Background: Breastfeeding is crucial in providing optimum nutrition and health for babies' to develop into healthy adults and has important emotional, physical and psychological benefits on maternal health. The UK has stubbornly low breastfeeding initiation and continuation rates. To address this, the government has policies targeting maternity and public health services. Furthermore, UNICEF UK introduced Baby Friendly Initiative (BFI) Hospital Standards in 1998 and Midwifery Education Standards in 2002. The University of Nottingham adopted BFI Education Standards in 2005 and have maintained accreditation since 2008. The BFI curriculum changes incorporated a knowledge, skills and attitude framework for teaching, learning and assessing. The embedding of positive attitudinal and skills facilitation of breastfeeding within the curriculum changes was essential. The influence of Trust's organisational culture on student learning was considered critical due to its impact on midwives working practises and pre-registration midwifery curricula having a minimum of 50% clinical practice. There is a lack of information about the efficacy of BFI Education Standards on student learning and application to practice. The aim of this study was to explore factors affecting student midwives competence and confidence when incorporating BFI Education Standards into clinical practice. Methodology and methods: A three year longitudinal multiple educational case study of a Bachelor of Midwifery programme commenced in 2009. Ethical and R&D approval were gained from the University and five Trusts, each at different stages of BFI clinical accreditation. The inclusion criteria were any student in the September 2009 midwifery cohort and their allocated midwife mentors. From a cohort of 32 students, 22 consented and 16 supplied data at each collection point throughout the three years. Students identified 92 midwife mentors, they had worked with, who were then invited to participate; 16 consented and 6 supplied data at each collection point throughout the three years. A total of 92 questionnaires and 70 one hour interviews were conducted. Data collected from students included questionnaire, individual interview and documentary evidence at 6, 18 and 30 months into the programme. Data from midwife mentors was questionnaire and individual interview at each stage. Documentary evidence was obtained from the students' NMC record of clinical skills and second year biology examination question on infant feeding. Data analysis used NVivo for qualitative data management, and PAWS for quantitative data analysis. Verbatim transcription of interviews was followed by thematic analysis. Findings: Findings are presented using BFI 'Ten Steps' Standards with the underpinning knowledge, skills and attitude framework. All students considered themselves to be competent and confident in 'normal' aspects of infant feeding but only competent in 'complex' feeding scenarios. Students self reported the theoretical component was most important to their learning in years 1 and 3 and clinical placements in year 2. Students who were mothers and students working in BFI accredited units had better examination results. Changes in workforce skill mix and reduced community midwife visits were factors in reported gaps of 'complex' breastfeeding learning opportunities. These were addressed by scenario role play. Reductions in Infant Feeding Advisor hours were found to correlate with increased formula supplementation. Mentors praised students' enhanced theoretical knowledge from their first year, and assessment and planning in the third year. They attributed this to the BFI curriculum. More prescriptive and structured organisational documentation facilitated student learning. Theory practice gaps existed at all five case study sites. At BFI accredited sites mothers and babies were statistically more likely to experience skin-to-skin following any mode of birth (n=1462 p<0.001 phi=0.21). At all sites a normal birth statistically increased the opportunity of mother-baby skin-to-skin (n=1462 p<0.001 phi=0.57) and initiation of breastfeeding (n=1462 p<0.001 phi=0.52). Students embraced a 'hands-off' technique to support breastfeeding and hand expression of the breast against prevailing clinical role modelling. Techniques students developed were 'shadowing', use of props, use of feeding cues and increasing the accessibility of their knowledge to women through facilitative communication skills. Use of infant feeding tools provided through the curriculum supported student learning. Detail provided within the postnatal data was poor and mirrored by mentors reporting poor use of relevant organisational documentation. Students had little opportunity to develop constructive formula feeding support, sterilisation of feeding equipment and reconstitution of formula milk. Anxiety was expressed by mentors and students in providing support to formula feeding women within a BFI framework. The use of interactive teaching methods and individual assessment through a workshop in year 3 were identified by students as significant to their learning. Students desire to support women to breastfeed grew over the 3 years. This was independent of personal feeding experiences of students who were mothers and the non-mothers embedded norms. The reinforcement and incremental delivery of the BFI curriculum in each year was identified as essential in this process. Conclusion: A BFI accredited midwifery curriculum positively impacts on student learning in infant feeding, raises the profile of infant feeding within postnatal care and enables students to create positive experiences for women. This study's findings would recommend that all midwifery curricula embrace BFI Education Standards within a knowledge, skills and attitudes framework.

