Background: Adolescence is a time of dynamic change during which puberty transition occurs, which is characterised as bringing profound psychological transformation to adolescents' identity, mental health and to impact on their overall behaviour. Literature has identified male adolescents to be less engaged in health promotion activities, and considered them a high risk population, particularly during puberty influencing their physical and psychological health outcomes, which may last longer. It is therefore essential that these young boys have good puberty experiences, as that will help to ensure better psychosocial adjustment in later life. However, socio-cultural factors play a significant role in Pakistan and other similar countries to create several barriers to puberty awareness and understanding of adolescent males, where only limited support is available for them in terms of enhancing their puberty experiences. It is because of these cultural factors that puberty and related topics have not been adequately researched in Pakistan, despite having enormous significance of puberty transition in male adolescents' life. Instead, studies that are more general have been conducted to assess the sexual and reproductive health (SRH) knowledge, attitudes and behaviours of adolescents of both sexes. In case where reproductive health (RH) needs of adolescent males are explored, puberty has only been a small part of it. It could be argued that understanding young males' puberty experience in predominantly patriarchal cultures such as Pakistan is particularly important in order to investigate and propose appropriate measures to provide good puberty experiences to adolescent males. As it may improve role-relationships in adult life, and reduces the cost of many preventable and chronic diseases, such as mental illnesses and sexually transmittable infections (STIs) as these adolescents make better choices regarding their SRH in the future. Aim: This study aimed to explore how young males aged 18-21 years from an urban city of Pakistan perceived their puberty experiences, by addressing the following objectives: 1. To explore the overall experiences of puberty from young males living in Pakistan. 2. To explore the barriers/challenges/difficulties Pakistani young males encountered during puberty, and how they may have overcome these. 3. To explore potential facilitating factors for Pakistani young males during adolescence that contributed to positive puberty experiences.   Method: An exploratory, generic qualitative study using an interpretive-social constructionist approach was conducted. The study included 22 participants from two study sites using convenient sampling, followed by snowball technique. Data was collected through individual semi-structured face-to-face and Skype interviews, each interview lasted between 60-240 minutes. Interviews were transcribed verbatim into their original languages (English and Urdu both) and data analysed thematically. NVivo10 and 11 software was used to manage the data. Ethical approval was received from the University of Nottingham, UK and official permissions were granted by the respective institutions approached, with written informed consent received from all the participants. Findings: The findings showed that the puberty phase was challenging for young males, and often resulted in negative psychological impacts, along with concerns related to their identity development. The negative effects mainly resulted from being unprepared and uninformed about pubertal changes, which was due to the socio-cultural factors, considering puberty a 'taboo' subject. As a result of which, there was a lack of awareness about puberty and difficulties in accessing trustworthy information. Consequently, participants during puberty felt confused, fearful, anxious and embarrassed of their experiences, which often resulted in isolation and depression. Alongside these experiences, participants were found to have adopted several coping strategies; nevertheless, they highlighted the need for additional material and health promotion programmes to aid the transition process. Participants also described the diverse puberty experiences challenged by the societal expectations and gender norms, as they sought power, acceptance and defined their sexual orientation whilst gaining social status and identity development. Their concerns about masculinity, sexual identity and developing an adult outlook along with stereotyped gender roles and responsibilities were shared which often resulted in personal tensions while negotiating through these societal expectations. Conclusion: This study is the first known study to explore the contextualised puberty experiences of young males in Pakistan. The study has established that young males' experienced and shared significant concerns regarding their puberty transition phase. These were related to information gathering, negative psychological impacts, coping strategies and identity formation in the patriarchal Pakistani context. The findings further demonstrated that currently the puberty transition does not necessarily provide positive experiences for the male adolescents, since the conjunction of personal and social worlds exposed participants to both negative and positive psychological impacts during their puberty and influenced their identity formation as an adult male. Findings from this study provide a new theoretical insight into the complex social and ecological factors at play in Pakistan during male adolescents' puberty transition, using social and ecological model (SEM) of human development. These findings can therefore be used to understand the gender appropriate educational needs of adolescent males around puberty and develop future health promotion programmes around male adolescents' puberty. Introducing and developing appropriate health promotion programmes around puberty could improve future male adolescents' experiences and may therefore impact positively on their long-term health and well-being, and assist them in developing a vibrant adult identity.

