The present thesis reports on the experience of children and their carers who have been subject to interpersonal violence. Chapter one is a systematic literature review of qualitative research studies investigating the experiences of children and adolescents who have witnessed domestic violence in their families. Empirical evidence was critically evaluated from 11 studies in order to identify what the various research findings tell us about children and adolescents experiences from their own perspectives. Reviewing this body of literature revealed three themes: impact of domestic violence, coping with domestic violence and life after domestic violence. A number of additional sub-themes were found. Findings are discussed and consideration is given to future research directions as well as the clinical implications of the review findings. Chapter two is an empirical study exploring the lived experience of staff exposed to violence from Looked after Children (LAC) in residential care. This qualitative study used Interpretative Phenomenological Analysis methodology to analyse data from eight semi-structured interviews with residential staff. Three superordinate and eight subordinate themes emerged from the data analysis. Each theme is explored and consideration is given to the implications for future research and clinical practice. Chapter three presents a reflective paper of the researcher's personal experiences while conducting this research. It explores the challenges faced during the research process as well as the way in which the researcher's personal and professional development has been shaped for the future. Additionally, the role of Clinical Psychology in LAC services is discussed.

Background: The major activity components that make up the 24 hours of daily life, the so-called 'movement continuum' are sleep, comprising ~40% of time, sedentary behaviour (~40%), low intensity physical activity (LPA) (~15%), and moderate-to-vigorous physical activity (MVPA) (~5%). To address fully the impact of movement behaviour on children's health, it is necessary to study the relationship between each of these components of the 'movement continuum' and children's health. Asthma is a chronic childhood disease that impacts children's activity and alters the balance between movement continuum components. Few studies have attempted to investigate the association between asthma and movement continuum components. The relationship between asthma in children and physical activity and sedentary behaviour is conflicting. Some studies suggested that asthmatic children are less physically active and more sedentary; others suggested that they are more active and less sedentary or that there are no differences between asthmatic and healthy children. The factors that led to this conflict are not clear. We conducted a systematic review that reviewed available published evidence regarding the association between objectively measured physical activity, sedentary behaviour and asthma in school aged children. The effect of asthma attacks on the movement continuum components is unclear, especially in the Middle East area. We hypothesized that in the acute stage following an asthma attack; children are less physically active, more sedentary and have sleep disturbances compared to the recovery stage. During recovery from asthma attack, there is inter individual variability in changes of movement continuum components. We conducted an observational study to measure levels of asthma control and movement continuum components of Kuwaiti school aged children week 1 and week 4 following an asthma attack. The study also compared movement continuum components of asthmatics at week 4 following an asthma attack with the same measurements in healthy controls. Methods: In our systematic review, a literature search of EMBASE, Medline, CINHAL, Cochrane library and PubMed was performed to identify articles published in English between 2000-2017 in which either physical activity or sedentary behaviour or both were assessed objectively in 6-12 years old school aged children with asthma in case-control, cross-sectional or longitudinal (cohort) studies. In our prospective study we recruited 23 asthmatic children admitted to Kuwaiti hospitals following an asthma attack (mean age of 8.1 (SD 2.02) yrs). For the control group, 23 healthy children from Kuwait youth centres (mean age of 9.0 (1.72) yrs) were recruited. Measurements of asthmatic children at week 1 (acute stage) were compared to those at week 4 after discharge from hospital (recovery stage). Measurements of asthmatic children at the recovery stage were compared to those in healthy controls. Asthma symptoms were assessed by Childhood Asthma Control Test (CACT) questionnaire. Pulmonary function testing was carried out using a portable spirometer. Physical activity, sedentary behaviour and sleeping behaviour were investigated using ActivPAL™ accelerometers. Results: In the systematic review, the literature search identified 71 publications. Of the studies identified, nine met the inclusion criteria (total subjects n= 2996 (asthmatics (n=839), and wheezers (n=37)). In eight studies (total subjects n=2644) there was no significant difference in physical activity between children with and without asthma. Only one study (n=352) reported that asthmatic children were less physically active. No study found that asthmatic children were more physically active. Sedentary behaviour was assessed objectively