Worldwide, only 41 % of infants are exclusively breastfed for the first six months while South Africa has an alarming figure of only 12 %. First-time mothers are inexperienced in the initiation and maintenance of exclusive breastfeeding, hence a need for support. Data on forms and quality of exclusive breastfeeding support as experienced by first-time mothers is minimal. The study explored the exclusive breastfeeding support available to first-time mothers in the Buffalo City Metro, South Africa.A qualitative explorative, descriptive and contextual study, and a non-probability, purposive sampling was used with 10 first-time mothers within the first six months postpartum. The in-depth face-to-face semi-structured individual interviews for data collection and Creswell’s steps of thematic analysis were used.Two themes emerged; challenges, empowerment, support and resilience during initiation of exclusive breastfeeding, and diverse support and resilience during maintenance of exclusive breastfeeding. First-time mothers received practical support majorly from nurses and other mothers during the initiation; social support was from family members, friends, and community members for the maintenance of exclusive breastfeeding. Sometimes there was a disjuncture between practical support from nurses and that from family members and the community. There were instances where the support was needed but not given or not supportive of exclusive breastfeeding.These findings illustrate that professional, practical and social support for first-time mothers is crucial in the initiation and maintenance of exclusive breastfeeding for the first six months. Timing and the kind of support given to these mothers is crucial for successful exclusive breastfeeding. First-time mothers need all kinds of support to succeed in Exclusive Breastfeeding (EBF). Inappropriate feeding practices are common for first-time mothers due to several reasons. Pressure from family members and the community may cause the first-time mother to choose a feeding method she may not be able to sustain , 2. AlsoWorldwide there are inadequate infant feeding practices, varying amongst the regions . FurtherDuring antenatal care, nurses support first-time mothers through information about breastfeeding practice, and during labour, practical support is given by assisting mothers to initiate breastfeeding . All motConsidering the BCM Health District context, increase in infant mortality rate and under five years related diarrhoeal diseases, and possibly owing to the infant feeding challenges, it was thus vital to describe the support available to first-time mothers to exclusively breastfeed for at least six months, in BCM, South Africa.A qualitative approach, with an exploratory, descriptive and contextual research design was most appropriate to understand the first-time mothers’ available EBF support within their natural environment , 14. TheOnce the University Research Ethics Committee granted ethical approval and permission recognized by the BCM sub-district health, informed consent was sort from participants before data collection .First-time mothers were recruited during the postnatal visits via poster advertisements displayed in both English and Xhosa in the health institutions with researchers’ contact details. Information sessions to outline the study objectives were held in the health institutions. Interested participants sent a “please call’ while others preferred to call for clarity. Interested participants gave verbal consent and a date, time and place for interviews were then set, where the written consent was signed. A non-probability, purposive sample of 10 first-time mothers was used . In-deptTrustworthiness was ensured by observing the principles of transferability, confirmability, dependability, and credibility , 20. InfTwo themes emerged from the data analysis. These were; (1) “Challenges, empowerment, support and resilience during initiation of exclusive breastfeeding” with a sub-category, “Support and resilience during EBF initiation”, and (2) “Diverse support and resilience during maintenance of exclusive breastfeeding” with a sub-category, “Support and resilience during EBF maintenance”.“I told myself during pregnancy that I am going to breastfeed, as a breastfed baby is healthy.” (P9).At the clinic, we are taught to exclusively breastfeed the baby and then give food and other things after six months.“ (P1).“Some first-time mothers reported having received support during the antenatal period and the initiation of exclusive breastfeeding.I was given the baby; it was not that long. I kept him with me…” (P1).““I was told to wait a few minutes, 5 minutes, I waited. My baby was brought in. Nurses said I must pull the nipple and put it in his mouth” (P6).“The Nurse gave me the baby and told me to sit up and breastfeed” (P2).Most first-time mothers emphasized that the baby was brought to them by nurses and were asked to start breastfeeding.“I was never shown that you do this way for you to breastfeed. … the nurse was busy with other things but she was saying put the breast in. I expected that when I get the baby I will be shown; how the baby sucks, hold the baby this way, insert the nipple this way …” (P1).While participant one reported that her baby was brought to her within a reasonable time, she did not feel supported according to the kind of support she needed.“I was not even able to hold him, how am I going to hold him. The nurse showed me how to do it. Even when breastfeeding what to do,” (P3).“I was taught how to breastfeed and the way of holding the breast for him. I was taught by the nurse that delivered me.” (P4).“They showed me that ‘hold him this way’.” (P5).“The nurses showed me how I need to position him here on my breast” (P10).“The nurse … showed me that I need to hold him with my left arm and I supported with my right one…” (P2).While this mother was not happy with the kind of support she initially received, some received a demonstration on positioning and attachment of the baby to the breast and saw it as supportive.“Nothing was coming out. I was given tablets. ….. then it started to come now” (P7).Practical support to manage early breastfeeding challenges such as ‘not enough milk’ through the supply of tablets and giving of injection were seen as supportive.“Also seeing from other mothers when they are breastfeeding” (P8).The support was from mixed sources; information and practical support were from nurses and social support from family members, friends, and community members. Other mothers who delivered around the same time as first-time mothers gave social support by encouraging these mothers by an example.“I think that if they have shown me and kept it from the beginning, it was going to be continuous throughout. For an example, I ended up with dry breasts until day three.” (P1).One participant associated her insufficient milk supply with the failure of the nurse to give her practical assistance during the EBF initiation period leading to her eventually mix feeding despite her intentions to EBF.These findings emphasize the need for resilience on the part of first-time mothers while learning the skills to EBF and dealing with related challenges including continued support from nurses, to succeed in EBF maintenance.During EBF maintenance, the source of social support was mostly from family members, friends, and other community members while information and practical support, which included teaching and observing the first-time mother’s breastfeeding techniques, were from nurses. Scheduled postnatal follow-up visits within three to six days of delivery were cited as helping support first-time mothers’ maintenance of EBF through practical assistance with breastfeeding challenges and appraisal. One mother who initially did not feel well supported to initiate EBF confirmed that she did get the knowledge and skill later during this period.“When I went back to the clinic, that is where I was taught that you breastfeed the baby, how you hold him when you are breastfeeding.” (P1).Support from the clinic is really good”. (P3)“Yes, there were students that were teaching there. The nurses there at the clinic are supporting me. …they motivate me to breastfeed the baby” (P9).“Another lady I was with there said it is not the first time she is having a baby. I must request tablets to produce milk. She said ‘I have seven children but my children, I do not have a child that I say he is not breastfeeding’.” (P7).“It is my grandmother and my older sister, my family, and my cousins. When I have a problem, I tell them.” (P6).“Most of the first-time mothers enjoyed the support from the family members, friends, and other mothers in the birthing unit whom they considered more experienced in breastfeeding than they were.When I started having tea then I had a lot of milk. My sister said, ‘my sister, I did not breastfeed my child because I was working, you are not working so for your baby to grow quick you need to give the breast’.” (P7).“One participant who previously did not have enough milk reported,“His weight was already increased; the nurses said ‘well done. I love what you have done’.” (P5).Encouragement by nurses seemed to motivate first-time mothers to continue EBF.While most first-time mothers received support from family members, some explained the pressure received from family and community members to feed formula, porridge or mix-feed, which sometimes they did not appreciate. First-time mothers highlighted socio-cultural aspects of breastfeeding through the comments of family members, friends, and community members’ involvement in the breastfeeding practice. Some comments were, neither accepted nor appreciated by these mothers.Other mothers that normally come to my house to visit my mother say I am keeping the baby hungry. I am supposed to be feeding him solids now.” (P4).“He was crying … my cousins, my friends came to see the baby and they already have children, said ‘I did not breastfeed … I bought a formula … buy him formula milk.” (P3).““I did not want anyone who is going to say, ‘No feed, steal a spoon for him or two spoons of porridge. Yes, there are such like ones, who say, ‘no this child is not getting enough from the breast.” (P7).“I do not feel well because my friends want me to be able to leave the baby behind to go out with them. So, I do not feel well.” (P9).One mother highlighted the importance of a supportive relationship between first-time mothers and nurses.It is important that there is a relationship between her and her nurses” (P1).““It would be beneficial, something nice the availability of those support groups … if the clinic is organising it at least it would give some weight. Maybe it can be done once a month or once a week or fortnightly but there must be interaction among first-time mothers so that they can share their experiences. Soon after breastfeeding the baby, she must attend those things those meetings.” (P1).She further reported in-depth the need for formulation of first-time mother’s EBF support groups. She highlighted how it should be run to ensure compliance by first-time mothers, including its benefits.My mother said, ‘we did not grow up like this, we fed children roasted this and that.” (P3).“In our homes, you are shown the thing this way but when you arrive at the clinic, all of that is criticised… At home, you are told to use the second finger next to the thumb and the one next to it, you put the breast in and support with your thumb.” (P1).“…There is, however, a need to include the communities in information sharing on EBF support to avoid conflict between nurses, communities, and first-time mothers. Some mothers explained the socio-cultural difference in breastfeeding practice between healthcare professionals and elderly community members. This was cited as possibly causing conflict between first-time mothers, community members, and the nurses.your child will never gain weight. Your child will never grow well because you are exclusively breastfeeding. Give him porridge. Do not listen to a friend because a friend sometimes misleads” (P5).