This thesis describes the evaluation of a targeted group intervention that is broadly based on cognitive-behavioural approaches. The intervention incorporates aspects of social skills training and anger management training, and utilises the concepts of cognitive behavioural therapy. The intervention aims to promote emotional literacy and behavioural change and to impact upon school exclusions in secondary school pupils. The theoretical and historical underpinnings relating to cognitive-behavioural approaches, the methods of cognitive-behavioural approaches, and emotional literacy are described and explored. The literature considering these areas within the educational context is highlighted. Further exploration of the literature presents a systematic literature review of secondary school-based studies using cognitive behavioural approaches in targeted group interventions; these studies aim to promote behavioural change and prevent school exclusion. The evaluation of the targeted group intervention employs a pre/post-test randomised controlled trial. The methodological implications of such a study are described and discussed. The study involves a mixed group of N=43 (20=experimental; 23=control) Year 8 pupils who were identified as having some behavioural needs. The study did not demonstrate any statistically significant impact on the participants’ behaviour or emotional literacy, and exclusion rates between the groups were equal. The findings of this study are discussed considering the methodology, measures used, and data analysis employed. How this study contributes to knowledge and research is explained and the implications the study may have for policy makers and educational psychologists are described.

During the transition from childhood to adulthood young people are vulnerable to relatively unique health problems and risks, whilst also developing personal autonomy, and learning when and how to access health services. This thesis describes three studies, the overall aim of which was to gain a greater understanding of how teenagers use general practice, and to identify those factors that influence this behaviour and ultimate health outcomes. The aim of the first two studies was to identify demographic, health, and attitudinal factors associated with both overall general practice consultation rates and consultation for specific types of condition. The first study involved identifying annual consultation rates and reasons for consultation from the medical records of 836 (94.4%) of 886 teenagers aged 13 to 15 registered with five general practices across the East Midlands, covering the 12 month period prior to the second study. In the second study, 713 (80.5%) of the 886 teenagers from the first study responded to a postal questionnaire survey, carried out between May and August 1997, which explored health concerns, help-seeking behaviour, health related behaviour, use of health services, and attitudes to general practice. The results from each of the first two studies were linked, in order to identify associations between self-reported health status, attitudes and behaviour and recorded consultation behaviour, based on the 678 teenagers for whom complete data sets were available. The median annual consultation rate was two, with 76.1% of teenagers consulting at least once and 23.8% consulting on four or more occasions. Consultation rates increased with age amongst girls, who had significantly higher rates than boys by age 15. Most consultations were for respiratory and skin problems, with consultations for psychological problems being least frequent. Teenagers reported a wide range of health concerns and, whilst general practitioners were identified as the most frequent source of health advice from formal health services, friends and family were cited far more frequently. Although 91.8% of survey respondents rated confidentiality as important, there was no association between attitudes towards confidentiality and actual consultation behaviour. In contrast, teenage girls who expressed concerns about embarrassment were less likely to consult about gynaecological problems and contraception. The third study was a case control study in which the general practice consultation patterns of 240 young women who subsequently became pregnant (having a recorded termination, delivery or miscarriage between January 1995 and January 1998) were compared with those of 719 age-matched controls without a history of pregnancy. Cases were significantly more likely than controls to have consulted in the year prior to conception with 93% of cases consulting at least once and 71% having discussed contraception at some time. Teenagers whose pregnancy ended in a termination were significantly more likely than controls to have received emergency contraception. In conclusion, whilst teenagers have been shown to use general practice for a range of health problems, the results from these studies suggest that there is a need to facilitate access for teenagers with more sensitive problems, and to improve identification and follow-up of those at greatest risk of adverse outcomes.

One in four IVF pregnancies is a twin birth. This research explored the impact of a multiple IVF birth on maternal mental health and examined whether twin status conferred additional risk for poor mother-infant interaction and parenting stress following a premature birth. It further surveyed factors which had influenced couples' decisions regarding embryo transfer. A prospective study of 175 mothers conceiving after IVF found mothers of multiples (n=56) had a three-fold risk of scoring above the threshold for depression in the postpartum period. Unsettled and irregular infant behaviour was another independent risk factor. Theme analysis revealed mothers of multiples were more likely to express negative themes such as 'tiredness'. More mothers of singletons described 'feeling wonderful'. Mothers of premature twins (n=17) were closely matched with mothers of premature singletons and compared using the Nursing Child Assessment Teaching Scale (NCATS), Home Observation for Measurement of the Environment (HOME) Responsivity subscale and the Parenting Stress Index. There were no differences in maternal NCATS scores but twin infants were less responsive and provided less clear cues. Mothers of twins were less responsive in an everyday setting and 25% (versus 0%) reported extreme levels of parenting stress. Singleton mothers had significantly lower scores for the parent child dysfunctional interaction subscale. None of the couples surveyed (n=68) had chosen to transfer a single embryo (eSET). Only 19.1% rated desire for twins as an important factor in their decision. Most important was desire to increase the chance of pregnancy (92.6%). Couples perceived eSET as reducing the chance of pregnancy. Most couples found the decision about number of embryos to transfer easy and rated medical advice as very important suggesting a need for more support for this complex decision. This thesis established that a single birth offers important psychosocial advantages for both mother and baby, findings which could promote informed decisions regarding embryo transfer.