in 3 studies (n=609); one study suggested that asthmatic children were less sedentary; and two studies showed no differences in sedentary behaviour between children with and without asthma. Our prospective study showed that CACT score improved significantly from week one to week four (week 1, 19.1 ± 4.39; week 4, 22.7 ± 3.77, P=0.000). The number of steps at week four was significantly higher than at week one (week 4, 11876 ± 3924; week 1, 10087 ± 2720, P=0.02). Total sitting time at week 4 was significantly lower than at week 1 (week 4, 7.7 ± 1.10 h/day; week 1, 8.7 ± 1.13 hours/day, P=0.001). During recovery from asthma attack changes in measures of activity continuum varied between individuals. Physical activity duration was increased in 14, but decreased in nine asthmatic children. Number of steps was increased in 16, decreased in six and remained the same in one asthmatic child. Total sitting time was decreased in 19, and increased in four asthmatic children. Sleeping time was increased in 13, decreased in eight and remained the same in two asthmatic children. Physical activity parameters of asthmatic children at week four were significantly higher than those of healthy controls; duration of physical activity (asthmatics, 7.40 ± 1.12 hours/day; healthy, 6.63 ± 2.04 hours/day, P=0.038); total activity counts (asthmatics, 840 ± 271; healthy, 650 ± 157, P=0.006); and number of steps (asthmatics, 11876 ± 3924; healthy, 8602 ± 2128, P=0.001). Sedentary behaviour parameters of asthmatic children at week four were significantly better than those of healthy controls; total sitting time (asthmatics, 7.7 ± 1.10hours; healthy, 8.3 ± 1.56 hours, P=0.05); number of breaks in sitting (asthmatics, 247 ± 97; healthy, 199 ± 65, P=0.05); number of sedentary bouts (asthmatics, 254 ± 89; healthy, 209 ± 54, P=0.045); and fragmentation index (asthmatics, 33.5 ± 13.0; healthy, 26.2 ± 9.6, P=0.001). In the summer in Kuwait, at the hottest time of the year, bed time shifted eight hours (0400 vs 2100) and wake up time shifted to late in the afternoon (1300-1400 vs 0500-0600).The summer sleep duration was ten hours, one hour longer than at other times of the year. Conclusions: The balance of available evidence in the literature strongly suggests that asthmatic and healthy children were of similar physical activity. This study showed that during recovery from asthma attack, asthma symptoms improved, physical activity increased and sedentary behaviour reduced. There were inter-individual variability changes in the activity continuum during recovery. In Kuwait, asthmatic children admitted with an asthma attack were physically active, not sedentary and had no difference in sleep time compared to healthy controls. During the period of very high external environmental temperature in the summer in Kuwait, there was a significant association changes in children's sleeping time and pattern.

Coeliac disease (CD) is an autoimmune condition of the gastrointestinal tract. In untreated patients, an inflammatory response to gluten results in destruction of the gut mucosa resulting in villus atrophy. This often presents with overt clinical symptoms but can also be silent in nature. Continual gluten insult can inevitably lead to a range of complications including nutritional problems from poor growth to deficits in bone mineral density (BMD). The CHIC study aimed to create a comprehensive picture of CD in children, taking into account growth and nutritional status, bone health, micronutrient status and further assessing children with the dual diagnosis of type 1 diabetes mellitus and CD. It is well established that early diagnosis of CD and the prompt initiation of gluten free dietary treatment (GFD) reduces the manifestation of complications. Yet in many previous studies the quality of a GFD and children's compliance to it have not been accounted for. This study assessed nutritional status and body composition in paediatric patients with newly diagnosed CD and found that the presentation of CD has changed, with the majority of patients presenting with normal and even over nutrition. Furthermore, the introduction of GFD with good compliance supports normal growth velocities and enables catch up growth in children presenting with short stature. When considering bone health in paediatric patients with CD the results remain inconclusive. Many previous studies have used the widely available DXA to assess bone mineral content, but in paediatric patients this may not accurately determine bone health. This study used peripheral quantitative computed tomography to distinguish changes in bone mineral density and investigate any alterations in bone microarchitecture. Thus, for the first time in paediatric CD patients identifying disruption to the remodelling mechanisms of trabecular bone, which may be particularly sensitive to resorption and mineral loss in patients with active CD. Furthermore, restoration of BMD was evident with good compliance to dietary treatment. Investigations into micronutrient status revealed that newly diagnosed children are vulnerable to micronutrient deficiency, this is likely due to malabsorption in the gut in patients with active CD. Deficiencies in zinc and magnesium were also identified in children treated with a GFD. This may be due to the inadequate micronutrients intakes with consumption levels of riboflavin, vitamin A, vitamin K, calcium, iron, magnesium and zinc lower than expected in treated CD children.

