The purpose of this dissertation research was to examine the associations among experiences of racial discrimination, perceived stress and birth satisfaction among Black women, and to examine the mediating effect of perceived stress on the association of experiences of racial discrimination with birth satisfaction among Black women. The first manuscript is an integrative literature review which evaluates prior research of the association of stress with birth satisfaction, with consideration to studies that included Black women in their samples. This review revealed a need for further research evaluating stress and birth satisfaction specific to Black women. The second manuscript examines the associations among racial discrimination, perceived stress, and birth satisfaction among a sample of 154 Black women. Experiences of racial discrimination were positively correlated with perceived stress. Perceived stress was negatively correlated with birth satisfaction. Experiences of discrimination were not related to birth satisfaction. Racial discrimination had a positive effect on perceived stress, and perceived stress had a negative effect on birth satisfaction. Racial discrimination had no direct effect on birth satisfaction; therefore, perceived stress was not applicable as a mediator in the model. The third manuscript presents challenges and successful strategies faced in the recruitment and retention of Black women in the immediate postpartum period. This dissertation adds to the current body of knowledge regarding the effects of racial discrimination on perceived stress, and the relationship between perceived stress and birth satisfaction, while also presenting successful recruiting strategies of Black postpartum women in nursing research, which is crucial to reducing racial disparities in health care.

No / Although recognised by policy incentives shaping children’s services, research and service development for children with complex healthcare needs have received limited attention. Both health-care professionals and families of those children affected frequently report fragmented care and unmet needs in the literature. Not only is the wellbeing of the family and health of the child jeopardised, but also the lack of consistent service coordination between diagnosis, impairment, functional need or disability, directly contributes to a lack of data for the subgroup of children with complex healthcare needs. In this scoping review, key themes are identified, proposing priorities for innovation of future services. It is clear from the literature, longitudinal data analysis providing a more accessible platform for service evaluation and improvement, specialist training for key workers, and further research around definitions and classification systems, is lacking. / White Rose Scholarship

This study aimed to explore children’s experiences of art therapy in order to create a theory of change processes within school-based art therapy. A total of 14 children were interviewed at two different schools, along with their parents, teachers, and art therapists. All children had received art therapy within the last 12 months. Semi-structured individual interviews were undertaken with 40 participants. Children completed a craft activity within their interview as a visual expression of their therapy experience. Interview data was analysed using grounded theory methodology. The results generated three theoretical models. The first model highlighted the systemic nature of the art therapy as well as describing it as mysterious. Model 2 described the processes within art therapy, focusing on the individualised child-centred nature of the intervention. Art doing was considered central to the children’s expressions and developing understandings. Model 3 described the trajectory of change for the children. The study recommends that psychologists consider art therapy for children who are struggling to verbalise their difficulties; that clinicians focus on therapeutic experiences being fun and enjoyable for the child, as well as embedded within the child’s system; and lastly that clear target problems are identified at the start of therapy.

In the absence of readily available physiological models of human growth, the effects of oestradiol on the human C28/I2 chondrocyte cell line were studied. The classical oestrogen receptors, ERα and ERβ, were shown to be expressed in both murine and human chondrocyte cell lines. Oestradiol and related chemicals, which alter the function of the oestrogen receptors (ER), were exploited to tease out the different functions of each ER in the growth plate. In the absence of foetal bovine serum, oestradiol had no effect on proliferation, differentiation or apoptosis of chondrocyte cells in monolayer culture or on the growth of the foetal metatarsal culture system. In addition, oestradiol did not convey a protective effect on chondrocytes exposed to the pro-inflammatory cytokines, tumour