Technological advances in neonatal care have meant that the survival rates of preterm infants have dramatically increased. Improvements in mortality have not been reflected in improvements in morbidity, however, and the chances of extremely preterm infants surviving free from serious morbidity remain low. Concerns regarding mortality and morbidity rates have resulted in a plethora of ethical debates surrounding extremely preterm infants. The application and cost of advancing technology has been questioned. The impact that the risk of severe disability should have on decision making, along with who should make these decisions, the parents or the health care professionals, remains under debate. The influence that advancing fertility treatment has on decision making has yet to be explored, despite causing controversy in the media. Improving mortality rates have also prompted a proposal to reduce the current abortion limits in the United Kingdom. Despite a wealth of research into these ethical dilemmas, the voices of neonatal nurses towards these debates surrounding the infants which they care for have remained silent. The aim of this study is to therefore explore the perceptions of neonatal nurses towards extremely preterm infants. Q methodology was used to explore the attitudes of 36 nurses working in a perinatal network in the United Kingdom. Nurses 'sorted' a set of 53 statements developed from literature and previous research which represented the debates surrounding extremely preterm infants. Nurses then participated in a 'post Q sort' interview to explore the rationale behind their placement of the statements. The findings indicated that there were three types of nursing perceptions towards extremely preterm infants, centred on the involvement of parents in making difficult decisions. Some nurses reported their belief in accounting for parental choice is making difficult decisions. For others, they discussed their beliefs that the health care professional should undertake difficult decisions. The remaining nurses reported a belief in technology over and above decision making, suggesting that technology would prevail and allow more preterm infants to survive. The findings reflected the complex neonatal environment where core 'learnt' nursing values were often difficult to implement. Highlighting the perceptions of neonatal nurses' towards extremely preterm infants allowed for an in-depth exploration of the rationale behind these patterns of perceptions. Conclusions were drawn from this regarding how to improve the engagement of not only neonatal nurses, but the parents also, in the infant's care. A palliative care policy is suggested from these findings in order to help nurses make the transition from curative to palliative care. The conceptual framework developed for the study was adjusted accordingly, and future clinical and research recommendations made.

Background: Breastfeeding is a key public health issue, conferring benefits associated with both infant and maternal health. Despite an increasing research base about what helps or hinders breastfeeding, there is a dramatic drop in breastfeeding prevalence within the first six weeks following birth. The reasons that mothers give for stopping breastfeeding suggest that few mothers gave up because they planned to. This would appear to suggest that there is a gap between women's experiences of breastfeeding and professional practice to promote, support and increase duration. Methodology: Using an interpretive phenomenological methodology this study was designed to capture mothers' own interpretations of their experiences of breastfeeding. In-depth interviews with 22 women from the city and surrounding areas of Lincoln were conducted and analysed. Findings: Analysis of the data from interviews with 22 primiparous and multiparous mothers resulted in the emergence of three main overarching themes: reality shock, illusions of compliance and tensions. Sub-themes Included idealised expectations, incessant demands, onus of responsibility, playing the game, breaking the rules, surveillance and scrutiny, conflicts and contradictions, and cultural constructs. Conclusions: The findings from this study revealed that women were ill-prepared for the realities of breastfeeding and for most women the shock of this experience was overwhelming. Those women who struggled to establish breastfeeding did so in silence. They tried to hide their vulnerabilities rather than admit that they were not coping. A lack of peer and family support, combined with the rigid and inflexible approach espoused by health care professionals, led to the perception that exclusive breastfeeding was an unrealistic and unattainable ideal. This has clear implications for practice and policy.