Background: A better understanding of the nutritional status of infants and young children who are HIV-Exposed-Uninfected (HEU) and HIV-Unexposed-Uninfected (HUU) during their first 1000 days is a key to improving population health, particularly in sub-Saharan Africa. Methods: A mixed-methods approach (explanatory sequential design) was utilised to compare the nutritional status, feeding practices and determinants of nutritional status of HEU and HUU infants and young children residing in representative selected districts in Botswana. In addition, themes associated with perceptions of caregivers, older family figures and healthcare workers in achieving optimal nutritional outcomes in these infants and young children were identified. In the quantitative strand (413 infants and young children, 37.3% HIV-exposed) aged 6-24 months attending routine child health clinics were recruited. In the qualitative strand 25 caregivers, 9 older family figures and 10 healthcare workers were interviewed using a semi-structured questionnaire. Quantitative data including anthropometric, 24-hour dietary intake and socio-demographic data was collected. Anthropometric z-scores were calculated using 2006 WHO growth standards. Modelling of the determinants of malnutrition was undertaken using logistic regression. Qualitative data was analysed using an inductive, interpretive/latent thematic analysis approach. Results: Overall, prevalence of stunting, wasting and underweight were 10.4%, 11.9% and 10.2% respectively. HEU infants and young children were significantly more likely to be underweight (15.6% vs. 6.9%), (p < 0.01) and stunted (15.6% vs. 7.3%), (p < 0.05) but not wasted (p= 0.14) than HUU infants and young children. HEU infants and young children tended to be formula fed (89.4%) whereas HUU infants and young children tended to breastfeed (89.6%) for the first six months (p < 0.001). In multivariate analysis, significant predictors of nutritional status were HIV exposure, birthweight, birth length, Apgar score and mother/caregiver’s education with little influence of socioeconomic status (p < 0.05). Qualitative thematic analysis revealed four themes; when “free choice” is an illusion: mother’s infant feeding decisions; “These people are dangerous.” negotiating access to healthcare services; “caring is how I show my baby love”; “our culture, our heritage”. Conclusions: HEU infants and young children aged 6-24 months had worse nutritional status compared to HUU infants and young children. Notably, birthweight was the main predictor of undernutrition in this population and, therefore optimisation of infants and young children’ nutritional status should focus on the nutrition and health of women in the pre- and antenatal period. These interventions should focus on equipping caregivers with skills and knowledge but also address external factors such as influence of the older family figure, community norms and cultures and experiences associated with accessing healthcare services.