Background: The number of children with life-limiting conditions in England is increasing. Families and professionals caring for such children face difficult care and treatment decisions. However, little is known about the factors which influence such decision making and the processes through which decisions are made. Aim: To explore the process of decision making and future planning for children with life-limiting conditions. Methods: This study employed a longitudinal, qualitative case study approach, involving eleven cases. Cases were centred around a child and their family, and additional interview participants, including healthcare professionals and extended family members, were nominated by the family to participate in interviews. Data sources included 46 interviews, 72 observations and review of medical notes. Data were analysed using narrative analysis. Findings: Key findings pertained to the importance of relationships and communication, the nature of decision making and strategies used within the process, and the role of best interests’ discussions during disagreements. Good relationships and communication were essential in decision making, as the process often involved multiple stakeholders. Poor inter-professional communication however was common and presented challenges for decision making. Analysis demonstrated that individuals recognise little practical or emotional difference between decision making and future planning, suggesting that they conceptualise both, simply as decision making. Within the process of decision making, numerous strategies were identified which aimed to achieve agreement between stakeholders. These were information framing, persuasion, appeals to evidence and justification. During protracted disagreements, occasionally reference to the child’s ‘best interests’ was made and occurred when professionals were concerned about harm to the child. Consequently the possible limits to parental decisional involvement through application to the courts, was highlighted, yet never actually implemented. Predominantly collaboration, which was indicative of shared decision making, was observed and reported. Conclusion: This study revealed the complex and nuanced nature of decision making. This research has highlighted the necessity of good quality relationships between families and professionals, and also communication in the inter-professional relationship. For those involved in decision making for children with life-limiting conditions, an understanding of each individual’s holistic wishes and values, alongside their perception of decisional risks to the child are important considerations, particularly during sustained disagreements. This study suggests that despite the policy drive towards shared decision making and the widespread perception that parents are the ultimate decision makers for their children, these assumptions are bounded. It calls for a professional awareness of the moral work undertaken by families in decision making, in order to further promote collaboration and prevent sustained disagreement.

Introduction: This thesis seeks to explore the feasibility and effectiveness of using text messages (SMS) to improve psychological wellbeing amongst young people involved in the Youth Justice System. As this group are likely to be exposed to risk factors impacting on their psychological health, yet unlikely to access mainstream health services, the provision of alternative and accessible interventions for this group should be a key priority for service providers, commissioners and academics alike. Method: A systematic review of the literature and meta analyses to explore current findings in relation to the use of text message interventions to improve psychological wellbeing in the broader adolescent population is presented in Chapter Two. In total 2,496 studies were identified, ten of which met full inclusion criteria. No significant pooled differences were evident between intervention and control groups. Reported effects and the feasibility of the approach are discussed. Findings indicate that, to date, there is no available research in relation to the use of an SMS approach to promote wellbeing amongst young people in the YJS. In preparation for a feasibility study to explore this, the psychometric properties of the KIDSCREEN questionnaires are considered in Chapter Three. Here the reliability and the validity of the tool is evidenced indicating its appropriateness for the use in the proceeding empirical research. The rationale and development of an SMS intervention to encourage self-determination and improve psychological wellbeing, co-designed with service users, are discussed in Chapter Four. In Chapter Five, the findings of the mixed methods feasibility study are presented. Conclusion: No significant differences in wellbeing were found between participants’ pre and post KIDSCREEN scores. Significant findings indicate that the intervention may be more acceptable for those with poorer wellbeing and for those subject to diversionary intervention as VAS scores (assessing acceptability of the approach) correlated with lower KIDSCREEN scores (pre intervention) and type of intervention (diversionary or statutory) respectively. Five themes emerged from the semi- structured interviews highlighting important factors to consider when designing or implementing an intervention of this nature for this hard to reach population. A synthesis of the findings is presented in the concluding chapter where recommendations for future enquiry are considered.

