Volume I is divided into two papers. The first is a literature review that explored the emotional experience of professionals who work with victims of domestic violence. Twelve papers are evaluated and the evidence of negative and positive effects is presented. The second is a qualitative study with young people, their mothers and their grandmothers which explored resilience after domestic violence. Data was analysed using Interpretative Phenomenological Analysis. Four themes regarding the memories of domestic violence, newfound stability, acceptance and strength and continued and re-scripted attachments were found. Volume II consists of five reports. The first describes the assessment of a 13-year-old boy with low self-esteem. His needs and strengths are formulated from two approaches: cognitive-behavioural and systemic. The next discusses a behavioural intervention and single case experimental design for a 15-year-old male presenting with challenging behaviours. The third paper outlines a Person Centred Care training program for staff working with older adults. The fourth is a case study of two siblings in local authority care. To consider care-plans, a formulation is informed by the complex trauma literature. The final report was an oral presentation of an admission assessment of a young woman in a high secure hospital.

Section A provides an overview of the literature investigating the relationship between parental mental health and child physical health within populations of children with chronic childhood illness. Evidence for whether this relationship definitively exists, as well as the potential pathways through which this relationship could operate, is evaluated. Carers of children with Chronic Kidney Disease (CKD) can experience burden and psychological distress, which has been shown to impact on the child's physical health. Section B is an empirical study aiming to assess the validity and reliability of the Paediatric Renal Carer Burden Scale (PR-CBS) , a 51 item psychometric measure designed to assess carer burden in carers of children with CKD. Factor analysis indicated retention of 21 items representing 5 factors; Illness worries (8 items), Impact on self (5 items), Impact on child (3 items), Responsibility (3 items) and Institutional burden (2 items). Together they explain 53% of the total variance. Internal reliability for both the full scale and sub-scales were acceptable. Convergent validity was demonstrated using the Hospital Anxiety and Depression Scale and Caregiver Strain Questionnaire and the scale was reported by respondents as being acceptable to complete. The PR-CBS has been shown to be a valid and reliable scale and as such is a clinically relevant tool with which to identify burdened carers and provide additional psycho-social support so as to ensure best outcomes for both carer and child. Section C provides a critical evaluation of the research process and reflections from the researcher on learning throughout the process of the study as well as clinical implications and future research directions.

Thesis (Ph.D. in Nursing) -- University of Colorado at Denver and Health Sciences Center, 2006. / Typescript. Includes bibliographical references (leaves 188-199). Free to UCDHSC affiliates. Online version available via ProQuest Digital Dissertations;

Significant global health attention and promotion has been focused on hand washing with soap due to the clear benefits observed in promoting and ensuring child health. However, the measurement and evaluation of hand washing behaviours remains complex. The Sanitation, Hygiene Education and Water Supply in Bangladesh Programme (SHEWA-B) is a large project being implemented by the Government of Bangladesh and UNICEF. This research assessed methodological issues of measuring hand washing behaviours through comparison of structured observation and responses to cross-sectional survey measures (spot-check observation, selfreported hand washing and a hand washing demonstration) and discusses the suitability of indicators. Focus group discussions with fieldworkers were also conducted. The results of this study indicate that hand washing behaviours were over-reported compared with structured observation findings. This implies that current estimates of hand washing from large scale surveys, for example, Demographic and Health Surveys (DHS) are also likely to be overestimates. In about 1000 households, approximately 1% or less of female caregivers were observed to wash their hands with soap or ash before preparing food, before eating, and 3% before feeding a child. Hand washing with soap was higher for defecation related events with approximately 29% of female caregivers using soap two thirds or more of the time after cleaning a child’s anus/disposing of a child’s stools and 38% used soap two-thirds or more of the time after defecation. Soap was observed at the hand washing location in about 50% of the households but actual practice was much lower. Reported knowledge was high; approximately 90% identified the important times for hand washing as being before eating and after defecation and approximately 50% identified before preparing food and after cleaning/changing a baby. The measurement of hand washing is complex and there has been limited research into the validity of different measurement methods. This research used an epidemiological style approach using the concepts of screening/diagnostic testing and calculation of kappa statistics to assess validity. In conclusion, this research demonstrates that self report hand washing measures are subject to over reporting. Structured observation provides useful information on directly observed hand washing behaviours and the frequency of behaviours. Spot check methods of soap and hand washing locations also provide more optimistic data than observations and can be used as an alternative to structured observation. In addition, the use of questions on the 24 hour recall of soap and other self report questions on knowledge and the availability of spare soap demonstrate potential for use as potential indicators as an alternative to structured observation. Further validation of measurement methods is required in different country settings.