Introduction: Malaysia is experiencing an increase in the prevalence of childhood obesity/overweight. This current study included the investigation of the psychosocial behavioural determinants and school environmental factors that could potentially mediate healthier eating in the school setting. Methods: In stage 1 of the work presented here, a survey was conducted in 8 randomly selected schools (4 urban/ 4 rural) in Terengganu. It involved 1000 children aged 10-12 yr. Weight and height were measured. Questionnaire to investigate psychosocial factors based on the Theory of Planned Behaviour (TPB) (attitude, subjective norm, perceived behaviour control, i.e. self-efficacy/ barriers) combined with knowledge were developed and validated (Cronbach's alpha ranged from 0.61-0.83). Chi-square tests and multinomial regression analyses were used to determine the association between psychosocial constructs and knowledge with weight status and sociodemographic factors. In stage 2 of the work, whole school mapping assessed the school environment on 4 levels (physical, economic, political and sociocultural) in these 8 schools, plus a further 4 randomly selected schools from the same area (6 rural; 6 urban in total). Results: The findings showed that nearly one-quarter (21.4%) of the sample was overweight/obese (WHO cut-offs), which was most prevalent in boys, urban children, older children and those in the higher socio-economic group (p<0.001). Findings for psychosocial constructs highlight that those who were in this overweight/obese category were significantly (p<0.0001) more likely to have negative attitudes (OR 31.52), more barriers (OR 24.12) less self efficacy (OR 19.00) and less subjective norm (OR 17.46) as well as low intention to eat healthily (OR 1.50) and less healthy eating behaviour (OR 23.56) compared with underweight and normal weight children. Interestingly, there was greater knowledge among obese children, but no significant difference in healthy eating behaviour, suggesting that knowledge alone does not help to improve behaviour to prevent obesity. No significant difference (p>0.05) between knowledge of obesity and psychosocial factors (with all the TPB constructs) also further supported the conclusion that increasing knowledge needs to be supported by enhancing other factors influencing behaviour in order to strengthen children's intention to eat healthily. Findings indicate there is much room for improvement in the physical, economic, policy and socio-cultural environments to improve healthy eating and physically active in the schools surveyed. Conclusion: The findings suggest that psychosocial factors among obese /overweight children need to be modified holistically. Enhancing knowledge and improving the school environment to help increase children's intention to eat healthily and be more physically active are required in order to prevent overweight/obesity among children.

This study presents an evaluation of the Lego® Therapy intervention (LeGoff, 2004) for six children, aged six to ten, with varying social communication difficulties. Lego® Therapy is a small-group, child-led and peer-based social development programme. Relevant theory and existing literature is explored firstly, before a systematic review of social communication intervention evaluations is presented. This is followed by a review of current Lego® Therapy studies, highlighting the limited evidence base that has been developed thus far. The present study’s aims of extending and applying more reliable and valid research designs to evaluate the intervention are then presented. An ABA single case experimental design (SCED) was used to evaluate the effectiveness of the intervention in increasing, maintaining and generalising the social confidence and independence, as well as the sense of school belonging, of the participants. Weekly classroom based video observations, which were coded, using an adapted version of Thunberg, Ahlsen and Sandberg’s (2007) Communication Coding Scheme, explored the participant’s social confidence and independence development and maintenance. Pre, post and delayed measures using The Social Competence Inventory (Rydell, Hagekull & Bohlin, 1997) and The Belonging Scale (Goodenow, 1993) assessed the participant’s parent and teachers perceptions of skill generalisation and the participant’s self-reported sense of school belonging. Outcomes from the SCED showed that the majority of the participants (five out of six) improved in at least one of the social communication skills measured and this maintained post intervention for three of the participants. An increase in perceptions of the participant’s social communication skills was reported within the school (five out of six) and home environment (three out of six). All participants rated a high level of sense of school belonging prior to the intervention, and change was variable per participant following the intervention. Study limitations require acknowledgement when considering the outcomes, particularly the generalisability of the findings due to the design of the study and stability of some of the participant’s Baseline phases that reduce the reliability of the measures. The study concludes with some support for the positive impact Lego® Therapy can have on social confidence and independence. Recommendations are made for future research to enhance the growing evidence base for this intervention.

