States of play: Irish childhoods, race and belonging

This thesis explores the meaning-making practices of migrant and non-migrant children in relation to identities, race, belonging and childhood itself in their everyday lives and in the context of ‘normalizing’ discourses and spaces in Ireland. The relational, spatial and institutional contexts of children’s worlds are examined in the arenas of school, home, family, peer groups and consumer culture. The research develops a situated account of children’s complex subject positions, belongings and exclusions, as negotiated within discursive constructs, emerging in the ‘in-between’ spaces explored with other children and with adults. As a peripheral EU area both geographically and economically, Ireland has traditionally been a country of net emigration. This situation changed briefly in the late 1990s to early 2000s, sparking broad debate on Ireland’s perceived ‘new’ ethnic, cultural and linguistic diversity arising from the arrival of migrant people both from within and beyond the EU as workers and as asylum seekers, and drawing attention to issues of race, identity, equality and integration in Irish society. Based in a West of Ireland town where migrant children and children of migrants comprise very small minorities in classroom settings, this research engages with a particular demographic of children who have started primary school since these changes have occurred. It seeks to represent the complexities of the processes which constitute children’s subjectivities, and which also produce and reproduce race and childhood itself in this context. The role of local, national and global spaces, relational networks and discursive currents as they are experienced and negotiated by children are explored, and the significance of embodied, sensory and affective processes are integrated into the analysis. Notions of the functions and rhetorics of play and playfulness (Sutton-Smith 1997) form a central thread that runs throughout the thesis, where play is both a feature of children’s cultural worlds and a site of resistance or ‘thinking otherwise’. The study seeks to examine how children actively participate in (re)producing definitions of both childhood and race arising in local, national and global spaces, demonstrating that while contestations of the boundaries of childhood discourses are contingently successful, race tends to be strongly reiterated, clinging to bodies and places and compromising belonging. In addition, it explores how children access belongings through agentic and imaginative practices with regard to peer and family relationships, particularly highlighting constructions of home, while also illustrating practices of excluding children positioned as unintelligible, including the role of silences in such situations. Finally, drawing on teachers’ understandings and on children’s playful micro-level negotiations of race, the study argues that assumptions of childhood innocence contribute to justifying depoliticised discourses of race in the early primary school years, and also tend to silence children’s own dialogues with this issue. Central throughout the thesis is an emphasis on the productive potentials of children’s marginal positioning in processes of transgressing definitional boundaries, including the generation of post-race conceptualisations that revealed the borders of race as performative and fluid. It suggests that interrupting exclusionary raced identities in Irish primary schools requires engagement with children’s world-making practices and the multiple resources that inform their lives.

The quality of diabetes care in the community: practice, policy and culture

Aim: Diabetes is an important barometer of health system performance. This chronic condition is a source of significant morbidity, premature mortality and a major contributor to health care costs. There is an increasing focus internationally, and more recently nationally, on system, practice and professional-level initiatives to promote the quality of care. The aim of this thesis was to investigate the ‘quality chasm’ around the organisation and delivery of diabetes care in general practice, to explore GPs’ attitudes to engaging in quality improvement activities and to examine efforts to improve the quality of diabetes care in Ireland from practice to policy. Methods: Quantitative and qualitative methods were used. As part of a mixed methods sequential design, a postal survey of 600 GPs was conducted to assess the organization of care. This was followed by an in-depth qualitative study using semi-structured interviews with a purposive sample of 31 GPs from urban and rural areas. The qualitative methodology was also used to examine GPs’ attitudes to engaging in quality improvement. Data were analysed using a Framework approach. A 2nd observation study was used to assess the quality of care in 63 practices with a special interest in diabetes. Data on 3010 adults with Type 2 diabetes from 3 primary care initiatives were analysed and the results were benchmarked against national guidelines and standards of care in the UK. The final study was an instrumental case study of policy formulation. Semi-structured interviews were conducted with 15 members of the Expert Advisory Group (EAG) for Diabetes. Thematic analysis was applied to the data using 3 theories of the policy process as analytical tools. Results: The survey response rate was 44% (n=262). Results suggested care delivery was largely unstructured; 45% of GPs had a diabetes register (n=157), 53% reported using guidelines (n=140), 30% had formal call recall system (n=78) and 24% had none of these organizational features (n=62). Only 10% of GPs had a formal shared protocol with the local hospital specialist diabetes team (n=26). The lack of coordination between settings was identified as a major barrier to providing optimal care leading to waiting times, overburdened hospitals and avoidable duplication. The lack of remuneration for chronic disease management had a ripple effect also creating costs for patients and apathy among GPs. There was also a sense of inertia around quality improvement activities particularly at a national level. This attitude was strongly influenced by previous experiences of change in the health system. In contrast GP’s spoke positively about change at a local level which was facilitated by a practice ethos, leadership and special interest in diabetes. The 2nd quantitative study found that practices with a special interest in diabetes achieved a standard of care comparable to the UK in terms of the recording of clinical processes of care and the achievement of clinical targets; 35% of patients reached the HbA1c target of <6.5% compared to 26% in England and Wales. With regard to diabetes policy formulation, the evolving process of action and inaction was best described by the Multiple Streams Theory. Within the EAG, the formulation of recommendations was facilitated by overarching agreement on the “obvious” priorities while the details of proposals were influenced by personal preferences and local capacity. In contrast the national decision-making process was protracted and ambiguous. The lack of impetus from senior management coupled with the lack of power conferred on the EAG impeded progress. Conclusions: The findings highlight the inconsistency of diabetes care in Ireland. The main barriers to optimal diabetes management center on the organization and coordination of care at the systems level with consequences for practice, providers and patients. Quality improvement initiatives need to stimulate a sense of ownership and interest among frontline service providers to address the local sense of inertia to national change. To date quality improvement in diabetes care has been largely dependent the “special interest” of professionals. The challenge for the Irish health system is to embed this activity as part of routine practice, professional responsibility and the underlying health care culture.

MicroRNA expression and function in neonatal hypoxic ischaemic encephalopathy

Hypoxic ischaemic encephalopathy (HIE) is a devastating neonatal condition which affects 2-3 per 1000 infants annually. The current gold standard of treatment - induced hypothermia, has the ability to reduce neonatal mortality and improve neonatal morbidity. However, to be effective it needs to be initiated within the therapeutic window which exists following initial insult until approximately 6 hours after birth. Current methods of assessment which are relied upon to identify infants with HIE are subjective and unreliable. To overcome this issue, an early and reliable biomarker of HIE severity must be identified. MicroRNA (miRNA) are a class of small non-coding RNA molecules which have potential as biomarkers of disease state and potential therapeutic targets. These tiny molecules can modulate gene expression by inhibiting translation of messenger RNA (mRNA) and as a result, can regulate protein synthesis. These miRNA are understood to be released into the circulation during cellular stress, where they are highly stable and relatively easy to quantify. Therefore, these miRNAs may be ideal candidates for biomarkers of HIE severity and may aid in directing the clinical management of these infants. By using both transcriptomic and proteomic approaches to analyse the expression of miRNAs and their potential targets in the umbilical cord blood, I have confirmed that infants with perinatal asphyxia and HIE have a significantly different UCB miRNA signature compared to UCB samples from healthy controls. Finally, I have identified and investigated 2 individual miRNAs; both of which show some potential as classifiers of HIE severity and predictors of long term outcome, particularly when coupled with their downstream targets. While this work will need to be validated and expanded in a new and larger cohort of infants, it suggests the potential of miRNA as biomarkers of neonatal pathological conditions such as HIE.