Background: Despite having limited access to specialist palliative care, countries can successfully satisfy palliative care needs by ensuring all health professionals are properly trained and educated in their respective roles. Effective communication is a fundamental element in ensuring the quality of care provided to children with palliative care needs and has a considerable effect on the well-being of children as well as their relatives and care professionals. Nonetheless, a broad overview of the existing literature reveals that nurses often feel inadequately trained or prepared in terms of the communication skills needed to deal with the difficult situations. They often lack the confidence to communicate properly with parents or to deal with difficult questions or issues of conflict. Whilst this seems to echo studies previously conducted across a range of countries worldwide, research shows that countries with an Arab culture face slightly different issues in terms of disclosing serious prognoses to families. The current study is the first to examine communication between children, parents, and health professionals, in the care of children with non-malignant life-threatening and life-limiting illnesses in Jordan, and in particular the cultural and spiritual context that affects this communication. Purpose: The purpose of the current study is to explore the experience of communication in the care of children with palliative care needs, from the perspective of physicians, nurses, and mothers in Jordan. Methods: this study employed a collective qualitative case study approach. It was conducted in three paediatric units in a Jordanian hospital. Each case comprised a child aged 1-12 years, their most involved family carer (mothers), physician(s) and nurse(s). Two data collection methods were employed: participant observation and semi-structured interviews with three categories of participants: mothers, physicians, and the nurses who cared for the children that participated in this study. Findings: the study was based on 15 cases, with a total of 197 observational hours and 60 interviews (conducted with 15 mothers, 12 physicians and 21 nurses). The findings indicate that a protective approach was taken by the study participants as they communicated together regarding their children’s care. The children attempted to shelter their parents from distress by not disclosing any anxiety or fear they were experiencing and parents similarly protected their children by not providing them with the all the details of their condition. In addition, parents avoided any situations where illness might be mentioned. Professional boundaries were adhered to by nurses as they cared for children and their families to avoid becoming emotionally involved. The nurses concentrated on routine care tasks as opposed to providing emotional support to children in order to avoid the significant emotional distress associated with the inevitable passing of the child. Doctors behaved similarly and avoided discussing death or other bad news with children to protect the well-being of children and families as well their own. Conclusion: These findings have implications. In the first instance, investigating the reasoning behind parents’ decisions to talk (or not) to their children about the details of their illnesses is a substantial issue. The findings of the current study indicate that while open and honest communication between parents and children is crucial, not all mothers agree with open communication about death with their children. Therefore, any future intervention planned for them should respect their autonomy and decisions. However, the role of health professionals could be significant, especially increasing the parents’ awareness of their children’s protective approach and its consequences on their mental and psychological health could be one of the most important interventions to improve mutual communication between parents and children.

Introduction Children with cerebral palsy (CP) often have to wear orthoses to help them walk. There is a growing body of evidence that orthotic tuning, that is, optimisation of the ground reaction forces in the lower limbs during walking, is recommended to ensure the maximum potential benefit for each child. Research demonstrates that orthoses can reduce the energy cost of walking for children with CP, but to-date there is no evidence as to whether this tuning process results in further energy efficiency or not [1]. Aim The aim of this research programme was to validate a method that would help to determine when an orthosis was optimised for each child; and then to investigate whether the use of orthoses that were optimally tuned for each child allowed a further reduction in energy cost during walking, compared with orthoses that had not been optimally tuned. Method A video vector system was used to allow visualisation of the alignment of ground reaction forces in relation to the lower limbs during walking. A simple measurement tool was validated that allowed quantification of the moment arm at the knee in stance, which was used to confirm when optimal alignment had occurred following orthotic tuning. The energy cost of walking was measured using the Total Heart Beat Index (THBI). Data were collected barefoot, with the original ‘un-tuned’ orthosis and with the final ‘tuned’ orthosis. Results Analysis of energy cost showed that for some children, energy cost was further reduced through orthotic tuning, but that this was not the case for all children. Preliminary findings suggest the influence of underlying level of disability, as determined by the GMFCS. Conclusion Orthotic tuning may help to reduce the energy cost of walking for some children with CP, especially those with greater levels of disability. Further studies with large participant numbers are warranted to further investigate this area.

This thesis explores the effects of adverse childhood experience, including childhood abuse and neglect, on adolescents. More specifically, it explores these effects in relation to offending behaviour. A literature review considered research investigating differences between sexual and non-sexual offenders. More consistent differences were identified for adolescents who sexually offend against children, as opposed to those who offend against peers / adults, when compared to other groups of offenders. Studies in this area are, however, subject to methodological limitations. Following this, an empirical research project investigates the prevalence and characteristics of adverse childhood experience in a sample of mixed sex adolescents detained in a medium secure specialist psychiatric hospital, alongside psychopathological traits. Male sexual offenders differed from violent offenders on a number of variables, including experiences of sexual abuse and a diagnosis of a Learning Disability (LD). Then, a single case study is highlighted which investigates and demonstrates the influence of adverse childhood experience and cognitive impairment on vulnerabilities and offending behaviour in an adolescent male detained in the aforementioned secure psychiatric hospital. The effectiveness of the intervention, designed to address this individual’s difficulties with emotional recognition and regulation, is demonstrated by changes in psychometric assessments scores and via clinical observation of behaviour. Finally, a critique is presented of the Coping Responses Inventory – Youth Form (CRI-Y) (Moos, 1993). This is a psychometric measure designed to measure styles of coping in adolescents. It is critically evaluated to demonstrate its psychometric properties, and its validity for clinical settings. This thesis emphasises the importance of considering developmental experience in the onset of offending behaviour, and the importance of engineering more comprehensive, systemic, and targeted early intervention programmes for individuals deemed at risk of committing particular offences or becoming delinquent in adolescence.