necrosis factor-α (TNF-α) and interleukin-1β (IL-1β) in monolayer culture. However, endogenous oestrogen appears to play an important role in maintaining chondrocyte proliferation in monolayer culture and mineralisation in metatarsal culture as reflected by the inhibitory effects of Faslodex, the non-specific ER antagonist, on chondrocytes and metatarsals in culture. In the presence of methyl-piperidino-pyrazole (MPP), a selective ERα antagonist, and raloxifene, a selective oestrogen receptor modulator with higher ERβ binding affinity, a reduction in chondrocyte proliferation and increase in apoptosis was observed in murine and human chondrocytes. Similarly, a marked reduction in linear growth occurred when foetal murine metatarsals were exposed to MPP and raloxifene in combination. A less marked reduction in growth was observed in MPP-treated metatarsals. These findings suggest that the oestrogen receptors may have opposing actions in the growth plate with ERβ acting like a brake on chondrocyte growth and ERα promoting growth. ERβ may regulate cell proliferation through control of cell cycle modulators affecting G1/S phase transition as MPP and raloxifene in combination reduced cyclin E and p53 levels on Western blot analysis. The aim of the second part of my thesis was to investigate the effect of oral oestrogen on linear growth in girls with primary ovarian insufficiency (POI). A retrospective review of girls with POI treated at a tertiary endocrinology clinic over an 11 year period was performed. As expected the majority of girls with POI had Turner syndrome (TS; 83.7%). Non-TS associated POI was rare and the leading cause was iatrogenic secondary to the effects of total body irradiation for bone marrow transplantation (12.8%). A significant proportion of these girls developed POI after full pubertal development so few cases were available to investigate the effect of oestrogen on growth. The oral oestrogen regime followed in individual patients with TS was highly variable so it was not possible to assess the effects of dose on height velocity or bone maturation in this retrospective audit. However, the second clinical study examined in detail the effect of oestrogen on growth in TS girls who received a standardised course of oral ethinylestradiol for pubertal induction and a standard dose of growth hormone (10 mg/m2/week). These girls participated in a prospective randomised double-blind placebo-controlled multi-centre study of growth promoting treatment in TS. The girls were initially randomised to oxandrolone or placebo at 9 years of age and further randomised to oral ethinylestradiol at 12 or 14 years of age. The results of this study are embargoed until published. The laboratory effects of oestradiol found in this thesis suggest that ERα may stimulate or maintain growth, and ERβ may inhibit growth. The obvious question is how these observations might be involved in the complex relationship between puberty, oestrogen and height velocity in humans. As affinity studies show that the half maximal effective concentration (EC50) of ERα is achieved at slightly lower concentrations of oestradiol than ERβ it is conceivable that the ERα effect could predominate at lower systemic oestradiol concentrations and that ERβ could become more important at higher concentrations for example in later puberty. Alternatively, it is possible that the expression of ERα reduces or ERβ increases in the growth plate after reaching peak height velocity.

In recent years awareness of childhood obesity as a clinical and public health problem has increased. However, a number of important issues related to childhood obesity were unclear when this thesis began. The aims of this thesis were as follows: 1. To estimate the prevalence of obesity in British and Iranian children. 2. To assess the strengths and weaknesses of the body mass index (BMI) as a way of identifying obese children/estimating obesity prevalence. 3. To investigate the factors associated with early 'adiposity rebound'. 4. To identify risk factors for obesity in British children. This thesis showed that prevalence of childhood obesity in British and Iranian children was significantly higher than expected and that obesity prevalence in children increased during the 1990s. These results are consistent with reports of increased childhood obesity in the USA, Europe, and some other countries. Using BMI 95th centile as the definition of childhood obesity has moderately high sensitivity and high specificity, though a definition of BMI 92nd centile was shown in this thesis to be optimum. This thesis indicated that the typical age of AR in British children must be sometime between 5-7 years. Further research on the factors associated with timing of AR is recommended. A number of independent risk factors for childhood obesity are identified. Parental obesity, birth weight, fizzy drink consumption, and time spent in the car had the strongest association.