This thesis explores the pathways through which individual and household factors are associated with temporal changes in child nutritional status. In this study the concept of nutrition deprivation is used in two ways: firstly as indicated by the child's anthropometric measures, and secondly in terms of food consumption. The thesis also explores how nutritional deprivation is linked with economic deprivation. The main objectives of the study are: to examine the physical growth trajectories of children, to investigate the household's economic and nutritional (food) deprivations, to explore the determinants of child malnutrition, and finally to investigate the relationship between temporal changes in the poverty status of households and temporal changes in child nutritional status. The study uses the Pakistan Panel Data collected by the International Food Policy Research Institute (IFPRI) from 1986-89, covering four rural districts of Pakistan. The study employs a comprehensive child health framework to establish the mechanism of child nutritional status by linking the various factors at child, household and community levels. This framework specifies poverty as the root cause of malnutrition. The basic need absolute poverty approach is used to work out the incidence and the dynamic nature of poverty. Various statistical modelling techniques for analysing the longitudinal data are used in this study. For example, to study the height and weight growth traectories of children a growth curve modelling technique is employed, and to study the determinants of child malnutrition a three-level hierarchical linear model for longitudinal data is used. The predicted average growth velocities indicate a slower growth during first year of child's life in comparison with the usual growth velocities amongst the normal children. However, in a particular cohort of children some evidence of growth acceleration is found during the third year of a child's life after a growth deceleration during the second year. Child level factors, such as breastfeeding and the incidence of diarrhoea and morbidity, are found to explain most of the variability in child nutritional status. The results reveal dissimilarities in nutritional status between children in a household. The results also indicate associations between poverty and stunting while chronic poverty is found to be associated with wasting. The results indicate that caloric and protein consumption amongst the study households was notably high. However, food consumption patterns mostly revolve around the staple food, and even in the top expenditure quintile this pattern remains persistent.

Resilience is offered as a theoretical framework from which the competent functioning of a small proportion of survivors of childhood trauma can be understood. Despite the likely deleterious impact of abuse and neglect some individuals continue to thrive and achieve positive outcomes. The literature investigating protective factors implicated in resilience to childhood trauma is reviewed. Studies indicate that certain individual and environmental protective factors provide encouraging experiences and promote positive adaptation. Although current literature needs to move to a more process orientated approach for investigating resilience, existing findings offer valuable insights for the direction of prevention and intervention programmes for at-risk populations. This focus on strengths rather than deficits paves the way for innovative approaches especially with disenfranchised groups who might otherwise be less receptive, for instance individuals marginalised from society such as homeless individuals. On this basis, the empirical study investigated the relationship between childhood trauma and maladaptive coping and the relative influence of resilience, in homeless individuals. A significant relationship between childhood physical abuse and maladaptive coping existed, which was moderated by high levels of resilience. It is postulated that resilience in the homeless population may have a greater protective effect against maladaptive coping as severity of childhood physical abuse decreases. Studies replicating these findings in this and other disenfranchised groups are essential in order to fully understand the role of resilience and potential benefit of promoting and enhancing resilience and coping in reducing tenancy breakdown and therefore chronic and repeated homelessness.