Malnutrition is a global health problem that affects infants and young children. It is frequently associated with infections and commonly affects children in developing countries. Malnutrition is the cellular imbalance between the supply of energy from macronutrients and micronutrients and the demand of the body for them in order to achieve normal growth, maintenance, and specific functions. Underweight (mild to moderate) and marasmus, marasmic-kwashiorkor, and kwashiorkor (severe) are the spectrum of malnutrition. Various pathophysiological changes, including fatty changes, abnormal rough endoplasmic reticula and mitochondria, decreased peroxisomes, and decreased quantity and quality of metabolising enzymes, are associated with malnutrition which may significantly influence hepatic drug metabolism. However, the effect of different categories of malnutrition on drug metabolism has not been extensively investigated. This research, therefore, aimed to determine the effect of malnutrition on drug metabolism. The specific objectives are (i) to perform a systematic review of the studies of drug pharmacokinetics in malnourished children, and (ii) to use the caffeine breath test to determine the effects of different types of malnutrition on the metabolising activity of hepatic CYP1A2 enzymes. The systematic review involved literature searches in the MEDLINE and EMBASE databases covering publications between January 1960 and December 2009. Articles describing drug pharmacodynamics and pharmacokinetic parameters in the four categories of malnutrition, limited to children from 0 to 17 years, were sought using both databases and by reference tracking. Altogether, 42 publications evaluated the disposition of 34 drugs in malnourished children. The drug absorption rate (Ka) was reported for eight drugs, of which gentamicin, metronidazole, phenytoin, chloramphenicol, paracetamol, and sulphamethoxazole showed no difference in the values of Ka for malnourished children and the control groups. The AUC of seven drugs did not differ for malnourished children when compared to their control groups but significantly decreased for carbamazepine (p < 0.05) and chloroquine (p < 0.001). By contrast, there was a statistically significant increase in the AUC of six drugs: metronidazole (p < 0.05), caffeine (p < 0.05), paracetamol (p < 0.05), phenobarbitone (p < 0.05), sulphadiazine (p < 0.01), and sulphamethoxazole (p < 0.001). The plasma protein binding of 19 drugs was evaluated in seven in vitro and two in vivo studies. There was a statistically significant decrease in the protein binding of 17 drugs in kwashiorkor when compared to healthy adults (p-values ranged from <0.0005 to <0.05). Nineteen studies evaluated the effects of malnutrition on the volume of distribution (VD) for 14 drugs. For most drugs, malnutrition had no statistically significant effect on VD. However, four drugs: gentamicin, quinine, streptomycin, and theophylline demonstrated contrasting results. The effect of malnutrition on the total clearance (CL) and elimination half-life (t½) of nine drugs that are primarily metabolised in the liver was evaluated in 15 studies. There was a statistically significant decrease in the CL of six drugs: acetanilide (p < 0.025), antipyrine (p < 0.05, p < 0.0025, p < 0.05), caffeine (p < 0.01), sulphamethoxazole, isoniazid (p < 0.01), and metronidazole (p < 0.01). There was a corresponding statistically significant increase in their plasma half-lives. For six drugs that are primarily eliminated by the kidneys, malnutrition has a varying effect on their total CLs. The total CL was significantly increased for penicillin in children with marasmus (p < 0.001), marasmic-kwashiorkor (p < 0.01), and kwashiorkor (p < 0.01), as well as increased for streptomycin in children with kwashiorkor (p < 0.01). By contrast, the total CL was significantly decreased for penicillin in underweight children (p < 0.01). It was also significantly decreased for cefoxitin in children with kwashiorkor (p < 0.025). The significantly decreased total CL of most of the drugs primarily metabolised by the liver may reflect decreased activity of the intrinsic hepatic metabolising enzymes. This would suggest a need to reduce drug dosage in malnourished children. More studies are therefore required to assess the activities of the hepatic metabolising enzymes in malnourished children. Following the systematic review, the caffeine breath test (CBT) identified as a non-invasive approach to study the effects of the four categories of malnutrition on caffeine metabolism. Caffeine is a 1, 3, 7 trimethylxanthine compound that is metabolised in the liver by 1-N, 2-N and 7-N demethylation, and C-8 hydroxylation to 1, 3, 7 trimethyluric acid. CYP1A2 is responsible for the 3-N demethylation of caffeine. The CBT involves oral administration of a non-radioactive stable isotope of caffeine (13C on the 3-methyl group). The caffeine undergoes 3-N demethylation in the liver which is a CYP1A2 dependent reaction. After N-demethylation, the 13C methyl group enters the carbon pool as it is converted to formaldehyde, formate and bicarbonate. The bicarbonate is exhaled as carbon-dioxide. The exhaled labelled 13CO2 is known to correlate with CY1A2 activity. Fifteen children each who were underweight or experiencing marasmus, marasmic-kwashiorkor or kwashiorkor were recruited from Lagos and Kano States in Nigeria. They were studied before and after nutritional rehabilitation. After ingesting labelled caffeine (3mg/kg) at 0900 hours, breath samples were collected in duplicate at -20, -10, -1 minute and every 15 minutes over 2 hours. The cumulative mean percent 13C-caffeine dose exhaled as 13CO2 was measured over 2 hours. Student’s t-test was used to compare the results for each category of malnutrition, before and after nutritional rehabilitation, at 5% level of significance. The mean cumulative percent 13C-caffeine dose recovered (CPDR) in underweight children was 7.56 ± 4.01% and 7.95 ± 3.68% before and after nutritional rehabilitation, respectively, and there was no significant difference in the mean values (p = 0.603). The CPDR significantly increased after nutritional rehabilitation in children with marasmus (from 6.80 ± 3.00% to 7.67 ± 2.81%, p < 0.001), marasmic-kwashiorkor (from 6.61 ± 2.26% to 7.56 ± 2.46%, p < 0.041), and kwashiorkor (from 6.29 ± 1.06% to 7.20 ± 1.80%, p =0.002). It is concluded that the present study may not have been adequately powered to detect a statistically significant difference in the results for underweight children. Such a difference would have been the basis for validating the results in a larger population of underweight children. However, doses of drugs that are metabolised by CYP1A2 enzyme may require modification in severely malnourished children.

