervention, post-intervention, and 3-month follow-up. Parents also completed self-report measures of child behaviour, parenting self-efficacy, parent’s perceptions of their parenting role experience, family relationships, and positive mental health at pre-intervention, post-intervention, and 3-month follow-up. Post-intervention semi-structured interviews were conducted with 12 parents and explored parents’ experiences of taking part in the programme, their perceived impact of the programme, and their implementation of strategies. The combined intervention produced promising changes in parenting practices and parental mental health. Parents perceived some positive impacts after attending the programme and generally the combined programme was acceptable to participating parents. Collectively, the findings from the two studies suggest that low-intensity topic-specific group parenting programmes have positive effects for young children and parents. Delivering multiple exemplars leads to added benefits and addressing parental mental health simultaneously has positive effects for families.

The benefits of breastfeeding for mother and baby are well established; however, only 37.5% of Scottish women are currently breastfeeding at six to eight weeks with less than 1% breastfeeding exclusively for six months, as recommended by UK and international health policy. Family influence is amongst the socio-demographic factors which affect breastfeeding initiation and duration and women who were not breastfed themselves are 25% less likely to initiate breastfeeding. While there is a growing body of literature which seeks to understand breastfeeding by exploring the perspectives of breastfeeding mothers, no studies can be found describing the experience of making a different feeding choice from that of one’s family-of-origin, nor of the potential impact of this decision on relationships with them. As such, this study exploring the experience of being the first in your family to breastfeed is novel. The aim of the study was to investigate the experience and meaning of being the first person to breastfeed in a family. Consequently, areas explored included women’s experience of initiating and sustaining breastfeeding when they have no immediate family history of breastfeeding, how women make sense of their decision to breastfeed and their understanding of how their decision has affected their relationships. A methodological development in the form of an Infant Feeding Genogram was used to record relevant demographic and family information and semi-structured interviews with fourteen women obtained in-depth narratives. Interpretative phenomenological analysis (IPA) was used as an approach and to analyse the data. Following the completion of idiographic analysis, cross participant analysis was undertaken and four superordinate themes emerged: Breaching Family and Social Norms; Volitions and Imperatives; Unprepared for the Challenge; and A Sacrifice but Worth It. Within these superordinate themes, 13 themes were identified and articulated. Findings from this research were synthesised to provide an account of how women experience being the first to breastfeed in a family, make sense of their decisions and the impact this has on their relationships with their family. This provides an understanding of women’s experience in an original context, and the contextualising within the existing literature generates commonalities and highlights differences between the experience of this group of breastfeeding women and the wider cohort. The findings of this research inform recommendations for practice at both an individual and public health levels, and have implications for policy makers, health professionals and breastfeeding support organisations. It is asserted that policy makers and the health service need to acknowledge the unanticipated consequences of some current breastfeeding discourses associated with health promotion practices, and take a mother and family focussed approach to breastfeeding that acknowledges women’s embodied experience, which often includes breastfeeding difficulties. A mother and family centred approach can identify and adapt to women’s support needs in their own particular context, which may include very limited community and family support for their decision.

No description available.

Le vieillissement de la population et la forte prévalence des incapacités qui lui est associée invitent à s’interroger sur les modes d’accompagnement de la perte d’autonomie. Tandis que l’aide reçue par les personnes âgées dépendantes provient majoritairement de leurs proches, les politiques publiques françaises favorisent le recours à l’aide professionnelle, dite aide formelle, pour les personnes résidant à domicile. Cette thèse se propose d’étudier les configurations d’aides formelles et informelles pour les personnes âgées en perte d’autonomie. Sous quelles conditions les individus ont-ils recours à l’aide professionnelle, et comment se détermine leur niveau de consommation ? Comment les producteurs d’aide familiale et professionnelle s’adaptent-t-ils aux contraintes de production qui leur sont propres ? Les quatre chapitres de cette thèse étudient empiriquement ces questions dans le contexte français. Mobilisant le cadre micro-économique et les outils économétriques, ils s’appuient sur des données d’enquête, des données administratives et des fichiers de gestion d’un service d’aide à domicile. Le premier chapitre porte sur l’aide apportée par les enfants à un parent âgé dépendant. Le deuxième chapitre étudie l’élasticité-prix de la demande d’aide formelle. Le troisième chapitre analyse comment le financement public de la demande et la régulation de l’offre affectent la décision de consommer de l’aide professionnelle. Le quatrième chapitre s’intéresse enfin aux coûts de transport des services d’aide professionnelle, comme contrainte de production pesant sur l’organisation de l’offre. Les résultats montrent que la demande d’aide est relativement peu sensible au prix de l’aide professionnelle, tandis que la régulation de l’offre affecte plus notablement les configurations d’aide. / In a context of population ageing, the demand for long-term care is rising. While relatives remain the major source of care provision for disabled elderly, most OECD countries tend to foster the use of professional care, also called formal care, when individuals live at home. This thesis studies the determinants of home care arrangements for the disabled elderly in the context of France. What are the determinants of formal care consumption, at both the extensive and intensive margins? How do formal and informal care providers adjust to their provision constraints? The four chapters present original empirical evidence on these questions in the French context. They build on micro-econometric frameworks and use national survey data, administrative data or management files from a professional provider. The first Chapter studies the care provided by children to a disabled elderly parent. The second Chapter estimates the price-elasticity of the demand for formal care. The third Chapter analyzes how the decision to consume formal care is affected by the generosity of the public financing and the regulation of home care providers. The fourth Chapter focuses on the travel costs borne by home-care providers and their effect on the home care provision. The demand for formal care is found to be fairly little sensitive to its price, while the regulation of the supply is more likely to affect care arrangements.