Two studies were performed to detect aetiology of acute diarrhoea in hospitalized children aged under five years in Tripoli, Libya. In the first study, two hundred and thirty-six stool samples were obtained. Of these, 118 were from patients admitted for acute diarrhoeal disease, and 118 age and sex-matched concurrent controls were admitted for other reasons. In the second study, eight hundred and ten stool specimens were collected 405 from patients and the same number from controls. All were admitted to the AIjala Children’s Hospital, Tripoli, Libya. The first study was conducted between August 1st 1997 and 31st October 1997 and the second study was conducted between January 1st 2003 and 31st December 2003. One or more enteric pathogens were isolated from 55.9% of patients and 13.6% of controls in the first study and 68.1 % of patients and 12.6% of controls in the second study. In the first study, the organisms were identified from stool of patients; Escherichia coli 22.9%, rotavirus 15.3%, Campylobacter 7.6%, Proteus 7.6%, Klebsiella 4.2%, Entamoeba histolytica 4.2%, Cryptosporidium 2.5% and Giardia lamblia 1.7%, Salmonella was not isolated in both studies, because not growth on ordinary media were used (MacConkey agar and Blood agar) but usually growth on Salmonella-Shigella medium where not used. In the second study, enteropathogens identified were: rotavirus 30.4%, Escherichia coli 16.5%, Entamoeba histolytica 12.5%, Campylobacter 6.7%, Giardia lamblia 3.7%, Cryptosporidium 3.2%, Klebsiella 2.9%, Proteus 2.2%. Libyan children under six months of age were the most susceptible to acute diarrhoea requiring admission to the hospital. This was remarked in 46.6% of patients in the first study and 43.2% in the second. Exclusive breast feeding in Libyan children was of a very low percentage. In the first study it was 19.5% and in the second 29.1%. Children use dummies were about 3 times more at risk of diarrhoea than the non users in the first study (OD: 5.95,95%, CI: 1.120-2.37, p<0.001) and RR: 3.1 and (0: : 2.986ý 95%. Cl: 2.13-4.16, P<0.001) and RR: 23 in the second, this fell to children being twice as much at risk of contracting diarrhoea. Watery stool was the most common stool consistency of patients in both studies. Fever was the most common clinical feature associated with acute diarrhoea in the two studies (72.9% and 71.6% respectively). Vomiting was present in 51.7% of patients among the first study and 58.3% among the second. Moderate and isotonic dehydration were the most common degree and type of dehydration across both studies. In the second study, Rotavirus peaked during the winter (cold season) while bacteria and parasites peaked during the summer and autumn seasons. API 20E and API Campy were used to identify bacterial isolated by cultures and the number of confirmed cases decreased from 142 to 112 samples. Polymerase Chain Reaction was adopted in the second study to confirm detection of Campylobacter spp. these were identified by API Campy technique, where all Campylobacter spp. were identified as the same as detected by API Campy and for 24 samples.

There is evidence that sedentary behaviour and breaks in sedentary time, independent of physical activity levels, influence human health. In order to explore this relationship, accurate and validated measurement instruments are required. Such tools are also required for exploring the effects of factors such as the differences in sedentary behaviour between groups, e.g. overweight/obese vs. healthy weight children. One promising instrument for making such measurements is the activPAL™ monitor. This is an event-based accelerometer with inbuilt inclinometer, and it may be more accurate for the measurement of sitting time and breaks in sitting than earlier instruments. An important setting in the monitor depends on the time required to define a new posture – the minimum sitting/upright period (MSUP). At present, the optimum activPAL™ MSUP setting is not known, particularly for children, who are likely to change posture faster than adults. This thesis includes four studies: Study 1 (Chapter 3): Using the activPAL™, we investigated the effect of variations in MSUP on total sitting time and breaks in sitting. Methods: Study 1a: In this in vitro experiment, the activPAL™ monitor was turned from a horizontal position to a vertical position manually (by hand) to simulate 5 sitting bouts. The length of the sitting time was varied from 1s to 10s. The number of the true events (i.e. 50) and the data from the activPAL™ (the number of sitting bouts for each bout length) was compared and represented in a graph. Study 1b: in data collected from children in a free-living environment (23 children (mean (SD) age 4.5yrs (0.7)) who wore the activPAL™ (24 hr/d) for 5-7d), we varied the setting of the MSUP. For each child, we calculated the following measures of sitting behaviour: volume (total time in sit/lie postures); number of breaks (number of sit/lie to stand transitions); number of sitting bouts (number of discrete periods spent sitting/lying); and pattern of accumulation of sitting (represented by accumulation curves and fragmentation index). We first studied the activPAL™ using the default setting of 10s MSUP, and then reduced this to 5s, 2s, and 1s. Results: Study 1a: the analysis software did not count sitting bouts of a shorter duration than the user defined MSUP in the new posture. For example, the sitting bouts with a period less than 10s were not counted when we used the activPAL™ setting of 10s MSUP. Study 1b: Comparing settings of 10, 5, 2, and 1s, there were no significant differences in total sitting time (6.2 hr (1.0), 6.3 hr (1.0), 6.4 hr (1.0), and 6.3 hr (1.6), respectively) between settings, but there