“… People from the streets will advise the wrong things. Their motive … is that as I am getting the grant on the date for grant pay-outs they want to go with me to the shebeen.” (P6).“Two mothers voiced the need to take advice with caution, as not all advice is good advice. These mothers explained the need to reject unhelpful advice as the motive might not always be genuine.“He was crying … my cousins, my friends came to see the baby and they already have children, said ‘I did not breastfeed … I bought a formula … buy him formula milk.” P3.“I did not want anyone who is going to say, ‘No feed, steal a spoon for him or two spoons of porridge. Yes, there are such like ones, who say, ‘no this child is not getting enough from the breast.” P7.First-time mothers reported feeling pressured to feed formula or porridge to their babies against their own choice. Most mothers did not like these suggestions.Support received by first-time mothers included socio-cultural values which sometimes was in line with the knowledge and skills received by first-time mothers during antenatal care. First-time mothers were able to accept or reject the support that they deemed harmful to the breastfeeding practice and maintenance of EBF.This study focused on understanding the EBF support available to first-time mothers in BCM. This was necessary because the first-time mothers are inexperienced in EBF and there are other challenges common to breastfeeding women resulting in few mothers maintaining EBF. First-time mother’s lack of experience and breastfeeding challenges can influence the initiation of breastfeeding. To achieve initiation, support is needed. The support received by first-time mothers in BCM was consistent with the support as conceptualized by House in Grassley’s  four supThe information was supported by instrumental or practical support by nurses aimed at ensuring the initiation of breastfeeding. The nurse seemed to expect the first-time mother to know how to put the baby onto the breast, as she continued to tell her to put the baby to the breast without demonstrating to her . While nOne first-time mother was not happy with the kind of support she initially received, while some received a demonstration on positioning and attachment of the baby to the breast and saw it as supportive. Also, some nurses might not be able to offer practical support needed by first-time mothers to initiate breastfeeding due to ward routine or other reasons, some can provide the kind of support needed. There is thus a need for consistency in providing practical support among nurses. Despite the information received most participants reported challenges of inability to initially attach and position the baby during breastfeeding, not enough breastmilk supply, even though most reported improvement with time. The information received prior needed additional support, practical, emotional and/or appraisal support. This is consistent with the findings that even with the information given during antenatal care, mothers still experience challenges leading to early breastfeeding cessation , 9, 24 hAll mothers who do not experience any problems postnatal are discharged home within 24 hours, consistent with the policy, which was the case with most of the study participants. Mothers are also expected back for a postnatal visit within six days for support relating to any problems experienced including feeding-related problems. It is thus important to ensure that breastfeeding initiation is successful, as family members and the community start to support these mothers. The first-time mothers reported that most family members, friends, and community members supported their EBF practice. This is consistent with the findings that not only nurses can provide support but also partners, friends, and family were key in supporting first-time mothers when encountering breastfeeding challenges .There are contrasting findings on the impact of the intentions to EBF on the maintenance of EBF, some mothers resorted to formula feeding or mix feeding as a feeding method of choice despite the good intention to breastfeed , 27. ConThere is also a need for individualised support following all aspects of House theoretical framework for the initiation of EBF to be successful. The nurses, as the main support source for these mothers, need to be vigilant of the special needs for each mother. Successful initiation will lead to the maintenance of EBF. Different aspects of support were cited by first-time mothers as helpful, included are information-sharing, practical support and emotional support received including positive motivation from nurses. The practical support included helping with positioning and attachment; supply of food and fluids including fluids perceived to assist with breastmilk production, such as tea and ginger .In this study, while most first-time mothers received support from family members, one first-time mother explained the pressure to mix-feed she received from community members. Advice from family members especially grandmothers was one of the reasons first-time mothers especially teenagers stop breastfeeding . Also, tAlso, socio-cultural issues may cause the support from nurses, family, and community members to contrast leading to confusion and frustration , 35. TheIt is important to note various limitations in the study’s methodology. The qualitative approach and the sample size of the study were small, thus limiting generalisation of the findings, however, the findings are similar to other studies done both qualitatively and quantitatively, abroad and nationally, including the Eastern Cape Province where this research was conducted.The nurses are not always readily available to assist first-time mothers to initiate breastfeeding because of ward routines. There is, therefore, a need for peer breastfeeding supporters to supplement nurses in giving practical assistance to first-time mothers before discharge.Even though mothers receive information during antenatal care, it is not easy for them to apply this knowledge during breastfeeding. Nurses, therefore, need to focus on individualised education based on individual needs and practical support.Mixed messages from the nurses and family members on EBF practices lead to confusion and frustration for first-time mothers. Nurses, need to unite with community members in providing updated, evidence-based practice on breastfeeding.There are policies in place on breastfeeding, including infant feeding in the context of HIV. However, there is a need for the formulation of compulsory physical or virtual support groups to provide additional support for first-time mothers.First-time mothers do need professional, practical and social support in the form of information, emotional support and encouragement for initiation and maintenance of exclusive breastfeeding for the first six months. However, timing and the kind of support given to these mothers is critical for successful exclusive breastfeeding. Individualised support after the delivery of the baby and postnatal period assist the first-time mothers to put the information received during antenatal care into practical use. There is also a need to ensure that the nurses and community members share the same knowledge and skills, to adequately support the first-time mothers succeed in EBF. Also, the formation of support groups whether in a physical or virtual space would bridge the gap for any additional support needed by these mothers. Exclusive breastfeeding means that the infant receives only breast milk, no other liquids or solids are given except for oral rehydration solution, or drops/ syrups of vitamins, minerals or medicines . Resilience exists when the person uses “mental processes and behaviours in promoting personal assets and protecting self from the potential negative effects of stressors”.


Raya, a new Muppet® was developed and introduced, advocating for healthier WASH behaviors. As part of the intervention, two approaches to health messaging were developed framing WASH as a personal behavior (the “me” intervention) or a social endeavor (the “we” intervention). In each country a three-armed approach employed groups focused on the “me” and “we” interventions and a comparison group. Both the “me” and “we” groups improved in WASH measures over the comparison group; however, there were limited differences between the “me” and “we” groups. Target behaviors, such as using the latrine, wearing shoes, and handwashing, improved when examining change before and after the intervention, and the intervention was predictive of positive knowledge, attitude, and behavior change. Results of this work are limited due to lack of a randomized control trial but suggest that participants who received the “Cleaner, Healthier, Happier” interventions will be more prone to engage in healthier hygiene behaviors.This article evaluates a pilot intervention of Sesame Workshop’s “Cleaner, Happier, Healthier” media program promoting water, sanitation, and hygiene (WASH) knowledge, attitudes, and behaviors among vulnerable children and their families in impoverished areas of Bangladesh ( Globally, one in 10 deaths among children under 5 years is caused by diarrheal disease, resulting in around 800,000 fatalities annually . One method that has proven successful in shaping behavior is the use of media  as an important educational resource for both their children and themselves, and it was a well-known information source for children’s healthy practices  to engage children.Mass media, such as television, has been useful in disseminating health messages in a cost-effective way to individuals, even for those living in rural areas  to create locally relevant educational content for mass media platforms, schools, and community settings.Cleaner, Healthier, Happier” because they saw the need for WASH behavior change communication programs targeted at young children and saw Sesame Workshop’s in-country presence in Bangladesh and India and the success of Sisimpur and Galli Galli Sim Sim as strengths. The teams from Sesame Workshop Bangladesh and Sesame Workshop India developed the “Cleaner, Healthier, Happier” content, co-created Raya, and adapted its implementation in high-need communities. Raya arose from a unique set of needs: there was a need for a strong young girl character at the heart of the project as WASH issues disproportionately affect girls and young women . Yet the Principal Investigator and the Sesame Workshop research team also recognized that hygiene is a public health practice and personal behaviors foster community health. Therefore, personal and social health messaging approaches were used in the intervention to allow for a comparison of these different types of messaging. This concept was reviewed and approved by the project manager in each country.In 2013, the Bill & Melinda Gates Foundation awarded funding to Sesame Workshop to develop a public health intervention in Bangladesh, India, and Nigeria. These locations were chosen due to great need in these areas. Due to the similarity in implementation, this paper focuses on the programs in Bangladesh and India. We acknowledge that while these countries share many cultural similarities, some WASH behavioral differences exist in these two locations which may contribute to differences in the findings regarding the intervention effects for each country. In addition to great need for WASH interventions in these countries, practically it was important to be able to create one intervention that could benefit people in multiple areas. The intervention was developed for delivery in both locations and this manuscript describes the implementation and results from both countries.