The Clinical Teaching Fellow role: exploring expectations and experiences.

BACKGROUND: Many UK junior doctors are now taking a year out of the traditional training pathway, usually before specialty training, and some choose to work as a clinical teaching fellow (CTF). CTFs primarily have responsibility for delivering hospital-based teaching to undergraduate medical students. Only a very small amount of literature is available regarding CTF posts, none of which has explored why doctors choose to undertake the role and their expectations of the job. This study aimed to explore the expectations and experiences of CTFs employed at NHS hospital Trusts in the West Midlands. METHODS: CTFs working in Trusts in the West Midlands region registered as students on the Education for Healthcare Professionals Post Graduate Certificate course at the University of Birmingham in August 2019 took part in a survey and a focus group. RESULTS: Twenty-eight CTFs participated in the survey and ten participated in the focus group. In the survey, participants reported choosing a CTF role due to an interest in teaching, wanting time out of training, and being unsure of which specialty to choose. Expectations for the year in post were directly related to reasons for choosing the role with participants expecting to develop teaching skills, and have a break from usual clinical work and rotations. The focus group identified five main themes relating to experiences starting their job, time pressures and challenges faced in post, how CTF jobs differed between Trusts, and future career plans. Broadly, participants reported enjoying their year in a post at a mid-year point but identified particular challenges such as difficulties in starting the role and facing time pressures in their day-to-day work. CONCLUSION: This study has provided a valuable insight into the CTF role and why doctors choose a CTF post and some of the challenges experienced, adding to the sparse amount of literature. Understanding post holders' experiences may contribute to optimisation of the role. Those employing CTFs should consider ensuring a formal handover process is in place between outgoing and incoming CTFs, having a lead person at their Trust responsible for evaluating changes suggested by CTFs, and the balance of contractual duties and personal development time.

Preparing for medical school selection: Exploring the complexity of disadvantage through applicant narratives.

Background: Despite a growing drive to improve diversity in medical schools, those from state schools and less-advantaged sociodemographic backgrounds remain underrepresented. We explore applicants' approaches to preparing for medical school selection, considering the complexity of sociodemographic disadvantage in this highly competitive process. Methods: Narrative interviews were undertaken with applicants to a United Kingdom medical school, exploring experiences of preparation for selection (n = 23). Participants were purposively sampled based on involvement in widening participation schemes, school background, gender, and ethnicity. Transcribed data were analyzed using Labov and Waletzky's analytic framework. Bourdieu's concepts of cultural capital and habitus provided a lens to constraints faced and variable experiences. This informed a consideration of the ways applicants approached and navigated their preparation, in the face of various constraints. Results: Constraints to resources and support were often apparent for those from state nonselective (SNS) schools. These applicants and those beginning their preparation later (12-18 months before application) appeared particularly vulnerable to myths and misunderstandings about the application process and appeared less confident and less discerning in their navigation of preparation. Some of the applicants, particularly those from independent and state selective schools, appeared confident and competent in navigating the complexities of the application process, while others (often from SNS schools) were more frequently lost or stressed by the process. Discussion: Those who lack particular preparatory tools or resources (materially, culturally, or perceptually) must "make do" as they prepare for medical school selection, In doing so, they may risk a haphazard, ill-informed or ill-equipped approach. Constraints to opportunities, more typically experienced by those from SNS schools, appeared to motivate the process of bricolage for a number of the applicants. Perversely, medical schools have introduced nonacademic requirements to level the playing field of disadvantage, yet applicants in this group appear to experience challenges as they prepare for selection.

The Clinical Teaching Fellow role: views of the Heads of Academy in the West Midlands.

BACKGROUND: Increasingly junior doctors are taking a year out of the traditional training pathway, and some opt to spend a year in a clinical teaching fellow (CTF) post. The CTF post mainly involves delivering hospital-based teaching to undergraduate medical students. In NHS hospital Trusts in the West Midlands, Heads of Academy (HoAs) have oversight of medical education at each Trust and therefore have responsibility for employing and directing the work of CTFs. Currently, only limited literature exists about the CTF role and exploring this from the point of view of different stakeholders in medical education is important in terms of contributing towards development of the role. This study aimed to explore the views of HoAs in the West Midlands region regarding CTFs employed at their Trusts. METHODS: All HoAs at the NHS Trust/teaching hospitals associated with the University of Birmingham were invited to take part in an in-depth interview about CTFs at their Trusts. Interviews were held via Zoom recorded using Zoom's recording functionality. Interview transcripts were then coded and analysed using thematic analysis. RESULTS: Seven out of 11 HoAs participated in an interview. Seven themes were identified: CTF duties/Job role, Relationship with students, Benefits of having CTFs, Challenges associated with CTFs, Popularity of the role, What Trust offers CTFs, and Future of the role. Primarily it was felt that having CTFs at their Trust was beneficial in terms of the amount of teaching they provide for medical students. The HoAs were keen to ensure the CTF posts were of maximum benefit to both the post holders and to the Trusts where they were based. The CTF role is one that they felt would continue and develop in the future. CONCLUSION: This study has provided the first insight into the CTF role from the point of view of senior doctors with responsibility for delivery of undergraduate medical education. The consistency and reliability of teaching provided by the CTFs was identified as a key benefit of the role. Future work exploring the role from the point of view of post holders themselves would be beneficial to contribute to development of the role.