were significant increases in: the apparent number of breaks - 8(3), 14(2), 21(4), and 28 (6)/hr) total number of bouts (118(18) vs 382 (80)); and Fragmentation Index (19.3 (3.7) vs 61.6 (16.4)), with a reduction in 50% bout length from 80s (14.7) to 42s (7.7) at 10s and 1s setting, respectively. Conclusion: With the activPAL™, breaks in sitting, but not total sitting time, are highly sensitive to the setting of the MSUP. Additional studies will be required to confirm these findings and to define the most appropriate MSUP for different age groups. Simple measures can characterise sitting behaviour in young children using the activPAL™. Study 2 (Chapter 4): Posture transitions are likely to be much more rapid in young children than in adults. We investigated the optimum activPAL™ setting of MSUP to define a change in posture for measurement of sitting time and breaks in sitting (not previously known). We evaluated the validity of different minimum event duration settings against direct observation as the criterion method. Methods: In a convenience sample of 30 pre-school children (mean age 4.1yrs (SD 0.5)), we validated the activPAL™ measures of sitting time and breaks in sitting at different MSUP settings against direct observation. Results: In comparison with direct observation, a 2s setting had the smallest error relative to direct observation (95% limits of agreement: -14 to +17 sitting bouts/hr, mean difference 1.83, p = 0.2). Conclusion: For pre-school children, 2s appears to be an appropriate MSUP to define breaks in sitting using the activPAL™. Study 3 (Chapter 5): The identification of risk factors for obesity is considered key to obesity prevention. Differences in time sitting compared to standing have been observed in obese and non-obese adults. Whether such differences are present between obese and non-obese children has not yet been examined. In a pilot study, we investigated differences in sitting behaviour between overweight/obese and healthy weight children. Methods: Overweight/obese children were recruited from weight management and dietetic clinics, the Active Children Eating Smart programme, and from three primary schools, while healthy weight children were recruited from schools. The participants wore the activPAL™ (24 hr/d) for 5-7d. During waking time, the time spent sitting, number of sitting bouts, the 50% and 90% sitting bouts length, and the Fragmentation Index were measured in both groups using the activPAL™ with a 2s MSUP setting. Results were available for 26 healthy weight children (mean age 6.4yrs (SD 0.9), median BMI Z-score 0.04 (range -3.24 - 0.66)) and 13 overweight/obese children (mean age 6.4 yrs (SD 0.9), median BMI Z-score of 1.38 (range 1.14 - 3.10). Results: In healthy weight children during the waking hours, the mean (SD) percentage of waking time spent sitting was 53.0 % (6.4) representing 6.8 hrs (0.9) per day; mean (SD) total number of sitting bouts per day was 280 (65). The median (range) of 50% and 90% of sitting bouts were ≤50.0s (40.0-50.0) and ≤3.5 min (2.0-6.0), respectively. The mean (SD) Fragmentation Index was 42.1(12.7). In the 13 overweight/obese children, the mean (SD) percentage of waking time spent sitting was 52.4% (5.2), representing 6.9 hrs per day (SD 0.8). The total number of sitting bouts was 284 per day (66). The median (range) of 50% and 90% of sitting bouts length were ≤50.0s (40.0-50.0) and ≤3.5 min (3.0-6.0), respectively. The mean (SD) Fragmentation Index was 41.5 (9.6). Conclusion: Both healthy weight children and overweight/obese children in this study spent the majority of their waking time sitting. Furthermore, there were no significant difference in the sitting time, number, or duration of sitting bouts and the Fragmentation Index between the two groups in this study. Study 4 (Chapter 6): Previous studies have shown differences in the total sedentary time between boys and girls using accelerometers where sedentary behaviour was defined as low movement or low energy expenditure. In the present study, we examined whether there were also differences in breaks in sitting time. Methods: A convenience sample of 62 (32 girls: 30 boys) free-living healthy children (mean age 5.8yrs (SD1.3)) was recruited from nurseries and schools in Glasgow and Edinburgh, Scotland, who each wore the activPAL™ monitor continuously for 5–7 days. For each child, the components of sedentary behaviour were measured. Results: The percentage of waking time spent sitting was significantly higher in girls, the mean (SD) (54.4% (5.6)) compared to boys (50.9 (5.6)), (2-sample t-test, p-value <0.02). The total sitting time in girls vs. boys respectively per day was 6.9 (0.8) vs. (6.5) (0.9), (p-value <0.08). There were no significant differences in the number of sitting bouts, Fragmentation Index, or in 50% and 90% sitting bout length between girls and boys. Conclusion: This study suggested that girls spend more time in sitting than boys. However, there were no significant gender differences in the number or duration of sitting bouts. Summary Conclusion: These studies have validated the activPAL™ as an instrument for measuring breaks in sedentary time in young children, and have established appropriate settings for making accurate measurements in this age group. Using these monitors to explore differences between obese and non-obese children, and between boys and girls, we found that, while there were differences between boys and girls in the total sitting time, there were no differences in the number of breaks between girls and boys, or between obese and non-obese children. These studies suggest that the activPAL™ may be useful to identify between group differences in sitting time and sitting fragmentation in future studies.