Introduction: Exposure to maternal obesity during early development can have profound consequences for health and programme for obesity and type-2 diabetes. However, the mechanisms of programming during gestation and lactation are poorly understood. Aim: To assess the relative contributions of exposure to maternal obesity, induced by a cafeteria diet, during gestation and lactation on rat offspring growth, behaviour, metabolic and cardiovascular health. Methods: A cross-fostering study was piloted and then implemented to assess the relative contributions of maternal obesity during pregnancy and lactation. Female Wistar rats were fed either a control (C) or cafeteria diet (O) for two weeks before mating in the pilot study and eight weeks in the second experiment, throughout pregnancy and lactation. Offspring were cross-fostered at birth to a dam on the same or alternate diet to before birth and weaned on a chow diet. The pilot study also compared offspring cross-fostered (CF) against those that were not (NCF). Endpoints measured in offspring comprised weight and body composition, blood pressure, circulating and hepatic lipids, glucose tolerance, locomotor behaviour and gene expression. Results: The pilot study identified no difference between CF and NCF groups in offspring body composition, blood pressure, glucose tolerance, or plasma TAG and cholesterol concentrations at eight weeks of age. Therefore, cross-fostering was an effective method for a larger scale experiment. Feeding female dams a highly varied cafeteria diet resulted in greater weight and 3.4 times greater adiposity than animals fed a control chow diet throughout pregnancy and lactation (P < 0.05). Exposure to maternal obesity during pregnancy was associated with lower birth weight in offspring, reduced locomotor behaviour in female offspring at eight weeks of age, and elevated hepatic omega 3 fatty acid composition in male offspring at twelve weeks of age. Exposure to maternal obesity in lactation was associated with reduced locomotor behaviour in male offspring at twelve weeks of age. It was also associated with greater adiposity. Compared to control offspring, male offspring had 40% greater perirenal adiposity at two weeks of age (P=0.043) and female offspring had 26% greater gonadal adiposity at twelve weeks of age (P=0.030). Fasting blood glucose concentrations were 8% greater in offspring exposed to maternal obesity during lactation (P=0.031) and male offspring demonstrated slower glucose clearance during a two-hour intraperitoneal glucose tolerance test, despite no differences in circulating insulin between groups. This indicated insulin resistance, which was further confirmed by reduced adipose tissue and hepatic mRNA expression of genes which code for the regulatory and catalytic subunits of PI3K, in the insulin signalling cascade. However, male offspring exposed to maternal obesity during gestation demonstrated up-regulation of insulin signalling genes in skeletal muscle and perirenal adipose tissue. An insulin resistance PCR array confirmed an mRNA expression profile favouring insulin sensitivity in offspring exposed to maternal obesity during gestation (key genes included ALOX5, APOE, CASP1, CCL12, STAT3, TNF P < 0.001) and resistance in offspring exposed to maternal obesity during lactation (CXCR4, OLR1, CCR5, TNF, P < 0.05). Conclusions: Cross-fostering successfully teased apart the relative contributions of exposure to maternal obesity before birth and during lactation. Maternal obesity during lactation has a greater influence in programming for insulin resistance and adiposity than maternal obesity in pregnancy.

Esta tese discute a evolução geológica - metamórfica e estrutural - e a correlação lito-estrutural de um setor da Faixa Paraíba do Sul, porção ocidental do Estado do Rio de Janeiro, nas regiões de Vassouras e Paracambi, baseando-se em dados petrográficos e estruturais e um mapa geológico na escala de 1:100.000. São reconhecidas seis seqüências lito-estruturais, a saber: 1) Seqüência de Valença - rochas granulíticas e charnoquíticas; 2) Seqüência de Quirino - biotita (hornblenda) plagioclásio-gnaisse migmatizado com migmatitos bandados e anfibolitos associados; 3) Seqüência de Barão de Vassouras - biotita gnaisse migmatizado com gnaisses granitóides, rochas graníticas e cataclásticas, com níveis de calcossilicáticas e mármores associados; 