®, a teal-colored girl puppet named “Raya,” was developed and introduced; this character advocated for health behaviors including using a safe latrine, wearing sandals, and handwashing. Raya was developed to be an appealing and relatable character for children in both Bangladesh and India. Raya is an energetic 6-year-old with long dark braided hair and wears a yellow embroidered kurta. She talks about latrines and defecation in ways in which children from Bangladesh and India can identify.The purpose of the intervention was to increase positive WASH practices among children and their families in these countries. Program components included various forms of media and in-person activities. A new MuppetAlthough there are some differences in the geographic areas chosen to implement this pilot program, there are also many similarities. While most Sylhet Bangladeshis are Muslim and most Kolkata Indians are Hindu, they share many historical and cultural characteristics. Food and diets resemble each other, with an emphasis on fish, vegetables, lentils, and rice. While both maintain traditional gender and family roles, there are challenges in terms of girls’ education and child labor. Although different dialects are spoken, Bengali is the dominant language in both locations. Many of the same writers, artists, and musicians are celebrated by both Indians and Bangladeshis. Finally, people of this region share physical traits in terms of skin, hair, and eye color, as well as clothing styles.Cleaner, Healthier, Happier” program. In-country teams, in consultation with local WASH experts, identified educational objectives and target communities. Project managers in each country were both from local universities and had background in early child development as well as skill in local language dialects. Prior to the implementation of the study, the Principal Investigator traveled to both India and Bangladesh for 1 week training sessions to discuss the ethics of data collection among vulnerable populations and reviewing and revising the survey instruments. Needs assessments were conducted in Kolkata, India and Sylhet, Bangladesh with community members to understand their knowledge, attitudes, and behaviors around hygiene and sanitation practices. This information was key to addressing gaps in communication and formed the foundation for content development and implementation strategy, aiding in refining the education objectives. Formative research was also conducted with children in these areas during the development of content, ensuring the materials were relatable to the target audience. Community members were also engaged during the implementation phase of this intervention. Community volunteer workers with a background in delivering content to young children were chosen by an NGO partner in each country. These volunteers aided in delivering the intervention material to children and families and created the timeline of activities, as they were most knowledgeable about the area and what could be completed in the desired time frame with the targeted audience.While this was a short-term pilot intervention, care was taken to involve the communities in the design and implementation of the “Previous work on WASH behaviors has not focused on examining the impact of intervention messaging based on whether it is viewed as a personal or social benefit to participants. That is why this study developed the “me”  and “we”  approach to health messaging. This dichotomy was selected for study, as hygiene behaviors involve both aspects. Using the latrine and handwashing is an individual behavior. Around the globe, the norm is for people to urinate and defecate by themselves. A boy puts on and wears his own sandals, a girl washes her own hands. That said, hygiene is a public health practice. Personal behaviors foster and affect the health of a community.I wear sandals every time I go to the latrine; it keeps me healthy and clean” focusing on the benefits for the singular participant, while the social motivation or “we” approach text reads “we wear sandals every time we go to the latrine; it keeps us healthy and clean” focusing on the impact of the action on multiple members of the community. All of the print materials’ text and images (in Bangladesh), the organization of the activities (in India), the facilitator training, and the facilitation of the program activities were either “me” or “we” focused.The pilot program explored different approaches in health messaging  and 2014/2015 (in India). The programs in both countries consisted of community-targeted mobile viewings where participants watched videos created for the project, followed by simple activities led by a facilitator such as small group games, stories to reinforce WASH messages, and activity sheets and child-targeted activities or workshops led by trained facilitators. Participants in Bangladesh had approximately 12 exposures to the project’s content and in India, participants had approximately 24 exposures.  Exposures happened in community spaces or at school facilities (activities were conducted in school facilities but happened after school hours and were open to everyone in the community). Young children were registered to participate in the program and were encouraged and reminded to attend. Program content and activities were specifically targeted at children, but parents and community members were also encouraged to attend.The intervention materials and activities were delivered by NGO partners in each country. Various media materials used included video  and print resources . India had additional digital games developed for this project because the program team in India had previous experience implementing such activities and saw them as an important, engaging, and motivating component of the project. In Bangladesh, the intervention happened in very remote rural tea gardens without a reliable electricity supply; a tablet-based element would not have been feasible. However, even though the medium of delivery may be different, care was taken to ensure that the WASH curricular messages were repeated and reinforced to the same extent in both countries with a set curriculum delivering the same health messaging and similar amount of exposure to the intervention materials for participants in each country. Lessons and themes reinforced through the produced materials were the same in both countries and included using the latrine, wearing sandals in general and to the latrine, washing hands, washing hands with soap, and safe water transportation and storage. Children were exposed to all content and activities in their community or through schools in Bangladesh, whereas adult caregivers were largely exposed only to the mobile community viewings, which were accessible to all members of the community.The Principal Investigator, in consultation with Sesame Workshop, created the research instruments and protocols. Great care was given to the research instruments so that questions were developmentally and culturally appropriate. This research began with a common survey in English. This was presented to the research team in each country for translation. It was then reviewed by “gate-keepers” in the chosen communities. Edits were discussed and incorporated. Because Sesame Workshop is an educational media organization, this program focused on messaging and behavior change communication, not the provision of infrastructure. Within the WASH development community, there is a strong acknowledgment of the need for educational messages and to start early in inculcating WASH practices. Questions were refined after some pilot-testing and reviewed by child development experts in the United States, Bangladesh, and India. The research Project Director in each country convened a team of a dozen in-country researchers, all of whom had experience working with young children prior to this study and led training sessions, which were intensive and in person.Cleaner, Healthier, Happier” program with either a focus on social motives (the “we” group) or individual motives (the “me” group). The training sessions were pilot tested by participants associated with the project prior to being conducted with the facilitators. Training focused on acquainting facilitators with the in-country productions of Sesame Street and the “Cleaner, Healthier, Happier” campaign, as well as teaching facilitation and monitoring skills, ensuring understanding of all campaign materials, and practicing mock sessions with workshop activities. The sessions focused on specific skills so that the data collection with the children and parents would be ethical, reliable, and valid.In-country researcher teams carefully chose community-based workers to take the messages of the project to the children and community members. These community workers were either referred by other community workers or had previously worked on projects led by NGO partners and were all from local communities. Once selected, the volunteer facilitators received multi-day training to implement the “In-country Project Directors each recruited teams of a dozen researchers. The Project Directors led training sessions, which were intensive and in person. Following the completion of their training, researchers conducted one-on-one, in-person interviews with each participant, in his or her preferred language. All interviews were conducted by researchers who were familiar not only with the communities’ language but also with the local dialect. It was critical that the children understand the words and even accents of the researchers. Surveys done before and after the intervention took around 40 min for the parent/guardian and 30 min for the child participants. In keeping with recommendations for interviewing this age group, children’s answers were mostly multiple choice or close-ended , all in the Moulvibazar District of Bangladesh’s Sylhet Division. Sylhet Division is in northeast Bangladesh, along the River Surma, and is bordered by India on the north and east. Sylhet is home to a large number of indigenous tribal communities, who are considered to be ethnic minorities in Bangladesh. The landscape is distinctive with sub-tropical hills; tea estates are in abundance in this area. The area has over 150 tea estates, and nearly 300,000 employers work these estates. Many people from Sylhet work intensively, with few tools, and for a meager wage. Tea estate laborers live in densely populated slums, which lack proper sanitation. There is no formal plumbing or piped water in this area. For most people, the main source of drinking water is ground or surface water. Wells, ponds, rivers, and/or springs are used for washing and cleaning clothes, bathing, and even for washing utensils. The majority of households and public buildings (like schools) lack a water-sealed latrine. People usually defecate in the tea gardens or near springs.The Sylhet region has poor health indicators; people of the tea estates suffer from a variety of illness, including headaches, skin diseases, hookworm, fever, malaria, cough and cold, acute respiratory infection among the children, gastric/ulcer, blood pressure, toothache, diarrhea, jaundice, and dysentery. According to the 2014 Bangladesh Demographic and Health Survey . In Bangladesh but not India, the change in use of an improved latrine at school was also significantly predicted by the intervention (p < 0.001).p < 0.001).As shown in p < 0.001; India (p < 0.01)] (see p < 0.05).The linear regression models indicate that change in wearing shoes outside the house was significantly predicted by the intervention in both countries  see . Additiop < 0.01, soap frequency p < 0.001, soap frequency after defecation p < 0.001). The “me” group scored higher than the “we” group; however, the intervention group change scores were not significantly different from each other.In Bangladesh, all three of these variables showed significant increases in the intervention groups compared to the comparison group, as seen in In India, the frequency of soap use when handwashing significantly increased for both intervention groups. The “we” group was slightly higher than the “me” group for all handwashing variables, but there were no significant differences between the intervention