There is a dearth of smoking research involving young children despite the knowledge that the developmental proocess begins in early childhood. This paucity hinders the development of effective smoking prevention strategies, which need to be based on an accurate understanding of the perspectives of the target group. Therefore basic research is required, to discover where primary school children are at in their thinking about smoking before any potent anti-smoking initiatives can be devised. Such an endeavour however, is exacerbated by the lack of appropriate methods of data collection for this particular age group. The aim of this research study was to explore the perspectives that Liverpool primary schoolchildren in their early years (four to eight years of age) have about smoking by examining the beliefs, knowledge, perceptions and behavioural intentions that inform their attitudes about the habit and subsequently, to assess any changes in these factors over time. This work not only provides the understanding and insight fumdamental to the development of proactive health promotion programmes aimed at tackling the increasing prevalence of smoking among local children but also the empirical evidence needed to fill the significant gap in the existing literature on smoking as well. To achieve these aims ,a multi-method, child-centred participatory approach was used. This between-methods traingulation included questionnaires The Draw and Write Technique, semi-structured interviews and focus group interviews. For the cross-sectional study, a representative sample of primary schoolchildren in their early years from wards of varying socio-economic status participated. All were involved in the quantitative method and a subsample partook in the qualitative methods. For the longitudinal study, the same research design was used to track one birth cohort - the children from Reception for a period of three years to document any changes in perspective over time. The research findings from both studies demonstrated that the children in this investigation had considerable understanding about the nature of tobacco smoke, had as yet to take up the habit and generally expressed little intention to smoke in the future. Their perspectives were predominantly negative, very stable and relatively homogenous. They were grounded in a broad knowledge base that was primarily influenced by cognitive development and socio-cultural experiences. They acknowledged the importance of the family and perceived parents to be both preventers and promoters of the habit. The children also harboured some misconceptions, believing that the health implications from smoking were far greater for children than adults. This belief has cultivated a widespread notion that smoking is an intrinsic part of adulthood. The study findings have substantive implications for the development of proactive smoking interventions in primary schools. The results suggest that any prevention strategy devised must be implemented as early as possible in the school curriculum, that it should be developmental in nature and more than knowledge- based. A grass roots approach, one that fosters empowerment tbrough the active involvement of the children in both the development and implementation of the strategy, in collaboration with the school, the home and the community is recommended, as this work has confirmed that children in their early years can be reliable and valid participants in the research process.

This thesis reports on a study that aimed to add to the understandings about head lice that were already available in society. Previous accounts of infestation had focused largely on its social and expert medical perspectives and there was limited comment on the experience at a personal level. In order to address this Liverpool mothers and grandmothers were asked about their perceptions and understandings of what it meant to experience head lice. The women's experiences spanned most of the twentieth century and this provided the study's historical dimension. The inquiry used hermeneutic phenomenology as a way of investigating highly personal aspects of an experience that had not been explored before. By using an approach that drew on hermeneutic phenomenology and anthropology it was possible to explore aspects of the experience that generated culturally specific beliefs and understandings. Lambert and McKevitt, (2002) argue that in doing this a phenomenon defines itself. In this inquiry the boundaries of mother's understandings concerned with the experience of head lice were unknown. Hermeneutic phenomenology allowed these hidden understandings to emerge. Van Manen's (1997) framework for phenomenological inquiry was used to guide the study and Colaizzi's (1978) method for the interpretation of the women's stories was used to highlight the understandings that emerged. The women who took part were of different ages though all had lived, been mothers and experienced head lice during the twentieth century. They were asked to tell their stories and these were recorded, transcribed and interpreted. The interpretation of their narratives generated themes of understandings. These included understandings about the responsibilities of being mothers and giving care, beliefs and views about the insect and infestation and the meaning and impact of social stigma. The understandings that the women expressed were concerned with their individual responses to infestation. Essential feature shared by them represented a complex interplay of guilt feelings about themselves as poor mothers and the importance of the responsibilities they felt they had to prrtect their children, their families and society from head lice. Their own mothers played a significant role in fashioning their understandings as did their childhood experiences. Images of others outside the family who had infestation were linked to stigma, poor mothering and to lay epidemiology. The women talked of other mothers' responsibilities to prevent and treat infestation and how this created a feeling of lack of control. They also told of the need to remove all traces of infestation from their home and with it the influence and presence of what constituted their image of an infested family. The women shared their stories, but as Widdershoven (1993) points out these have little value unless their relationships to other sources of experience are also considered in some way. Therefore the women's understandings were placed into context by examining the way in which they linked to other available discourses about head lice. A search was made of the social, historical and expert medical sources available during the twentieth century; local Liverpool sources were consulted wherever possible. The understandings that emerged from these were then considered alongside those of the women. There was a link between the women's understandings and those in the social discourse concerning the public health role of women during the twentieth century. Infestation was used as a measure of mothering by social discourses and the women alike. This gave healthcare practitioners and society the opportunity to comment on, influence and control what went on in the family. Stigma, exclusion and labelling were evident in both the social discourses explored and the women's stories particularly in relation to experiences of school and the school nurse. Personal and social discourses about prevention, detection and treatment reached no overall consensus with evidence based approaches being used alongside those influenced by myths and more socially constructed understandings.