4) Seqüência de Vassouras - rochas granitóides, migmatíticas e cataclásticas associadas; 5) Seqüência de Paracambi - gnaisse granitóide porfiroblástico migmatizado com níveis de gnaisse kinzigítico, anfibolitos e calcossilicáticas; 6) Seqüência de Japeri - migmátitos homogêneos e heterogêneos com gnaisses, granitóides e granitos associados. Estas seqüências lito-estruturais são relacionadas às Séries (Grupos) Juiz de Fora e Paraíba, de Ebert (1956) e à Série (Grupo) da Serra dos Órgãos, de Rosier (1965). As análises petrográficas revelaram composição tonalítica e quartzo diorítica para a primeira seqüência; granítica a tonalítica e monzodiorítica a quartzo diorítica para a segunda; granítica e granodiorítica para as terceira, quarta e quinta seqüências; e granítica a tonalítica e quartzo diorítica para a sexta seqüência. As relações texturais destas rochas (seqüências) indicam a atuação conjunta de processos de deformação e recristalização em pelo menos duas fases, cujos registros são observados nos porfiroclastos e nos cristais da matriz. O metamorfismo atingiu os facies granulito e anfibolito alto, ambos de pressão média. São caracterizadas quatro fases de dobramentos superpostos. A primeira e a segunda, identificadas respectivamente por Dn e Dn+l, apresentam dobras cerradas e isoclinais que afetam o mobilizado Mn; as demais, Dn+2 e Dn+3, são fechadas a suaves e afetam o mobilizado Mn+1. As três primeiras fases mostram orientações axiais aproximadamente NE-SW, e a quarta, NW-SE. O magmatismo é expresso por cinco grupos de rochas ígneas: ortoanfibolitos de composição básica e ultramáfica, granitóides sintectônicos com migmatitos associados, granitos tardi e pós-tectônicos, rochas básicas e rochas alcalinas. / This Thesis discusses the geologic (metamorphic and structural) evolution and lithostructural correlation in a section of the Paraíba do Sul zone in the Vassouras and Paracambi regions, western part of the State of Rio de Janeiro, based on petrographic and structural studies and geologic mapping a scale of 1:100.000. Six informal lithostructural sequences are distinguished: 1) The Valença Sequence - granulitic and charnockitic rocks; 2) The Quirino Sequence - migmatized biotite (hornblende) plagioclase gneisses with associated banded migmatites and amphibolites; 3) The Barão de Vassouras Sequence - migmatized biotite gneiss with associated and marble; 4) The Vassouras Sequence - granitoids, migmatites and associated cataclastic rocks; 5) The Paracambi Sequence - migmatized porphyroblastic granitoid gneiss with kinzigitic gneiss and calc-silicate intercalations; and 6) The Japeri Sequence - homogeneous to heterogeneous migmatites with associated gneiss, granitoid and granitic rocks. These sequences may be correlated with the Juiz de Fora and Paraíba \"Series\" (Groups) of Ebert (1956) and Serra dos Órgãos \"Series\" (Group) of Rosier (1965). Petrographic analysis revealed tonalitic and quartzdioritic compositions for the second sequence; granitic and granodioritic compositions for the third, fourth and fifth sequences; granitic to tonalitic and quartz-dioritic compositions for the sixth sequence. The textural relations of these rocks indicated the interaction of the deformation and recrystallization processes, for at least two different phases, as recorded in the porphyroclasts and matrix. Metamorphism took place under conditions medium pressure and reached the granulite and high amphibolite facies. Four folding phases are recognized: the first and second phases, Dn and Dn+1, exibit tight to isoclinal folds that affected the first phase of migmatization (Mn), whereas the others, Dn+2 and Dn+3, exibit closed to gentle folds and affected Mn+1. The first three phases of folding show axial trends approximately NE-SW, and the fourth, NW-SE. Five groups of igneous rocks are distinguished: basic and ultramafic ortoanphibolites; syntectonic granitoids with associated migmatites; late and post-tectonic granites; basic dikes and sills; and intrusive alkaline rocks.