groups.p < 0.001) and frequency of soap use by children after defecation (p < 0.001) ].In the linear regression models for Bangladesh the intervention was a significant predictor for change in the frequency of children washing their hands immediately after defecation (001) see . The intCleaner, Happier, Healthier media intervention improved hygiene knowledge, attitudes, and behaviors among parent and child participants in Bangladesh and India. While the research design limits our ability to make causal inferences, these findings offer that communities exposed to intervention activities and materials performed better in sanitation and hygiene measures. Target behaviors, such as using the latrine, wearing sandals, and handwashing, improved when examining change before and after the intervention.This study suggests that the ®, who encourages latrine use, handwashing with soap, and sandal wearing, was well known by participants.The strength of this study is that we are confident that this media intervention successfully reached the participants, as we observed high recall and understanding of the presented and novel materials. Raya, a new Muppetall the community’s children. Most children and all the adults across groups perceived the intervention as a social good, and not about improving individuals’ health. There are several possible explanations. To begin, the distinction between social and individual orientations in South Asia may be less pronounced than it is in other countries. Culturally, people may think in a group and not personal orientation based on more collectivist traits of the may think of the group and not have a personal orientation, drawing from collectivist traits  compared to the comparison group. This may be due to lack of adult involvement with the intervention materials and messaging, as the program was targeted toward young children.Participants in both countries reported significant gains in the targeted behaviors of latrine use, sandal/show wearing, and handwashing. Neither the “me” nor the “we” intervention group consistently outperformed the other. Also, there were other outcomes that were not impacted by the intervention in a significant way. The lack of differences between the “me” and “we” groups led to combining the intervention groups when conducting regression analyses. Participants in both groups were exposed to the new character Raya and similar intervention content, differing only in the focus on healthy behaviors benefiting the individual (“me” group) or the community (“we” group). The intervention (“me” and “we” combined) was a significant predictor of many targeted behaviors, including latrine use, sandal/show wearing, and handwashing.Cleaner, Healthier, Happier” program with either a focus on social motives (the “we” group) or individual motives (the “me” group). In-country researchers all had prior experience working with children and were trained in data collection methods.An important strength of this research was that great care was taken to implement this study; local researchers were well-trained and instruments were designed with the young child in mind. Research instruments were designed by child development experts and were refined by in-country team members to ensure cultural and age appropriateness of materials. In-country researcher teams, along with NGO partners, carefully chose community-based workers to take the messages of the project to the children and community members. These program facilitators received multi-day training to implement the “When interviewing children, pictures were used and researchers accepted pointing or a head nod as a correct answer. This was important in order to receive reliable answers from young children, who are unfamiliar with and might be hesitant to participate in the research process , it was unfeasible to randomly assign children to one group in these settings with a high degree of fidelity. Additionally, it was skeptical that in these slum locations contamination across groups could be controlled if randomization occurred within a community. It was also beyond this pilot to randomly assign enough communities to different groups, as it would have required 60 to 90 communities. As a result, in each country the interventions occurred in two separate but similar communities (one “me” and one “we” intervention group) and had a comparison group with a nearby, similar community.Another limitation is that this was not a randomized controlled trial. Researchers had hoped to randomize children into control versus the intervention groups; however, because the intervention was being delivered through the community (and also Cleaner, Healthier, Happier interventions will be more informed and more likely to engage in healthier behaviors. This study showed significant gains among young children and their parents with a small intervention; future implementations of this program will likely continue to have positive effects on improving WASH knowledge, attitudes, and behaviors in resource poor areas.This intervention lasted for 3 months and does not include research or information on long-term effects. It is possible that longer-term exposure would result in similar or even better outcomes. A sanitation and hygiene intervention in Zimbabwe showed greater improvements in handwashing and latrine use than previous short-term work by having a multi-year long education effort (Waterkeyn and Cairncross,


Thematic analysis of interview data led to formulation of three themes: Valuing Communication, Literacy and Learning; Exerting Control; and Seeking Support. The first theme is discussed with reference to Bronfenbrenner’s Bioecological Model. Participants offered reflective and rich views on their lived experience. They provided perspectives on features of successful interaction with peers and authority figures, importance of effective communication and the difficulties they encountered. This study argues for additional communication support for young people in the justice system.International research evidence has firmly established a high prevalence of language disorder in young offender populations. Less is known about young offenders’ perspectives on their own language abilities. The study recruited an opportunity sample of 10 young men in custody at a Scottish youth offending institution who had recent experience of segregation. This mixed-methods study investigated participants’ views on their language and communication abilities to inform future support and intervention, and formal language assessment was also administered to investigate indicative prevalence of language disorder within the sample. It focused on their communication with professionals and peers in justice, education and welfare settings. Results of standardised language assessment indicated the presence of language disorder in 44% ( Young people who offend are commonly from highly disadvantaged backgrounds, live in areas with few amenities and have reduced access to educational services and employment opportunities which could otherwise further their individual development ,2,3. In Over the past 15 to 20 years, a high prevalence of language disorder has been identified within offending populations. Cohort studies have consistently indicated that between 60 to 90% of young people who offend have a language disorder ,8, compaWhile most young people who offend are diverted away from further criminality, a smaller but significant group become involved in more persistent and serious offending, with some going on to receive custodial sentences . While iIf the needs arising from language disorder remain unidentified and unmet, an individual’s chances of engaging effectively with criminal justice processes can be limited, thereby reducing opportunities to access support and receive fair treatment. This reduction of opportunity would amount to a contravention of UN Convention on the Rights of the Child Articles 12 (right to be heard) and 13 (right to freedom of expression) . Over thSpeech and language therapy has been viewed as a cost-effective service in terms of public savings that may be made by involvement of young offenders with the service ,24. TherIt is a key notion in Speech and Language Therapy practice that access to means of effective communication is fundamental to an individual’s wellbeing; in addition, a holistic approach by professionals when considering the needs of that individual is an ethical requirement of practice . In the A suitable theoretical framework that allows a holistic view of the individual located within the relevant systems they occupy is Bronfenbrenner’s Bioecological Model. Applying this framework to an investigation of the views of young men within the criminal justice system around their interactions with others and their own abilities provides us with an opportunity to examine the experience of a group of individuals who regularly interact with a variety of institutions but whose own views and attitudes about those interactions is, to date, not well documented in the literature. Bronfenbrenner’s Bioecological Systems Theory (BST) emphasises the active role the individual plays in their own development while interacting within and with these systems. The theory was originally conceptualised as the Ecological Systems Theory (EST) in the late 1970s ,30 to acSystems within the model are placed at increasingly distal levels from the individual, who is situated at the centre; this has been described by Bronfenbrenner  as a “seEach of the model’s components is examined briefly below:“Individual”: The individual is placed centrally to the model and characterised as a self-contained biological system. Genetic and biological factors influence the developmental course of the individual into adulthood. Biological, hereditary and genetic influences affect the individual’s lived experience and their development within the four hierarchical systems in which they are embedded. “Microsystem”: The microsystem consists of the immediate settings and environments experienced by the developing individual in which they typically have direct, face-to-face contact with other individuals. Bronfenbrenner describes microsystems as “a pattern of activities, social roles, and interpersonal relations experienced by the developing person in a given face-to-face setting...”   “Macrosystem”: The outermost layer of the Systems Model, the macrosystem describes the cultural and social norms, political systems, beliefs and values that underpin and influence the opportunities for development of the individual, in all of the other systems of the model. Rosa and Tudge  characteBy reformulating the Ecological Systems Model into the Bioecological Systems Theory , BronfenProcess.Person.Context.Time.These components are conceptualised as:Regarding “Process”, the main drivers for individual human development are proximal processes, defined as “enduring forms of interaction”  (p. 317)In the case of “Person”, three characteristics were described by Bronfenbrenner as influential on developmental outcomes—force, resource and demand.Force properties are characterised as generative or disruptive. A generative force is a personal quality promoting the influence of proximal processes, for example, curiosity, responsiveness to others; initiating activity with others; ability to defer gratification in favour of longer-term aims. The disruptive characteristic is one that hinders or interrupts proximal processes, for example, “impulsiveness, explosiveness, distractibility, inability to defer gratification, or, in a more extreme form, (readily) resort to aggression and violence.”  