BACKGROUND The United Kingdom has the highest rate of teenage pregnancy in Western Europe, and also ranks highly on an international level. Previous research has shown that factors such as socio-economic status are strongly associated with variations in pregnancy rates and outcomes of pregnancy. However, the impact of service provision, specifically primary care based services, is less clear. AIMS AND OBJECTIVES The primary aim of this thesis is to describe the incidence of teenage pregnancy in the former Trent health region, and to identify any factors associated with variations in rates and outcomes. The specific objectives are as follows: To describe the incidence of teenage pregnancy in Trent, and identify any factors associated with outcome of pregnancy, and with risk of intervention at delivery. To describe general practice and family planning services in Trent, with an emphasis on services specifically provided for teenagers. To identify any potentially modifiable general practice characteristics associated with variations in teenage pregnancy rates. To explore the opinions and attitudes of GPs towards key issues such as prescribing contraception to under 16s, and relate these to both GP characteristics and pregnancy rates. METHODS Data for all pregnancies in women aged under 20 years at the time of hospital admission during the period 1994-1997, were collected from the Trent hospitals admissions database. General practice characteristics data for all 826 practices in existence in Trent in 1997 were collected from all health authorities that were part of the Trent region at the start of the study period (1994). These data were collected for inclusion in a cross sectional survey of potentially modifiable practice characteristics associated with variations in teenage pregnancy rates. Hours of service and location of family planning clinics within Trent were identified through a survey of all clinics in existence in 1997. A cross sectional survey of all GPs and practice managers from four health authority areas, was carried out to identify both the number and nature of teenage specific initiatives running during the study period, and also to explore GPs attitudes and opinions towards key issues relating to the care of young teenagers. RESULTS A total of 18692 pregnancies were identified, and 5.1 % of these were to women aged under 16 years. Outcome of pregnancy was significantly associated with deprivation status, with women from poorer areas being more likely to continue with their pregnancy (OR 4.04 95%CI 2.40-6.78, P<0.001). Of the 10554 women who continued with their pregnancy, 22% experienced intervention at delivery, and this was associated with place of treatment (hospital), with women who delivered at one hospital for example, having 1.5 times the risk of experiencing either a vaginally assisted birth or a caesarean section (OR 1.53 95%CI 1.30-1.81, P< 0.001). Risk of intervention at delivery was not associated with age or deprivation status. In terms of service provision, of the 826 general practices identified, 58% had at least one female GP and 39% had at least one GP aged under 36 years. Twenty one percent of practices from the four health authority areas studied in detail, offered teen specific services, and 11 % had a specific confidentiality policy for under 16s. In terms of family planning services, 108 clinics were identified, which provided 498 hours of service and 261 of these were accessible to younger teenagers. General Practices with younger GPs (OR 0.67 95%CI 0.49-0.93, P=0.02) and practices that were running teenage specific initiatives (OR 0.61 95%CI 0.41-0.91, P=0.02) had significantly lower teenage pregnancy rates in women aged under 16 years. In terms of attitudes towards key issues related to the care of younger teenagers, age of GP was significantly associated with most issues, with older GPs being less likely to prescribe contraception to under 16s without parental consent (OR 0.55 95%CI 0.33-0.93, P<0.001) and also being more likely to believe it was illegal to do so (OR 4.27 95%CI 1.50-12.22, P<0.001). CONCLUSION Deprivation status was associated with incidence and outcome of teenage pregnancy. General Practices with younger GPs (aged under 36 years) were found to have independently lower teenage pregnancy rates in women aged under 16, as were practices that were running a teenage specific initiative. Younger GPs were found to be more likely than older GPs to prescribe contraception to young women aged under 16 without parental consent, and to believe that it was legal to prescribe contraception to this age group. These issues of age of GP, and the impact of teen specific services,should be further researched in order to fully understand their relationship with variations in teenage pregnancy rates.

Vaccination is regarded by the medical profession as one of the greatest public health success stories, and recent opposition, for example over the MMR (measles, mumps and rubella) vaccine, as a failure of understanding. Relatively little social scientific analysis exists on vaccination opposition. However, risk, trust and science are dominant themes within literature on public resistance to technology, and in contemporary theories such as risk society. This thesis therefore evaluates the relevance of these themes for an understanding of vaccination resistance in the UK. The empirical research primarily involves a discourse analysis of interview, document and website data generated from ten parental organisations, established to campaign against aspects of vaccination policy. The study defines these organisations as 'Vaccine Critical groups' and further classifies them into Radical and Reformist categories. In contrast to smallpox vaccination in nineteenth century England, vaccination is no longer compulsory in the UK. Nevertheless, from a governmentality perspective, the individual is still subjected to, what can be termed, the 'imperative of vaccination'. This thesis argues that the Vaccine Critical groups resist this imperative: first, by reframing risk as unknown, non-objective and individual specific; second, by demonstrating an ambivalent relationship with science; and third, by challenging faith in professional expertise and constructing the parent as the potential vaccine expert. These discourses create another type of moral imperative, which actually conforms to developments in the new public health that are encouraged by the state and the medical profession. The findings demonstrate the limits of a realist approach to risk, challenge existing theories of risk society and complicate assumptions about a public crisis of trust in expertise or science. Policy implications include the need to engage with vaccine resisters and their critical discourses, and to reassess the value of risk communication strategies.