Esta tese discute a evolução geológica - metamórfica e estrutural - e a correlação lito-estrutural de um setor da Faixa Paraíba do Sul, porção ocidental do Estado do Rio de Janeiro, nas regiões de Vassouras e Paracambi, baseando-se em dados petrográficos e estruturais e um mapa geológico na escala de 1:100.000. São reconhecidas seis seqüências lito-estruturais, a saber: 1) Seqüência de Valença - rochas granulíticas e charnoquíticas; 2) Seqüência de Quirino - biotita (hornblenda) plagioclásio-gnaisse migmatizado com migmatitos bandados e anfibolitos associados; 3) Seqüência de Barão de Vassouras - biotita gnaisse migmatizado com gnaisses granitóides, rochas graníticas e cataclásticas, com níveis de calcossilicáticas e mármores associados; 4) Seqüência de Vassouras - rochas granitóides, migmatíticas e cataclásticas associadas; 5) Seqüência de Paracambi - gnaisse granitóide porfiroblástico migmatizado com níveis de gnaisse kinzigítico, anfibolitos e calcossilicáticas; 6) Seqüência de Japeri - migmátitos homogêneos e heterogêneos com gnaisses, granitóides e granitos associados. Estas seqüências lito-estruturais são relacionadas às Séries (Grupos) Juiz de Fora e Paraíba, de Ebert (1956) e à Série (Grupo) da Serra dos Órgãos, de Rosier (1965). As análises petrográficas revelaram composição tonalítica e quartzo diorítica para a primeira seqüência; granítica a tonalítica e monzodiorítica a quartzo diorítica para a segunda; granítica e granodiorítica para as terceira, quarta e quinta seqüências; e granítica a tonalítica e quartzo diorítica para a sexta seqüência. As relações texturais destas rochas (seqüências) indicam a atuação conjunta de processos de deformação e recristalização em pelo menos duas fases, cujos registros são observados nos porfiroclastos e nos cristais da matriz. O metamorfismo atingiu os facies granulito e anfibolito alto, ambos de pressão média. São caracterizadas quatro fases de dobramentos superpostos. A primeira e a segunda, identificadas respectivamente por Dn e Dn+l, apresentam dobras cerradas e isoclinais que afetam o mobilizado Mn; as demais, Dn+2 e Dn+3, são fechadas a suaves e afetam o mobilizado Mn+1. As três primeiras fases mostram orientações axiais aproximadamente NE-SW, e a quarta, NW-SE. O magmatismo é expresso por cinco grupos de rochas ígneas: ortoanfibolitos de composição básica e ultramáfica, granitóides sintectônicos com migmatitos associados, granitos tardi e pós-tectônicos, rochas básicas e rochas alcalinas. / This Thesis discusses the geologic (metamorphic and structural) evolution and lithostructural correlation in a section of the Paraíba do Sul zone in the Vassouras and Paracambi regions, western part of the State of Rio de Janeiro, based on petrographic and structural studies and geologic mapping a scale of 1:100.000. Six informal lithostructural sequences are distinguished: 1) The Valença Sequence - granulitic and charnockitic rocks; 2) The Quirino Sequence - migmatized biotite (hornblende) plagioclase gneisses with associated banded migmatites and amphibolites; 3) The Barão de Vassouras Sequence - migmatized biotite gneiss with associated and marble; 4) The Vassouras Sequence - granitoids, migmatites and associated cataclastic rocks; 5) The Paracambi Sequence - migmatized porphyroblastic granitoid gneiss with kinzigitic gneiss and calc-silicate intercalations; and 6) The Japeri Sequence - homogeneous to heterogeneous migmatites with associated gneiss, granitoid and granitic rocks. These sequences may be correlated with the Juiz de Fora and Paraíba \"Series\" (Groups) of Ebert (1956) and Serra dos Órgãos \"Series\" (Group) of Rosier (1965). Petrographic analysis revealed tonalitic and quartzdioritic compositions for the second sequence; granitic and granodioritic compositions for the third, fourth and fifth sequences; granitic to tonalitic and quartz-dioritic compositions for the sixth sequence. The textural relations of these rocks indicated the interaction of the deformation and recrystallization processes, for at least two different phases, as recorded in the porphyroclasts and matrix. Metamorphism took place under conditions medium pressure and reached the granulite and high amphibolite facies. Four folding phases are recognized: the first and second phases, Dn and Dn+1, exibit tight to isoclinal folds that affected the first phase of migmatization (Mn), whereas the others, Dn+2 and Dn+3, exibit closed to gentle folds and affected Mn+1. The first three phases of folding show axial trends approximately NE-SW, and the fourth, NW-SE. Five groups of igneous rocks are distinguished: basic and ultramafic ortoanphibolites; syntectonic granitoids with associated migmatites; late and post-tectonic granites; basic dikes and sills; and intrusive alkaline rocks.