Demand characteristics are the perceived qualities of the individual by others within the individual’s social environment; these are characterised as having a knock-on effect on whether opportunities for proximal processes to influence development are offered or established. The authors  gave exaThe “Context” component of the PPCT developmental framework essentially comprises the four nested systems of the earlier Ecological Systems Model . Proximal processes (the “engines of development” as described above) were conceptualised as taking place within the interpersonal microsystems level of the Context component of the model. The “Time” element added the developmental significance of the passage of time. The Time component was conceptualised as comprising three levels: microtime, mesotime, and macrotime, with microtime as “continuity versus discontinuity in ongoing episodes of proximal process”  (p. 995)Individuals are conceptualised as having personal, genetic, biological and psychological characteristics (“Person”) and personal developmental history with its significant events such as death of a parent or starting school (“Time”). The social environment, which comprises the nested systems (“Context”) may limit or promote access to the “engines” of human development, proximal processes (“Process”). Application of the model provides opportunities to consider the asymmetric power relationships that characterise the interactions between the individual young person and criminal justice staff. These interactions occur in a wide array of differing criminal justice microsystems: prison, court, police station and Children’s Hearing room, to name a few; in addition, other microsystems to which the participant does not currently have access, for example, family, or community peers may also be considered and discussed. This model can provide a framework in which to examine: the individual’s views about their own language and communication abilities (“Person”) and significant past events  (“Time”), and how they view their interactions with others at the same or at differing levels of the model  (“Context”). It also aids the researcher in gaining views on the ways in which the prison as an institution and its staff attempt to alter the individual’s developmental course with positive aims by means of educational training, work parties and offering opportunities to gain academic qualifications  and to discuss factors that lead to more negative outcomes  (“Process”).The microsystemic interactions in a single setting, for example the prison, may be further broken down into peer/peer interactions in cells, or in halls; peer/staff interactions in the healthcare unit, in halls or in teaching rooms or work parties. The model provides a means for participants to reflect on how they themselves have developed over time: while some interactions are recent and interconnected, occurring within the criminal justice system, police settings, court, prison, others are historical, e.g., an individual’s educational and/or looked-after experiences.Research questions were formulated to investigate the prevalence and nature of language disorder in young people in custody with experience of removal from association, and to investigate their views on their own abilities and interactions within a wider variety of social settings than had previously been captured within the literature. What is the prevalence of language disorder in young people who have been recently segregated?What do the young people think of their language, communication and literacy abilities, their interactions with peers and authority figures, historically and currently?The study took place at Scotland’s only Young Offender Institution, housing males aged 16 to 21 years. An opportunity sample of 10 young male offenders was recruited for the study. All participants were currently incarcerated at the YOI, and all had recent (within 2 months) experience of having been removed from association (“segregated”) in the prison’s dedicated wing. All had English as a first language, and none were receiving speech and language therapy intervention during the study. Participants were aged between 17;5 and 22;10 years . All participants were given pseudonyms in accordance with confidentiality and anonymity requirements. Pseudonyms and ages of participants are shown in All participants were of White Caucasian ethnicity. The figure is in close alignment with recent Scottish Centre for Crime and Justice Research (SCCJR) figures on the ethnicity of prisoners in Scotland where the population is 98% white . Data onn = 5) had experienced non-mainstream educational provision. One participant had no looked-after experience (10%), and eight (80%) were reported as having looked-after experience either by self-report during interview  or from Criminal Justice Social Work Reports (n = 3) and there was no data for one participant. Accommodation settings were reported as secure care (n = 3), foster care/secure (n = 1), foster care (n = 2) and residential school (n = 1). From available data, half of the group (n = 2), personality disorder (n = 2); “mild learning difficulty” (n = 1) and “anger issues” (n = 1) were reported.Only one participant had previous experience of receiving speech and language therapy. Incomplete data was available for current mental health and learning difficulty diagnoses; diagnoses of ADHD .All four CELF-4 Core Language subtests were administered to nine of the 10 participants.A thematic analysis approach  to the iFamiliarising self with the data; generating initial codes; searching for themes; reviewing themes; defining and naming themes; producing the report.Theme A, valuing communication, literacy, and learning.Theme B, exerting control.Theme C, seeking support.Thematic analysis was appropriate, as it allowed a flexible and dynamic approach to the interview data. The first author followed this process in the course of the data analysis as closely as possible. Coding led to the formation of three superordinate themes: This article focuses only on Theme A as it relates specifically to long-term outcomes. Results for other themes are published elsewhere.5/9 (56%) of the group scored within normal limits (CLS 86–115).2/9 (22%) of the group scored below normal limits in the Marginal range (CLS 70–85).2/9 (22%) of group scored in the very low/severe range (CLS < 70).Group Core Language Score results are summarized as follows:Results discussed below focus on valuing communication, literacy, and learning. Participants were asked to give a definition of communication and to rate themselves as communicators. These responses are reported together as often participants would provide their reasons or further elucidation of their responses.n = 9) emphasised “speech”, “speaking” or “talking”. Half of participants included the social dimension in definitions, referring to “people”, “two people” “other people” or “others”:Participants were asked to define “communication”, then “good” and “poor” communication. A majority  we’ll both talk and listen, and there’s a, there’s like a just a natural respect if you know what I mean?”Michael: “Being understood and that.”1b. “Poor” communication: definitionsDefinitions of “poor/bad communication” were wide ranging, with some personal experiences offered. A majority of participants focused on various perceived deficits of verbal aspects of communication, with insufficient talking or information sharing:Lucas: “Bad communication is when you just sit there, dinnae talk to anybody, tell anybody your problems, and stuff like that.”David: “No’ talking to anybody or nothing.”being an arsehole and being cheeky (Alan); getting aggressive (Mark), but also:Several participants focused on pragmatic/social aspects of communication, for example, Stephen: “Somebody who doesnae pay attention to anybody, doesnae listen.”Lucas: “(…) you need to talk to people, need to be able to socialise with people. You cannae just sit and keep everything to yourself. Cos that’s when things start going wrong in your head.”While participants frequently characterised good communication in positive personal/social terms, examples of poor communication commonly described situations where speakers either did not like or were not known to each other:James: “…if you try and communicate with someone you don’t get on with, it can be difficult.”Stephen: “(…) if you knew the person better, that could help communication as well.”Participants were asked if they felt that good communication was significant or important to them. In response, participants offered a wide variety of views, some describing situations with very high personal stakes. Andrew discussed his reasons to try and be a more effective communicator:“For me, it’s important, […] right now it is, man, cos if I just start screaming at people and that, I’m never gonna get parole, and I’ll have to dae a full six years, so for me, it’s important.”Also, Lucas provided a highly personal account of his experience of depression and self-isolation, where he underlined his own view on the importance of communicating with loved ones:“Good communication is important, aye. (R: How?) (…) At one point in my life, I was suicidal, and like, never telt anybody anything, and I tried to take my own life, and I woke up with tubes down my throat and everything, I was in the hospital. My mum found me foaming out my mouth lying on my bed, so I suppose aye, you do really need to talk to people sometimes.”The remainder of responses discussed the impact at an everyday level where messages in conversation needed to be understood or everyday contact with the outside maintained:John: “Aye, obviously it is, cos… em… (…) to get on with people and that, and obviously understand other people’s point of views, or…whatever it is you’re talking about.”Mark: “Mm. Pretty much, if you’re not communicating well enough, like, there’s… they might not understand what you’re trying to get through to them.”Participants were asked to rate their communication skills on a scale of 1–5, and then prompted to expand further on their rating; some participants did not respond verbally to these prompts.James discussed a change in his communication behaviours as a result of self-imposed pressures to be a “hardman” and working to change his thinking on this image of himself:“Er… I’d put myself at about a 3…(…) A 3 or 4. […]it’s almost like the way I force people, they should know just how to act around me, if you know what I mean, but this is again, this is just getting in that mentality, in that hardman mentality.”He goes on to describe the frustrations he experiences at his own—as he sees them—weaknesses in his communication skills:“When I feel myself getting worked up, I find it hard to… verbally communicate with people, (…) I feel like I’m always having to explain the situation, and it ends up dragging on. And it never gets the response that I want, it never happens the way I want it to (…) then I get overexplaining things, and I get myself worked up, because…cos I’m overcomplicating things, they’re butting in on it, and I’m like that, no! No! No! You don’t understand what I’m saying (…)”Alongside James, Stephen offered detailed reasons for his rating as a communicator (2½–3): he describes feelings of uncertainty and some concern that his style of communication is not effective when dealing with others:“Between a 2½ and a 3. (R: 2½ to 3. Why do you say that?) Cos, I just feel, as if, when I’m talking to somebody, I feel as if they don’t really understand me, or… See when I say something to somebody, it’s like… I’m either speaking too fast or they cannae make out what I’m saying.”While Martin did not offer a numerical rating of his communication skills, he offered a clear opinion about his communication strengths, and settings in which he knew he found communication more challenging:“I’m only good at it with the people I’ve been brought up with and the pals I’ve been brought up with. Other people, nah.”A majority of participants offered perspectives on their experiences while at primary and secondary school. The first author asked participants to describe their experience of school and whether they had experienced support.Where provided, participants gave predominantly negative views of their interactions with school teaching staff, with what they perceived as unreasonable behaviour by teachers as the main reason. Stephen and Mark characterise interactions with teachers at school by a mutual lack of respect, and reciprocity of “attitude”, which was typical of a majority of views:“Like, sometimes, see if teachers, pure strict teachers, I never had any luck man, they pure…pure had an attitude wi’ me, anytime I’d try and get my attitude back, man, they’d be like, “Less of that attitude…!” And I’d just be like that (sucks teeth). That’s by the time I got to high school, I started… I turned into a teenager and that, I wasnae having it.”