The aim of this research was to provide a detailed description of emotional expression in infants, with and without disabilities. 30 typically-developing infants (aged four to five-and-a-half months)were video-recorded in four situations: immunisation, oral polio vaccination, social play and response to a surprise toy. These were designed to elicit a range of emotional behaviours. 20 infants with congenital, developmental disabilities of varying aetiologies were matched on developmental age and filmed in the same situations. Facial expressions were coded using the Maximally Discriminative Facial Movement Coding System (Max) (Izard, 1983) and emotional behaviour during interaction with Monadic Phases (Tronick, Krafchuk, Ricks, Cohn & Winn, 1980). Infants with disabilities showed fewer expressions of pain involving the whole face, and more expressions resembling blends of pain with fear, than typically-developing infants. This was due to several of these infants drawing back the mouth into a horizontal-stretch, rather than opening it fully. There was no group difference in time to respond to needle penetration with a pain expression, although median response time was higher for infants with disabilities. Both groups of infants had negative correlations between reaction time to pain and intensity of pain expression and time to recovery, indicating that infant emotion systems are integrated and coordinated with other behavioural systems. Expressions of infants with disabilities were also more fleeting and they showed reduced muscle movement in the upper-face and unconventional movements in the mid-face. They also showed fewer joy and interest expressions using the whole face, and more uncodeable expressions. Carers and female students were shown pictures of the infants' facial expressions and asked to describe the emotions they showed. There was no difference between carers and students, in accuracy of discriminating expressions of typically-developing infants, supporting claims of innate recognition of facial expressions. Expressions of sadness, fear, joy and surprise of infants with disabilities were discriminated less accurately than those of typically-developing infants. All expressions of infants with disabilities were perceived as giving significantly less intense signals than those of typically-developing infants. There were some systematic errors in judgement, with anger and pain, fear and sadness and interest and surprise expressions being mistaken for each other. This was explained in terms of morphological similarities between these expressions. Carers of infants with disabilities were more accurate at judging their own infant, but otherwise no more accurate than other judges. Coding of interactive behaviour revealed that infants with disabilities showed significantly more social attend and avert, and less social play, object attend and object play, than typicallydeveloping infants. These differences were attributed to delayed changes in functional use of eye contact and greater need to use aversion as a mechanism for regulating arousal in infants with disabilities. Carers of infants with disabilities showed less social play than those of typicallydeveloping infants. In these dyads, there was some evidence of lower frequency of agreement between infant and carer behaviours. This study provides a more comprehensive description of emotional behaviour, and involves a smaller range of developmental ages and a wider range of emotion-eliciting situations, than previous studies. The findings are useful for informing interventions for infants with disabilities and their carers.