Background: The relative importance of malaria anaemia as a cause of childhood morbidity and mortality varies between and within regions. However, malaria anaemia remains an important cause of childhood morbidity and mortality. It has been estimated that globally, severe malaria anaemia occurs 1.42 to 5.66 million times per annum and kills an estimated 190,000 to 974,000 under-5 children. Studies from different countries endemic for malaria have emphasised the importance of anaemia in malaria-associated morbidity and mortality. Most of these studies have conclusively shown that severe malaria anaemia increases the risk of death in children with malaria; and in many reports, children with severe malaria anaemia often die before blood transfusion could be commenced. In addition, blood transfusion, which is the standard management for severe malaria anaemia, apart from not being available in many rural clinics, exposes the child to transfusion related infections such as human immunodeficiency virus (HIV). Better understanding of the pathogenesis of malaria anaemia therefore will enhance its prevention and management. The pathogenesis of malaria anaemia is multifactorial and involves such mechanisms as immune and non-immune mediated haemolysis of parasitized and non-parasitized erythrocytes, bone marrow dysfunction, altered cytokine balance, nutritional deficits and interactions with common haemoglobinopathies and red cell defects such as glucose-6-phosphate dehydrogenase (G6PD) deficiency. An important component of the pathogenesis of malaria anaemia is iron delocalisation characterised by the sequestration of iron by the reticulo-endothelial tissues (the monocyte-macrophage system) as a result of malaria-induced inflammation. Iron sequestration creates a state of false iron deficiency which recovers after the inflammation has subsided. Therefore if the malaria-induced inflammation can be resolved more quickly, the degree and duration of malaria anaemia will be reduced. In addition, since the destruction of non-parasitized erythrocytes accounts for more than 90% of erythrocyte loss, use of anti-inflammatory drugs could minimize red cell loss. Chloroquine is an antimalarial with proven anti-inflammatory properties. In addition, it is cheap, safe and has been shown to reduce iron delocalisation in vitro. A proof of concept study was designed to investigate its potential use in the management of children with mild malaria anaemia. Aims and hypothesis: The goal of the study was to investigate the effect of acute and continuing administration of chloroquine on haemopoietic response after a malaria episode. My hypothesis was that the anti-inflammatory and anti-macrophageal iron-loading effects of chloroquine will enhance erythropoietic recovery after a malaria episode. Methodology: The study was designed as a randomised placebo controlled trial and was conducted over two malaria seasons. In the first year, the study consisted of four arms with a 2x2 design and only two arms in the second year. In the first year, the participants were initially randomised to receive antimalarial treatment with either chloroquine-sulphadoxine-pyrimethamine or co-artemether. All children with negative peripheral smear for malaria parasite by day three were subsequently randomised to receive either weekly chloroquine or weekly placebo until day 90. In the second year of the study, all the children were initially treated with co-artemether; subsequently, those with negative peripheral smear for malaria parasites were randomised to weekly chloroquine or weekly placebo as in the first year. Children randomised to weekly chloroquine and weekly placebo were followed up for three months. Various clinical and laboratory measurements were conducted on days 0, 3, 7, 15, 30, 45, 70 and 90. In year two of the study, no data were collected on days seven and 70. The main outcome measure was change in haemoglobin from day three to day 30 and from day three to day 90. Other outcome measures were 1. Changes in Hb in the placebo arms of the CQ-SP and ACT treatment groups 2. Changes in measures of inflammation – neopterin and cytokines 3. Changes in markers of iron status 4. Prevalence of sub-microscopic parasitaemia Results: In 2007, 1445 children were placed under malaria surveillance, of which 105 malaria cases were recorded and 61 completed the 90 days follow-up. In 2008, of 1220 children under surveillance, 49 malaria cases were recorded, and 31 completed 90 days follow-up. There was no difference in Hb change from day three to day 30 and from day three to day 90 between the weekly chloroquine and weekly placebo arms. Although not statistically significant, the Hb change in children treated CQ-SP in 2007 was nearly twice the change in children treated with ACT at both days 30 and 90. The changes in the markers of iron status – MCV, MCH and ZnPP did not differ by treatment group and by randomisation group. During the acute malaria phase, neopterin concentration was high but by day 15, the levels had fallen to near zero levels and remained at this low level until day 30. Prevalence of sub-microscopic parasitaemia in the group was 15.1% and was similar in both randomisation arms. Iron deficiency was highly prevalent among the study participants. The independent predictors of Hb change were Hb at day 0, presence of iron deficiency, age of the child and height-for-age z score. Conclusions: Giving weekly chloroquine at a dose of 5mg/kg to children with mild anaemia associated with malaria did not confer any advantage to bone marrow recovery compared to children who received placebo. The data, however, suggests that the initial therapeutic dose of chloroquine (10mg/kg/day over three days) could have some positive effects on bone marrow recovery post malaria. The Hb recovery following treatment for malaria is determined by the age of the child, the Hb at diagnosis, the presence or absence of iron deficiency, and the height-for-age z score.