“[on teacher] […] he used to come in and (…) I was…just straight out of the class. Sent out. I would literally just be coming in, putting my bag on the floor again, look at him and that’d be it, it’d be straight back out. […] Just basically cos he didn’t like me.”A majority of participants described frequent interruptions in their education as a result of removal from mainstream schooling:Researcher: “Where did you go to school?”David: “All different schools. Behavioural ones.”Lucas: “Got kicked out, I was on behavioural support when I was in Primary 5, til I was…went to high school. And then in that school I was on behavioural support and missed all my days. I got kicked out for life at the start of third year. When I was 15.”Lucas’s description of the circumstances around his removal from mainstream schooling centred on what he saw as an unjust resolution to an argument between himself and the rector of his school:“(…) I’d go to the rector and he’d end up shouting at me, end up laughing at him and then it gets into a big heated argument and he starts spitting on me…So… I just pushed him, and got kicked out for life. Got charged with assault (laughs). He was spitting in my face… Ken like, when he shouts, spit comes out, and it’s no nice. I wouldnae spit in his face, so… Why should he do it to me?”Two participants described their experiences of further education which had been curtailed due to involvement with the criminal justice system and subsequent imprisonment:James: “I got myself on an access course so I changed to construction and engineering, general level, and then you get a curriculum head for the construction, and I done like 2 months of construction and engineering […] this is when I started getting in trouble with the police and going to jail, so I never finished…I finished a good like 85% of the course but I never finished it all.”Lucas describes how he had plans to be a chef, with his course attendance was interrupted a number of times by spells in prison:“Put me into college and got kicked out of that and then like, school wasnae for me so I went and got my NQT Qualification, I want to be a chef. And then I done half my second year, come in here, started that again, come in here, been in here a few times.”He reported that he still had a goal of being a chef and resuming his studies on release. He spoke with enthusiasm about his favourite elements of the course and the satisfaction he got from hard work and ingenuity:“Then we’d sit and cook like 40 covers. Starters, mains, desserts. […] It was hard going, you just keep constantly on the move. Making bread fae scraps, making all sorts. Make everything fae…next to nothing.”Half of participants described being motivated to change their behaviour, attempting to do so by modifying their communication style, and the language they used, and the tensions they experienced in their efforts to make these changes.Andrew: “It’s just…cos I’m doing an LTP and I’ve got it says parole an’ that, you’ve gotta fuckin… Just the daft wee things you’ve gotta stop (…) if I just start screaming at people and that, I’m never gonna get parole, and I’ll have to dae a full six years, so for me, it’s important. … daft wee guys, they might not give a fuck in here.”James: “…don’t even like fighting any more. It just doesn’t appeal to me.”Stephen: “It feels if… It feels as if I belong here. I know I pretend I don’t, but it feels if…I fit in here. That’s something I’m trying to change. […] I’m gonna try… try and get out the habit of just…the routine of going back in.”Applying Bronfenbrenner’s Ecological Systems Theory  to the fBronfenbrenner describes human development as a product of interaction between the environment and the individual, firstly in terms of the systems surrounding them, and in later iterations of his theory, emphasizing the processes underlining development as part of the PPCT (Process-Person-Context-Time) model . This alBronfenbrenner and Morris  define p“Examples of enduring patterns of proximal process are found in feeding or comforting a baby, playing with a young child, child-child activities, group or solitary play, reading, learning new skills, athletic activities, problem solving, caring for others in distress, making plans, performing complex tasks, and acquiring new knowledge and know-how.” (p. 797)Applying this concept to activities and processes reported by participants within the prison environment, we may see any activity that is regular or enduring as an example of a proximal process, for example: regularly attending and engaging with prison education or visiting projects; learning new skills in work parties such as plumbing or painting; reading books or newspapers; writing letters to family or friends; involvement in experimental research studies; playing an instrument; writing music and performing for others; talking to peers and officers about transferring to other halls or a different prison; receiving visits from family; visiting the gym with friends, or other recreational activities such as football or pool.Quantitative findings for Research Question 1 are that language disorder occurred in a significant proportion of the participant group, with 44% of the group below normal limits and one participant performing above the mean for age equivalent 16;11. The presence of language disorder fundamentally reduces opportunities for young people with an already established pattern of involvement with the justice system to engage with the proximal processes inherent to the microsystems in which they interact with peers and others. As such, the young person is less likely to be engaged in those crucial formal proximal processes that intend to support their development. Generally, in the presence of other risk factors such as parental disengagement, absence of a consistent carer, or lack of key supportive authority figures, there is greater likelihood of involvement in what Johns et al.  refer toBronfenbrenner’s model can be applied in order to answer Research Question 2. Clear examples of proximal processes emerge from the interview data and subsequent themes. The school environment is a primary microsystem for proximal processes to support development. Reduced success in formal proximal processes such as education, according to Johns et al.  may leadOnly one participant had experienced SLT involvement and his view was unclear as to why. The presence of an unsupported language disorder in children and young people is also well evidenced to increase the likelihood of disengagement from school ,43,44, oYouth justice institutions may be seen as attempting to build positive relationships on a microsystemic and mesosystemic level  in order to counteract negative microsystemic ones .Bronfenbrenner and Morris  conceptu“Disposition”: In the case of young male offenders, disposition may be influenced by previous experience of home, justice settings, the peer group, and so on. The young person may, due to previous experiences, have varying levels of motivation according to the setting, contributing to readiness or otherwise to engage with the proximal processes that occur within that setting, as discussed above. Many participants describe their school experiences as difficult, with frequent exclusions, leaving school before 16, or entering alternative schooling; however, a change in motivations is also observed for a number of participants where they discuss attempts to change their communicative behaviours to reduce their aggressive or destructive behaviours in the prison environment and generalise these to life outside post-liberation. Andrew, Lucas, and James all discuss their need to make changes to how they interact in the prison environment—despite reporting a different manner of interaction in community—in order to attain goals of, for example, ‘Enhanced’ status (a higher level in the Incentives and Earned Privileges Scheme), early parole, or movement to adult prison. They make use of avoidance strategies in their interactions in the prison and make decisions to engage with education and work programmes in order to prepare them better for life post-liberation.“Resource”: Resource characteristics—experience, skills, knowledge, and abilities, but also experiences and social and material resources such as access to amenities like housing, transport, or food, and also educational or employment opportunities—may often be unseen or hidden ,48 and “Mental health conditions e.g., anxiety, depression, behavioural disorders such as ADHD or ODD all act to affect the capacity for and degree to which the individual may be able to interact substantially to allow proximal processes to influence development.Out of the participants, 44% had an unsupported language disorder; this condition is highly likely to limit an individual’s access to the very proximal processes that could strengthen these assets and further his or her development; increased speech and language therapy provision in the justice estate would provide tailored support to provide opportunities to strengthen these assets.“Demands”: It is well established that young people with unidentified language disorder are at greater risk of misinterpretation of their lack of understanding or reduced expressive abilities as non-compliance when dealing with authority figures and professionals in the justice system ,51,52. TIn the model, the familiar concentric systems are viewed as “contexts of development” where proximal processes influence the development of the individual. Interactions within the microsystems of school and prison were the main focus of this article; not all participants discussed all interactions in all microsystems but what is clear is that a majority of participants had difficulties in historical settings, e.g., in the school environment, or were currently finding interactions within many of the microsystems they inhabited as challenging.At the individual/microsystemic level, the importance of reflection to participants on their interactions with friends is apparent. Reflection informs consolidation and justification of self-protective, often non-proactive communication behaviours, both in community and in prison. Conversely, some participants, e.g., James, Lucas, and Andrew, described attempts to rupture this systemic influence by using an avoidance strategy both in community and prison environments, reducing contact with peer influences who might distract or manoeuvre them away from their goal of timely liberation or staying out of trouble.Bronfenbrenner  conceptuParticipant descriptions of their interactions—whether with peers, family, and professionals were often in terms of the changeability and lack of regularity of their interactions in the microsystems they inhabit: leaving and starting at different schools, the variety of care placements they encounter by type and duration, repeatedly coming into and out of prison, starting further education courses but not being able to finish them. Extended and frequent interactions within microsystems that could have direct beneficial developmental effects are rare within the interview data and subsequent themes.Johns et al.  describeMost participants discussed the importance of changing their behaviours, of perceived changes in themselves in terms of their attitudes and plans while they had been in the prison, with some discussing the changes they had seen in themselves while in prison, or the desire to do so. Participants were able to describe the importance of change, of development over time, and