Background: Effective delivery of dental services must be based on reliable information regarding the prevalence and severity of disease in the target population. Evaluation of the various factors known to influence the severity and progression of disease is essential for health policy makers to promote oral health resources and address oral health needs. Objective: The overall aim of this research is to describe the situation of dental caries and investigate the associations of level of oral health knowledge, teeth irregularity, BMI and other life style variables (TV viewing, internet use, passive smoking and dietary habits) with dental caries, including the impact of socio-demographic factors amongst school children in Qatar. Materials and methods: A cross-sectional study was conducted in Qatar from October 2011 to March 2012. A total of 2,113 children aged 12-14 years were randomly selected from 16 schools from different areas. Clinical examination was conducted by three calibrated examiners using World Health Organization criteria for diagnosing dental caries. Teeth irregularity was determined clinically according to a method described by Björk et al (1964). A pre-tested and structured questionnaire was used to assess oral health knowledge and life style data. Data analyses were performed. Results: The mean decayed, missing and filled teeth index values was 4.62 (±3.2), 4.79 (±3.5), and 5.5 (±3.7), respectively, for the 12, 13 and 14 year old children. The caries prevalence was 85%. The mandibular incisors and canines were least likely to be affected by dental caries, while maxillary and mandibular molars were the most frequently attacked by dental caries. Of the total sample, only one quarter reported a high level of oral health knowledge. There were more incidences of teeth crowding (44.1%) than teeth spacing (9.5%). The overall prevalence of underweight, overweight, and obesity was 5%, 10%, and 5% respectively. Almost half of the children spent > two hours watching television and 46% spent > two hours using internet. Approximately 35.8% of children had exposure to passive smoking. Concerning dietary habits, 99.4% of children consumed sugar containing snacks in between meals. Approximately 65% consumed sugar containing snacks within one hour of bed time. Almost 49.1% skipped eating breakfast regularly and 22.7% skipped eating lunch regularly. Around 83.8% consumed diary snacks in between meals. Overall, 74.2% drank tea in-between meals and 80.1% chewed gum in-between meals. All variables were affected by socio-demographic factors, but significant differences were found in female children in that they were more at risk to dental caries than male children. Also, children who resided in semi-urban areas were more at risk to dental caries than children who resided in urban areas. The occurrence of dental caries is significantly associated with the level of oral health knowledge, teeth irregularity, and other life style variables. Conclusion: The need to reduce sedentary behaviors and to promote a more active and healthy lifestyle is becoming increasingly essential in Qatar. Implementation of a community-based preventive oral health programs on a healthy diet and practices of adequate oral hygiene should be promoted in schools through integration into the school curriculum and services to combat the growing problem of dental caries.

Preterm delivery is one of the important causes of infant morbidity and mortality in the United States (U.S.). Annually, 12% of infants are born preterm in the U.S. and preterm birth related causes of death account for approximately 35% of all infant deaths. Using the latest (2012) National Survey of Children’s Health, the study aims to estimate the prevalence rates of preterm birth in the U.S., and identify key risk factors associated with it. Data (n=42,282) was obtained from the 2012 NSCH. Using the American Academy of Pediatrics and the American College of Obstetricians and Gynecologists recommendations, preterm birth was defined as one occurring less than 37 completed weeks of gestation from the first day of Page 26 2015 Appalachian Student Research Forum the last menstrual period. Based on existing literature, the following maternal and child characteristics were included as potential factors associated with preterm birth in the U.S. – infant gender, race, maternal smoking or maternal exposure to secondhand smoke (SHS), family income and maternal general health status. Descriptive statistics were reported using frequencies and proportions. Multiple logistic regression analyses were conducted to assess the association of selected variables with the preterm birth. Overall, 10.65% of live births were born preterm in the U.S. during 2012. Preterm birth prevalence rates were higher among males (12.07%), non-Hispanic blacks (14.34%) and those born to mothers who were smokers or exposed to secondhand smoke during pregnancy (23.8%). Males had higher odds of being born preterm (OR 1.07 95% CI 1.01-1.15) than females. Non-Hispanic White is less likely to be born preterm (OR 0.86 95% CI 0.74-0.99) compared to non-Hispanic black. Infants born to mothers who were smokers or exposed to SHS during pregnancy had higher odds of being born preterm (OR 1.05, 95% CI 0.97-1.13) compared to those born to women who were non-smokers and not exposed to SHS. Infants born to women who reported better general health status were less likely to be born preterm (Excellent/Very good vs Fair/Poor: OR 0.51 95% CI 0.46-0.56, Good vs Fair/Poor: OR 0.68 95% CI 0.61-0.75) than referent group. Approximately one-tenths of live births in the U.S. were born preterm. Study findings demonstrated infant race, gender, maternal general health status and maternal smoking or secondhand smoke exposure during pregnancy as factors associated with preterm birth. Determining these factors is important in the development of effective intervention programs and policies to reduce the rates of preterm birth in the U.S.