Childhood obesity in the UK is a serious public health concern. In some ethnic minority groups obesity prevalence is significantly higher than the national average (The NHS Information Centre, 2010). Therefore, it is recommended that interventions to manage childhood obesity are tailored to the needs of ethnic minority groups (NICE, 2006). GOALS (Getting Our Active Lifestyles Started!) is a community based, childhood obesity management programme that focuses upon physical activity, nutrition and behaviour change in families (Watson et aI., 2011). However, monitoring data has suggested an unrepresentatively low proportion of ethnic minority families who are referred to GOALS choose to access the service. Therefore the aim of this research was to improve the cultural relevance of the GOALS programme, whilst also contributing to the evidence-base for local and national strategic planning surrounding obesity and ethnicity. Studies set out to explore perceptions surrounding childhood weight, diet and physical activity in different ethnic groups; identify cultural preferences, and barriers to participation in healthy lifestyle interventions; to implement and pilot a culturally accessible intervention, using the GOALS framework for development; and to assess the acceptability and effectiveness of the pilot intervention. A multi-method, pluralistic, research design was employed that recognised the complexity of the research aims. In total three empirical studies were conducted, and parents (of children aged 4 to 16 years) and school-aged children participated. A combination of process and outcome data was obtained. Quantitative methods were used for descriptive and explanatory purposes and included questionnaire (Study 1,2 and 3b) and BMI measures (Study 3b). Qualitative methods included focus groups (Study 2 and 3a), face-to-face interviews (Study 3b) and the write-and draw-technique (Study 3b). Exploratory data gave context and depth to the research. In Study 1, parents (n=808) identified their ethnic background as Asian British, Black African, Black Somali, Chinese, South Asian, White British and Yemeni. Ethnic background was significantly associated to parental perceptions of weight in childhood. Results showed Black Somali parents exhibited the lowest level of concern for overweight in childhood in comparison to other ethnic groups. In Study 2, parents (n=36) and children (n=31) from six ethnic groups (Asian Bangladeshi, Black African, Black Somali, Chinese, White British and Yemeni) identified intrapersonal, interpersonal and environmental barriers to healthy weight. Findings demonstrated that influences to health behaviours were sometimes specific to particular ethnic groups. For example, dominant cultural norms valuing overweight in childhood were apparent among Yemeni, Black African, Black Somali and Asian Bangladeshi parents and Asian Bangladeshi children. Results from Study 3a with parents (n=33) from ethnically diverse backgrounds, identified barriers and preferences to attending an intervention were often related to cultural and religious values of ethnic groups. Parents considered the ethnic composition of the group important, and suggested an intervention should be relevant to the ethnic background of all families attending. Based on these findings, 'surface' and 'deep' (Reniscow et al., 1999) structural modifications were made to the GOALS programme. Nine families from Asian British, Asian Bangladeshi, Yemeni and Black Somali backgrounds attended the pilot intervention to examine its appropriateness. Process and outcome data from Study 3b illustrated families benefited from a healthy lifestyles intervention that was designed to be culturally acceptable to multiple ethnic groups. This thesis has added to the limited evidence base surrounding the cultural relevance of family-based childhood obesity management programmes for ethnic minority groups. Differences in cultural norms between ethnic populations, and variations in assimilation to Western norms and acculturation within groups, highlight the complex task in addressing childhood obesity in multiple ethnic groups. Knowledge gained from the successful engagement of ethnic minority families in a culturally sensitive healthy lifestyle intervention, has lead to the development of key recommendations for policy and practice that extend beyond childhood obesity management to health promotion more widely.