Time use studies are an effective way of finding out more about individuals’ daily lives and when used with semi-structured interviews can provide a form of participant observation. Large multinational studies have been performed over the past 40 years providing comprehensive data on general populations, including couples with children. However, little is known about the daily lives of couples with children with complex disabilities, and whether there are differences in time use decisions and quality of life for this group of parents. Quantities of time spent on different activities can affect quality of life; the way activities are performed can affect their quality. This study considers these issues of quality versus quantity in the time use of parents. Aims and Objectives: 1) To explore the time use of parents with a young child with complex disabilities and compare this with the time use of similar parents with young children without any identified disabilities; 2) To explore what factors influence parents’ time use decisions, and relate these to quality of life and parental satisfaction and 3) To use this knowledge to guide service delivery. Methodology and Methods: This is a critical ethnographic mixed methods study. Three group of parents participated: 1) Parents with a preschool child with complex health needs dependent on technology; 2) Parents with a healthy preschool child with autism and 3) Parents with a healthy preschool child without any identified disabilities. All parents completed the PedsQLTM Family Impact Module Survey followed by a specifically designed precoded time use diary for seven consecutive days. Parents in groups one and two were then interviewed to explore their feelings around time use and family life. Secondary analysis of the Multinational Time Use Survey (MTUS) data from the UK 2000/1 provided a further comparison data set. Results: Data are available on 28 couples and an additional 200 couples from the MTUS data. Significant differences in time use were found between the groups with regard to sleep, leisure, social contact, work, and quality of life measures with parents in groups one and two disadvantaged in these aspects compared to the parents in group three. Five main themes emerged from analysis of the interviews: ‘feeling trapped at home’; ‘twenty-four seven caring’; ‘trying to achieve a balance’; ‘discovering a whole new world’; and ‘evolving roles’ with ‘trust’ emerging as a unifying theme. Trust was found to provide the threads that linked parents in a complex web of relationships. The quality and quantity of these trust threads affected parents’ time use decisions and quality of life as highlighted by the reduced quality and quantity of sleep and leisure experienced. The interparental trust relationship varied between couples with different levels of trust defining ‘dictatorship’, ‘coalition’ and ‘democracy’ groups. Conclusion: Quality and quantity of sleep and leisure time are reduced for parents with a disabled preschool child. This decreases opportunities for parents to ‘re-charge’ and hence can impact on parents’ health and wellbeing. Levels of trust between mothers and fathers influence parental time use and are an important determinant of parental quality of life.

Paediatric gastroenteritis [GE] is a common and important condition that causes a considerable burden on the NHS, the families and the patient. Despite this, the evidence for effective management is limited. Only a proportion of patients (and parents) consult, but we know little about their reasons for consulting and how they manage the illness at home. Using a mix of methods this project aimed to explore the current management of paediatric gastroenteritis in the United Kingdom, focussing specifically on home management and primary care consultations. A prospective case series was designed in which primary care clinicians within Wales identified and invited paediatric patients (and their parent) to take part in the study. Baseline information was recorded for all eligible patients. Parents of eligible patients were invited to take part in a qualitative telephone interview as well as being identified through social media. Clinicians were approached to take part in a separate qualitative study. Anonymous patient records of paediatric patients presenting to primary care between 2003 and 2012 were extracted from CPRD Results show a decrease in consultation rates over 10 years however hospital referrals and stool sample requests have increased. Parents’ attitudes toward GE management impacted on their actions around prevention of illness and transmission. The variety of beliefs around causes of and threats from GE also influenced their actions. Reported clinical decisions and advice to parents were often not in line with current guidance from expert bodies. Many clinicians were not aware of guidelines on managing paediatric GE which might account for some of the variability in their management. Variation can ultimately result in inappropriate management and thus increase the burden of illness on both families and the NHS. Parent and clinician beliefs need to be addressed in order to ensure management of GE is appropriate and not detrimental to patients.