the pressing need to do so.The majority of participants discussed their experiences of difficulties at school, school exclusion, education in a variety of settings, looked-after experiences, emotional and behavioural difficulties, and inevitably, involvement with police and the courts before their sentencing and imprisonment. They describe repeatedly a reduced experience of successful interactions with the authority figures they encountered, from school, to family breakup and care experience, to the courtroom, to police interview, and to prison. Through the lens of Bronfenbrenner’s Ecological Systems Theory, this lack of successful interaction is mirrored in the reduced experience of positive proximal processes that may support their development throughout the micro- and meso-systemic level interactions they experience.It is at these crucial junctures that intervention in the pathway is essential. A number of initiatives to implement intervention with SLT involvement are in existence, for example, the No Wrong Door project run by North Yorkshire County Council includes two speech and language therapists within both of its dedicated professional support teams. The team also consists of care workers, clinical psychologists and police liaison officers. The aim of the No Wrong Door initiative is to provide integrated support in the community for young people with escalating needs who are on the edge of care. In the five-month period from April to September 2016, 83 out of 142 referred young people were found to have an unidentified speech, language or communication need; the communication support workers were then able to signpost and also offer indirect intervention by offering training, consultation, and advice to other professionals and family involved with the young person. Evaluation of the initiative after two years highlighted the following outcomes: reduction in criminal activity by the young people involved, an increase in those involved in Education, Employment, or Training, and a reduction in high risk behaviours including substance use and absconding. On the basis of the success of the No Wrong Door initiative, Perth and Kinross are taking a similarly hub-based multidisciplinary approach with their REACH project which recently reported a successful multidisciplinary approach .Milton Keynes Youth Offending Team has adopted a “screening out” approach to communication support needs, rather than “screening in”, where there is a base assumption that young people referred to the service will have some form of a special educational need that needs to be met in order to begin to bring about a better outcome . EngagemIndeed, the quantitative and qualitative findings of the study have implications for SLT practice in the prison environment. There is a still a lack of crucial speech and language therapy services in the justice and care systems, despite the now established positive effects of involvement of SLT in these areas on the lives and outcomes of the young people affected. Police , and ScoAt the moment, no specific language skills screening procedures are in place for newly sentenced and housed prisoners. A screening tool examining an individual’s receptive and expressive language skills, narrative skills, vocabulary, and literacy as they entered the prison would allow professionals to have an overview of the immediate formal needs of the individual and tailor intervention and support accordingly.Common to all of the above examples is the screening of communication support needs at a point where the individual embarks on new interactions within microsystems that are part of exosystemic justice, prison, and care institutions. Each “system” comprises smaller, one-to-one or group microsystemic interactions that, through proximal processes, shape that young person’s future development. Whether the young person is entering or at high risk of entering care, or beginning to make use of youth offending team services, or entering prison, these are the points at which gaining detailed knowledge of their communication support needs—by use of assessment and interview data—can be most effective in informing intervention with the aim of providing better outcomes for those individuals. The need for training of staff located at all these junctures about language disorder is vital. Recent Scottish Government proposals to raise the age of referral to the Children’s Hearings system to include 16- and 17-year-olds would also provide another point of contact by which language and communication needs arising from language disorder could be recognised and met successfully.www.rcsltcpd.org) for justice professionals to support them in identifying communication difficulties of the people they work with and understanding their impact on individuals involved in the justice system. Studies have shown staff training in this area has been shown to be effective [Training on communication difficulties in vulnerable and at-risk populations can provide another means of intervening in the pathway. Need for training has been identified in the Children’s Hearings System  and poliffective ,57,58.Participants frequently offered insightful and reflective views about their own language and communication abilities, the importance they placed on communication and literacy, and the selectivity with which they described their motivations to communicate. Participants frequently discussed issues they felt arose around their language and communication abilities, for example, Stephen on his concerns he was not understood by his peers, or James feeling as though he was overly expressive and often took a long time to get his point across. Given the paucity of standardised assessments for this age group, and the subtlety of language difficulties in adolescence and early adulthood ,60 usingThe wide variety of historical and current experiences described by participants suggest that imprisoned young offenders have several crucial junction points in their lives that have ultimately led them to their current situation. This study shows the value of viewing the young person’s reports of their own lived experience through the Bioecological System lens. All participants had had contact with the justice system previously with little or no contact with Speech and Language Therapy Services. Pathways to imprisonment for young people, while individual in the sense that the circumstances that lead to imprisonment will vary for each person, are broadly similar. Key themes, features, and experiences arise between individuals which offer indications of risk. Unidentified and unmet communication support needs are a crucial component of this mosaic of risk, because of the well documented evidence surrounding the associations between unidentified needs and school exclusion and educational attainment, increased risk of mental health difficulties and increased risk of behavioural diagnoses. Identifying and meeting the communication support needs of this vulnerable group is a key element in the effort to disrupt the pathway many of these young people are travelling.


There is a need for effective behavioural interventions in dentistry. This paper presents an innovative behavioural intervention for young adults with dental caries, in an interdisciplinary collaboration between dental personnel and licensed psychologist in general dental care. The intervention has been evaluated in an RCT, with positive effects on oral health behaviour.The intervention, Acceptance and Commitment Therapy (ACT), a recent form of cognitive behaviour therapy (CBT), was adapted to young adult patients (18–25 years of age) with high dental caries activity.The intervention included two individual sessions, provided by a clinical psychologist at general dental clinics. The rationale for selecting ACT as the theory base is presented, together with the treatment manual and a case illustration.ACT may be a promising alternative for behavioural interventions in dentistry for patients with oral diseases, specifically dental caries. Interprofessional collaboration between psychologists and dental personnel opens up for new possibilities to help and treat patients with various health issues in public dental care.ISRCTN15009620www.isrctn.com, retrospectively registered 14/03/2018.TRN  Dental caries is a major public health issue, affecting 60–90% of adolescents and nearly all adults worldwide , 2. EarlTraditionally, interventions for patients with dental caries include prevention, oral health education and restorative treatment. Oral health education increases patients’ knowledge of oral health, but has limited effects on oral health-related behaviour and other clinically relevant outcomes . High-quHealth behaviour science provides several well-established theories of behaviour and behavioural change. The theory of planned behaviour and the transtheoretical model of behavioural change, for instance, have influenced interventions in dental care . In a syAcceptance and Commitment Therapy (ACT)  is a recThus, we developed a two-session manual-based ACT behavioural intervention for young adult patients with dental caries. The intervention was evaluated in an RCT where positive effects on oral health behaviour were found, and significantly more in the ACT intervention group than in the control group . The larThe aim of the present paper was to present the rationale and the treatment manual (including a case illustration) for a brief behavioural intervention for young adults with dental caries. The intervention was an adapted form of ACT, provided by a clinical psychologist, for use in general dental clinics.The overall aim in ACT is increased psychological flexibility, which enables the individual to maintain functional behaviours and to change dysfunctional ones, in order to live in accordance with chosen life values . AccordiAcceptance includes a willingness to experience and explore memories, thoughts, feelings and bodily sensations, also when they are uncomfortable [fortable . The oppfortable . Patientfortable .Mindfulness exercises aim to increase the awareness of the present moment [t moment . Caries-t moment .Defusion is a process and an ability to recognise thoughts and mental events for what they are, rather than as true representations of reality [ reality . A painf reality . A patieSelf as a Context makes it possible to see oneself, situations and obstacles from a broader perspective [spective . Each paValues: According to the theory behind ACT, people are often out of touch with their values in life and their behaviour is guided by other factors [ factors . We find factors . Oral anCommitted Action includes the ability and willingness to engage in valued behaviour [ehaviour . ChallenThe ACT intervention was developed and adapted for young adults with dental caries by the authors HW, CY and UW, all clinical psychologists with CBT and ACT competence, in collaboration with a specialist in dentistry (MH). The intervention was documented in a manual specifying the included ACT exercises. The intervention was tested in several patients, resulting in the selection of the main exercises, including the Bull’s Eye  and a deThe ACT treatment manual for young patients with dental caries is outlined below. The patient receives two individual ACT sessions (45 min each), two to three weeks apart, delivered by a clinical psychologist with competence in CBT and ACT at a general dental clinic. To increase treatment adherence, work sheets are used for the sessions. For a treatment overview, see Table The psychologist welcomes the patient and asks about his/her expectations and hopes for the session. If the patient seems ambivalent or hesitant, potential underlying values guiding the patient’s choice to participate in the intervention in the first place are investigated. The aim (1) and rationale (2) of the intervention are then presented: 1. “This is a health counselling session, with the aim to explore possible improvements of your oral health.” 