A large proportion of UK children do not meet the recommended guidelines for participation in physical activity, which is a public health concern as the prevalence of overweight and obesity among children is rising. Increasing perceptions of competence and levels of fundamental movement skill proficiency are potential strategies to promote physical activity. The aims of this thesis were to, a) investigate the prevalence of skill proficiency and levels of perceived physical competence in UK children, b) examine the relationships between fundamental movement skill competence and physical self-perceptions with children's physical activity, fitness and body fatness, and c) determine the effectiveness of non-curricular interventions to increase fundamental movement skills and enhance perceptions of competence. The first stage of research presented is the cross-sectional study of 152 children (41% boys; Age mean 9.7?0.3 years), which were recruited from 8 primary schools. Children completed the Children and Youth Physical Self-Perception Profile (CYPSPP) and were assessed on 8 skills using video-analysis and process measures. In addition, cardiorespiratory fitness was directly measured during a treadmill protocol to exhaustion; body fat (%) was determined by dual-energy x-ray absorptiometry; and physical activity was assessed by accelerometers over 7 days. The results revealed that children generally had positive perceptions of their physical self. However, levels of physical self-perceptions did not significantly predict physical activity behaviour. Perceptions of physical condition and physical strength were weak predictors of cardiorespiratory fitness and percent body fat, collectively explaining 7% and 7.8% of variance. Children's perceptions of competence were not related to their actual competence levels. Prevalence of proficiency in fundamental movement skills was low-to-moderate in boys and low in girls. Chi-square tests revealed a significantly (P < 0.01) higher proportion of boys were rated as proficient than girls in the kick (x = 37.4), catch (x = 25.3), strike (x = 28.4) and throw (x = 44.1). Total skill score significantly (P < 0.01) accounted for 11% and 9.2% of the variance in physical activity and percent total body fat, respectively. Locomotor skills significantly (P<0.01) predicted 7.7% of unique variance in moderate-to vigorous physical activity, 5.6% of total physical activity, 13.4% of cardiorespiratory fitness, and 23.7% of variance in percent body fat. Object-control skills weakly predicted total body fat (2%; P=0.04) but did not account for variance in other outcomes. This study highlighted the importance of fundamental movement skills to children's health and identified the need for interventions to enhance skill competence in older children. The next stage of research sought to determine the efficacy of interventions to increase skill competence and physical self-perceptions. An exploratory study examined the effects of a 9 week afterschool multi-skills club on skill proficiency, physical self-perceptions and body mass index (BMI) in 8-9 year old children. Two schools were randomly assigned to either a comparison (n = 15) or multi-skill club (n = 19) group. The multi-skill club received 18 coaching sessions designed to improve movement skills, while the comparison group followed normal routines. Children completed the CY-PSPP and assessments of seven movement skills, and were measured for stature and mass to calculate BMI. It was found that children in the multi-skill club had higher BMI (P<0.05) and possibly lower perceptions of body attractiveness and physical condition than children in the comparison group at post-test. Participation in the multi-skill club delivered significant (P<0.01) improvements in proficiency at post-test in static balance, whilst potentially practically important improvements were observed in performance of the catch, throw and kick skills. It was concluded that an afterschool multi-skill club offers a viable opportunity for movement skill acquisition, but any such programme would need to run for a longer duration to identify if this type of activity could benefit all skills. The final study was unique in that it was the first study to assess the impact of three different 12 month interventions on children's skill levels and perceived physical competence. One hundred and fifty-two 9-10 year old children were randomised by school to one of four conditions: a bi-weekly high-intensity physical activity afterschool club (HIPA; n=36); a bi-weekly multi-skill (fundamental movement skill) after-school club (FMS; n=37); a behaviour-modification programme (PASS; n=45); or a control-comparison (CON; n=34). Outcome measures, as employed within the cross-sectional study, were assessed at baseline, 9- and 12 months. It was found that participation in the FMS group was associated with moderate positive intervention effects on skill competence and increased the likelihood of attaining proficiency at post-test skill in 7 out of 8 skills. Participation in HIPA was associated with a small positive intervention effect on locomotor skill competence, and increased likelihood of proficiency in 5 skills, while PASS had no effect on skill competence but did increase the likelihood of attaining proficiency in 3 skills. In boys, participation in FMS and HIPA were associated with higher perceptions of sports competence, condition, and physical self-worth; HIPA elevated perceptions of strength, and, FMS increased perceived body attractiveness. PASS was associated with more positive perceptions of sports competence and body attractiveness at 9- but not 12-months. In girls, there were no positive intervention effects on CY-PSPP subscales, whilst all interventions were associated with more negative perceptions of body attractiveness. No group differences were found for body fat or physical activity, which increased from baseline to mid-test but fell sharply at post test in all conditions. Boys in HIPA improved fitness levels relative to controls, whilst girls participating in the FMS and PASS groups had lower fitness at post-test. It was concluded that multi-skill afterschool clubs are most effective at improving fundamental movement skills. Afterschool clubs may provide a means to augment boys' perceptions of competence, irrespective of activity mode; however, after-school clubs do not appear to enhance physical self-perceptions in girls. Behaviour-modification programmes appear least effective at improving actual and perceived competence, but a combined structured exercise and behaviour modification programme may be necessary to improve health outcomes. A subsequent follow-up study is required to assess long term impact of the interventions. The studies within this thesis have provided a detailed insight into the effects of different interventions on children's actual and perceived competence. To summarise, it was found that many children are not proficient at fundamental movement skills, which is important given their associations with important health outcomes. A multi-skill club programme can best impact such skills, whilst other forms of physical activity can also promote skill development. Perceptions of physical competence do not appear to have strong associations with children's health at this age. The influences of interventions on perceptions of competence appear complex and gender differences suggest that different forms of interventions may be necessary for girls.