Access to health care for children is important. It is dependent on access to health professionals and also parental attitudes towards illness. Children have the right to receive medicines that are scientifically evaluated for both efficacy and safety. Counterfeit and substandard medicines unfortunately result in the death of many children worldwide. There have been particular problems with diethylene glycol which has been used as a solvent in counterfeit medicines. It has also been found in contaminated substandard medicines. It has been responsible for the death of many children in different countries throughout the world. I performed a literature review of all cases of diethylene glycol poisoning that have been published. I have described the clinical signs and symptoms and hope that these findings increase the awareness of diethylene glycol poisoning in children. It is well known that there are clear inequalities in health and access to health care in the UK. This inequity has been particularly noticed amongst certain minority groups. Children of “at risk” groups, such as Asylum Seekers and Refugees, and Gypsies and Travellers, were recognised as having possible barriers in accessing health care and medicines. I conducted a study to explore children’s access to medicines in the East Midlands area in the UK. Alongside determining accessibility to health care the study also wished to explore parental attitudes towards receiving treatment for pain, asthma and epilepsy Both quantitative and qualitative research methodology was used in this study. The research data was gathered with the aid of semi-structured interviews with parents from the “at risk” groups and control parents. Fifty parents from each group were selected and interviewed regarding their children‟s health and their access to health care and medicines. The semi-structured interviews allowed participating parents to state their opinions about any barriers they had encountered to their children receiving medicines. Parents from both “at risk” groups and children from the Traveller group had more health problems than the controls. The attitude of some Gypsy and Traveller parents (11%) not to immunise their children was a significant problem. One in six Refugee parents reported difficulties while obtaining medicines. The two main barriers were language/communication problems and financial difficulties. Both Refugee and Traveller children received fewer OTC medicines than the children of the control group. It was not clear from the interviews whether this was due to financial difficulties or reluctance to use medicines without a doctor having seen the child first. Parents from both “at risk” groups were less likely to give analgesics for treating earache than those in the control group. Parents of Refugee children were more reluctant to tell others about their child’s epilepsy. Access to health care is an essential human right. Children are dependent upon both their parents and the health system for ensuring access to health care. This study has identified problems both within the system and also in relation to parental beliefs that may affect the access to health care and treatment for children. It is important that both of these potential barriers are addressed in order to improve the health of children of “at risk” groups. It is hopeful that the findings in this study will help to identify ways of improving access to health care and medicines for these groups.

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.

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.