2. “I will first ask you some questions about your life situation and then about your oral health, after which we will discuss a plan for you to improve your oral health. How does that sound? We have about 45 minutes today and another session in two weeks.”The patients are asked questions about their life , generaThe patients are asked to notice the current status of their oral health. The psychologist assists the patient with instructions, such as, “If you feel your gum and teeth, how do they feel today?”. The exercise aims to increase the awareness of oral health but can also give an indication of the patient’s openness and engagement in the treatment.At this stage, behaviour of importance to the patient’s oral health is summarised and the patient is asked if there is any behaviour that he/she is willing to try to change to improve their oral health. Clinically relevant information is then gathered through the focused questions in a “Focused interview” , includiDuring the work described above, a behaviour analysis is performed  for a deThe patient is encouraged to think about what oral health he/she desires, how it might feel, why it is important and what the patient would be able to do. Patients may wish for whole and white teeth to eat and smile with, and to feel fresh so that they can kiss their loved ones. A modified version of the Bull’s Eye Value Survey  is also The psychologist actively addresses fused material that could be of importance for the patient’s oral health behaviour. The psychologist describes and labels thoughts as thoughts and asks perspective-taking questions.The patient specifies by writing a plan for behavioural change  and helpful strategies when faced with obstacles. The psychologist may add suggestions, such as functional strategies that the patient has mentioned or shown in terms of ACT-relevant skills. The patients are also asked to rate how likely it is that they will comply with the behavioural plan on a scale from one to ten. If the patient rates below six and there is time left, the plan is revised, otherwise the work continues in Session 2. The patients also get a copy of the Bull’s Eye to take home.The patient is asked how the prior session was experienced and to describe how the plan for behavioural change has worked. Additional strategies, solutions and obstacles are noted. Setbacks are separated from relapses, and value-driven actions highlighted as more important than reaching goals. The patient is then asked to rate how much of an issue their oral health is today on a scale from one to ten (as in Session 1).The patient is asked to perform the same mindful oral health exercise as in Session 1.The psychologist provides a copy of the patients’ Bull’s Eye Value Survey from Session 1 and a new one. The patient is asked to put a new “X” on the second dartboard, representing how close to their values they are at this point. The patients are asked to reflect on how they feel, if they are satisfied with where the “X” is now or would like to discuss possible actions to reach the Bull’s Eye. The patient writes down what has worked since the last occasion , possible obstacles in the year to come and helpful strategies to handle them.In addition to the strategies used in session 1, the exercise found in Harris  is used.In this session, a new written behavioural change plan is formulated. The psychologist helps the patient to formulate realistic and specific plans for change and normalises and helps the patient handle possible setbacks. The patient rates the likelihood of each suggested behavioural change being carried out on a scale from one to ten. If the rating is below six, additional work is considered. The patient gets a copy of the new Bull’s Eye to take home. The psychologist encourages the patient to continue to attend the dental clinic for examinations, health promotion and treatments, and to take an active role in the treatment planning.This is a hypothetical case illustration, constructed using material from several individuals.The  patient Eva (E) is 22 years old and works at a café. According to the focused interview, E lives with her parents during the week and with her boyfriend at weekends. She brushes her teeth every morning, but rarely in the evening. E drinks a can (33 cl) of soft drink on a daily basis, and about one litre on weekends. E is overweight, says she often feels stressed and smokes half a pack of cigarettes every day. E has had a number of restorative dental treatments due to dental caries. During the mindful oral health exercise, E notices her latest two fillings, and the taste of a snack she ate just before the session. She rates her oral health as an issue as a four on a ten-point scale (ten being the maximum). When her oral health-related behaviours are summarised, E says she would like help to drink less soft drink.During the functional behavioural assessment E describes that she started drinking soda on a daily basis when she got a job at a café. She stopped drinking it for a couple of months when she was out of work, but started again when she got another job at a café with easy access to it. “I usually open a can after an hour at work and sip on it until lunch, and on weekends I share a two-litre bottle with my boyfriend.” When asked the focused questions, E says that she drinks soft drinks because she loves the taste and wants to stay alert. She knows it only works momentarily, because she is often thirsty or tired again after a while. When asked about costs, E says that it is not that expensive. The psychologist rates E as being fairly open, but not in contact with her emotions at this stage of therapy. When asked about other costs of soft drink consumption, E says diabetes. The psychologist notices how E clenches her teeth and looks away. The psychologist asks if E notices what is happening inside her at that moment. E says: “Nothing”, but then “Anxiety”. The psychologist asks where in the body and E points at her chest. The psychologist normalises this and credits E for being in touch with her feelings. E says that she has seen the consequences of diabetes. With a bit of encouragement, she describes those consequences. Afterwards E sighs, and says she really does not want that for herself.The session naturally shifts focus to values. When E is asked about what oral health she desires instead she first replies: “Whole and white teeth”. When asked why that is important , E answers that it is a sign of taking care of oneself. And when asked to elaborate, E says that she wants to be healthy. The psychologist asks what E would be able to do then, whereby E answers with emphasis: “Have children!” The psychologist: “It sounds like that is truly important for you?” “Yes, I have always dreamt of having children”. E then summarises her values in writing: “It is important for me to have whole and white teeth, to take care of myself, remain free from illness and be able to have children”. E puts an “X” halfway to/from the centre of the Bull’s Eye dartboard. E writes “stress” and “the urge for soft drink” as her main obstacles to change, and rates them as a seven on a ten-point scale. She writes that she could try to stop drinking soft drink and drink water instead. After considering what else might be helpful, she adds: “Not carrying coins with me, and tell my family about my plan for better teeth”. When asked how likely it is that she won’t drink soft drink the next two weeks she says eight on a ten-point scale.E immediately says: “I have stopped drinking soft drinks! Can you imagine?” According to E, it was a great challenge the first week, with tiredness and an urge for soft drink, but she had stuck to the plan and the urge wore off. E says that she has thought a lot about her teeth, and that she told her family and boyfriend, who suggested brushing together in the evenings, which has worked well. E says that she has also started to pay off a loan using the money she saves on not drinking soft drink. She seems happy and says she also feels proud. E rates her current oral health as a three as an issue on a ten-point scale, and puts her “X” one step closer to the Bull’s Eye (the middle of the dartboard). When doing the oral mindful exercise, E notices freshness in her mouth after brushing before the session; however, E says that she has thought about another habit detrimental to her health: chocolate drinks. E says she drinks eight glasses per day, and has done so since she was a teenager. Similar factors contribute to these behaviours.The psychologist introduces the defusion exercise. E writes, “tastes good”, on a post-it sticker. During the exercise, E identifies more obstacles, such as tiredness, stress and the thoughts, “I need chocolate”, “I must have chocolate”. When asked to show how persuasive these thoughts may be, E puts the post-it stickers on her face. When asked how well she sees the Bull’s Eye, she says: “I don’t see it at all!” E laughs and speeds up. The psychologist shares noticing that E laughs, but also asks how she feels inside right now. E pauses and says: “Actually, I feel that anxiety in my chest again”. The psychologist helps E stay with that emotion. E slows down and says: “All this (points at the post-it sticker) feels overwhelming sometimes, but at the same time, I know I can change. I mean I stopped drinking soft drink! I had all these thoughts but I didn’t listen to them.” The psychologist praises E for noticing, and recommends her to write that down. E writes: “I can notice but not act on my thoughts or urges for soft drinks and chocolate”. E specifies a plan for how to keep brushing twice a day, for not drinking soft drink and for giving up chocolate drinks. After information about potential setbacks, E rates the likelihood of her following her plan as a ten out of ten. E still smokes, but seems more willing and committed to seizing opportunities for a healthier life.In this paper, we have presented the manual for a brief behavioural intervention for young adults with dental caries. The intervention was a cognitive behaviour therapy method called Acceptance and Commitment Therapy (ACT) delivered by a clinical psychologist at a general dental care clinic.ACT has previously shown promising results for different patient groups , 30, 31,Previous studies on behavioural interventions in dentistry have been criticised for methodological weaknesses, such as inadequate sample size , 8. ACT In addition to the request for more theory-based behavioural interventions , the neeThere is growing interest in developing evidence-based interventions for behaviour change within dentistry. There are several areas in clinical dentistry where behaviour change plays an important part for treatment, prevention and health promotion, and various methods may be needed to address different problems , 34. ACTn = 26) concerning pain, tinnitus, depression and anxiety, included in the systematic review by Öst [Common questions about behavioural interventions concern the dose, the use of an individual or group setting, and the provider of the intervention. The format of a brief intervention was selected to attract patients with limited time and varying motivation for treatment; i.e., young adults, and to make it possible to treat more patients in a cost-effective way. However, a booster session performed either at the dental clinic or by phone might enhance the effect. Another important issue is which profession is best suited to provide behavioural interventions. A systematic review reported that different professions were used ; however, the difference in effect between different providers could not be evaluated . In the w by Öst , the cleIn this paper, we have presented a brief behavioural ACT intervention adapted to young adult patients with dental caries. ACT has the possibility of being an effective behavioural treatment for patients with oral diseases, and interprofessional collaboration between psychologists and dental personnel opens up new possibilities to aid and treat patients with various health issues in general dental care.