Sweden is seen as a successful adopter of English as an additional language (EAL) and the country is a frontrunner in the globalization of the English language. Much of the success could be attributed to the large presence of English in Swedish society. Additionally, EAL learners are acquiring the English language out-of-school to a larger extent, often referred to as Extramural English (EE). Therefore, it is important to investigate how EE affects learners, teachers and discuss how it can change education. This has been done by evaluating the current state of research through a systematic literature review. It was found that learners engage in a variety of EE activities, with playing online games and watching movies being the activities with the most English exposure. Learners engage in these activities mostly out of their own interests or because of other socially driven motives. EE affects their opinion of English and could have negative effects on their attitude towards school English. Teachers are aware of the gap between EE and school English and try to integrate activities similar to EE activities in class. However, it is a challenge to find authentic material that fits a large number of learners’ interests. In conclusion, there is a need for more research that could point to a clear cause-and-effect relationship between EE and high proficiency in English. This thesis also calls on teachers, principals, and school leaders to prepare to change education if EE becomes a more widespread phenomenon.

The increasing multicultural and multilingual population of the UK has set new challenges for the education system. This study focuses on a particular aspect of this, namely pupils in schools in the city of Leicester who use English as an additional language (EAL). It compares their lexical understanding with that of their monolingual English-speaking peers, when both sets of pupils appeared to have attained the same surface proficiency in reading. This work also investigates teachers' awareness of any lexical comprehension gap that might exist for their EAL pupils. These key issues could not be studied in isolation, so this research was set in a sociocultural framework. This drew together social and cultural strands to give a situational understanding of the target pupils in city schools. It encompassed their teachers' observations and perceptions through a series of thirty interviews undertaken with these practitioners. This was complemented by interviews with ten key management personnel from the Language Support Service undertaken to investigate the objectives of the Service, and how successfully these were implemented in schools. The empirical research of this study was a Vocabulary Test undertaken with one hundred primary school pupils to test the key hypothesis that EAL pupils' lexical understanding was not as comprehensive as that of their L1 peers. Fifty of the pupils used English as an additional language, forming the EAL group of this study, and these were matched with fifty monolingual English-speaking pupils, the L1 group. The results of the Vocabulary Test substantiated this hypothesis for the target lexemes included in the test, and they also substantiated the additional hypothesis that mainstream teachers did not always fully recognise lexical misunderstandings that their EAL pupils might have. The research was classroom-based, and incorporated some principles of action research. A key factor in the action research paradigm has been disseminating the finding to schools and to teachers to effect changes in classroom practice by increasing awareness of lexical difficulties that EAL pupils might have. For this study, the dissemination has taken the form of Vocabulary Workshops for school staff, and these are ongoing at the present time. The workshops are designed to help teachers enhance EAL pupils' understanding of lexis in English and their learning through English.

The assessment of pain in children has been an enduring theme in the research literature over many decades, with particular focus on how pain can be adequately measured and the extent of under-measurement of pain (American Academy of Pediatrics 2001; Coyne, 2006; McCaffery & Beebe 1989; Subhashini et al., 2009). Definitions of pain, and hence development of pain measurement tools, are often criticised for not addressing the influence of culture and ethnicity on pain (Bates et al., 1993; McCaffery & Beebe 1989; Zinke, 2007), in children, the perception and expression of pain is also affected by cognitive development (Hallström and Elander, 2004). Whilst there has been an increase in the number of children living in the United Kingdom (UK) who do not speak English as their first language, it has been acknowledged that the measurement and management of pain by health service professionals relies predominantly on their experience with English speaking children (RCN, 2009). This study aimed primarily to examine how primary school age children in key stage 1 who speak English as a primary or additional language experience, express, and explain pain. This aim was addressed through three research questions: (1) how do primary school age children in key stage 1 talk about pain? (2) What are the similarities and differences in the language used to talk about pain by children with English as a primary and additional language? (3) Are there differences in the perceptions of pain by children of different age, gender, language background, and country of birth? A second aim was to examine whether language would affect actions taken by final year child health students and nurses working in Minor Injuries Units to manage pain in primary school age children. Study objectives were addressed using a two phase mixed methods design. The first aim was addressed using six focus group interviews with groups of primary school children (aged 4-7) (Phase 1). Two methods were used in the interviews: use of drawings from the Pediatric Pain Inventory (Lollar et al., 1982) to capture the language used by children to describe pain and observation of the children’s placing of pain drawings on red/amber/green paper to denote perceived severity of pain. Following data collection, the vocabulary of each child was assessed using a standardised lexical test (British Picture Vocabulary Score version II - BPVS II) (Dunn et al., 1997). To address the second aim, a factorial survey was conducted (Phase 2) with nurses working in Minor Injuries Units and child health nursing students to determine whether language has an impact on decisions made about the management of children in pain following a minor injury. Phase 1 findings demonstrated that children from English as an Additional Language (EAL) backgrounds used less elaborate language when talking about pain but tended to talk about the pictures prior to deciding where they should be placed. The children’s placement of pain drawings varied according to language background, gender, and age. The calculated language age of English lexical comprehension (BPVS II score) of monolingual children (M=69.85, SD=19.27) was significantly higher than EAL children (M=47.93, SD=14.32; t (32) = 3.60, p =0.001, two-tailed). However, when these differences were explored in terms of year group, the differences remain significant with foundation and year 2 but not with year 1. For the EAL children, there were also significant relationships between BPVS II score and length of stay in the UK (spearman’s rho 0.749, p = 0.33). The Phase 1 findings were used to construct vignettes, describing hypothetical care situations, for Phase 2. Multinomial logistic regression was used to analyse the impact of a child’s age, gender, language, parent’s language, injury mechanism, and reaction to pain on the way in which the child’s pain would be assessed and whether parents or an interpreter would be invited to assist in pain assessment. Findings demonstrated that observing the child’s behaviour is the most significant assessment process that is used to assess EAL children, rather than the Visual Analogue Scale (VAS), which was used with non-EAL children. This is significant as VAS is the mostly widely used tool to assess pain in health care settings. However, VAS is only effective if it can be understood by the child. Further, MIU nurses and child health students were more likely to involve parents who speak English well than those who speak English poorly but would ask for an interpreter if their involvement was necessary. In order for the respondents to explain their decisions, they were asked an open ended question for each vignette. They reported that language and age of children are the most common difficulties they faced during assessment of pain. Therefore, they suggested some solutions, like using an age appropriate tools for assessing younger children. Respondents also identified that using an interpreter is a time consuming process, which might delay the management of pain. In light of the growing numbers of EAL children in the UK; this research has application in a number of contexts. The variation in language would apply if children were reporting their own pain. However, the findings emphasise the need for sufficient time to be allocated to pain assessment to allow an individualised approach. Study findings suggest several factors that may be important in assessing pain in EAL children; these should be explored further in the context of clinicians’ assessment of pain. The implications of the study impact on policy, practice, education, and future research.