An assessment of the impact of formal preparation activities on performance in the University Clinical Aptitude Test (UCAT): a national study.

BACKGROUND: Previous studies have shown performance in the University Clinical Aptitude Test (UCAT) to be associated with measures of candidate socio-economic advantage such as parental occupation and type of school attended. It is possible that access to preparation support and materials may in part explain these associations. In this paper we determine whether use of formal preparation resources is associated with higher UCAT scores and whether differences in use of preparation resources exist between socio-demographic groups. METHODS: After completing the 2017 UCAT UK school-leaver candidates (n = 14,332) were asked to answer a questionnaire regarding their use of official UCAT and commercial resources, school-based support, and time spent preparing. Multiple linear and logistic regression models were used to evaluate the associations between preparedness, demographic characteristics and UCAT performance. RESULTS: Five thousand, four hundred thirty-nine (38%) candidates responded to the questionnaire. Use of freely available UCAT official practice tests, paid commercial materials, attendance at school-based preparation courses and spending more time preparing were significantly associated with higher UCAT scores. Candidates who were from less deprived backgrounds and attending independent or grammar schools were significantly more likely to use paid commercial materials and spend longer preparing. CONCLUSIONS: Reported use of preparation resources varies between candidates from different socio-demographic backgrounds and is associated independently with performance in the UCAT. Increasing the availability of freely available resources may mitigate some of these differences.

Why do students struggle in their first year of medical school? A qualitative study of student voices.

BACKGROUND: Struggling at medical school incorporates academic failure, course disruption and early course exit. Struggling is usually multi-factorial involving academic, personal, financial and health factors. Struggling students may fail to engage with available support. First year students are particularly susceptible as they transition to university and a professional career. METHODS: The study aim was to explore medical students' own voices on struggling and assess how they match up to existing literature. During one academic year, all first year medical students at the University of Birmingham (UK) who opted to leave or were required to withdraw (n = 52) were asked to participate in an individual exit interview. Fifteen students responded and fourteen (27%) agreed to be interviewed. Interviews were face to face (n = 10), telephone (n = 3) and via email (n = 1). Interviews were unstructured and led by a general open question. Framework analysis identified key data themes. RESULTS: Students described year one of medical school as a critical transition. They simultaneously needed to adapt to being a university student, a medical student and a doctor. A six-group typology of students emerged, each of which struggled with one or more of these adaptations. The groups were: wrong degree choice, mental health problems, acute crisis, at capacity, slow starter and family rock. Some students experienced an isolated problem from within this typology. Most had a multi-factorial story of struggling. Mental health problems and acute crises were the most common issues. Early professional identity formation was a key hurdle. Help-seeking behaviours were varied. CONCLUSIONS: This study explores the narratives of medical students who struggled from an early stage and presents a data-driven typology of their issues. It advances existing qualitative understanding of this topic, which to date is predominantly derived from educator perceptions and not specific to early course issues. Although our results broadly cohere with existing knowledge, we also present novel findings which may reflect our focus on first year students. Issues around early professional identity formation may reflect the increasing emphasis on professionalism in medical school curricula. Listening to these narratives could help university staff to identify students at risk of struggling for targeted support.

Factors affecting consultant attitudes to undertaking undergraduate medical student teaching in the UK: a systematic review.

OBJECTIVE: This systematic review aimed to explore consultant attitudes towards teaching undergraduate medical students in the UK. DESIGN: Systematic review. METHODOLOGY: Standard systematic review methodology was followed. MEDLINE, EMBASE and OpenGrey were searched from inception to August 2019 to identify studies exploring senior doctors' attitudes towards teaching undergraduate medical students. Two reviewers independently carried out key methodological steps including study screening/selection, quality assessment and data extraction. A narrative synthesis was undertaken. RESULTS: Five studies were included in the review dating 2003-2015. Two studies used questionnaires, and three used focus groups/semistructured interviews. Key findings identified across all studies were consultants generally found teaching undergraduate medical students enjoyable, and consultants identified time constraints as a barrier to teaching. Other findings were consultants feeling there was a lack of recognition for time spent teaching, and a lack of training/guidance regarding teaching students. CONCLUSIONS: This is the first systematic review to explore senior hospital doctors' attitudes towards teaching undergraduate medical students. Despite these five studies spanning 12 years, the same attitudes and issues regarding teaching are identified by all, suggesting lack of time particularly is a persistent problem regarding consultant-based teaching. An anecdotal impression is that consultants are no longer as enthusiastic about teaching as they once were, but it is evident over the 12 years of these studies that enjoyment levels, and presumably enthusiasm, have not changed significantly.

The Food provision, cUlture and Environment in secondary schooLs (FUEL) study: protocol of a mixed methods evaluation of national School Food Standards implementation in secondary schools and their impact on pupils' dietary intake and dental health.

INTRODUCTION: Excess free sugar intake is associated with obesity and poor dental health. Adolescents consume substantially more free sugar than is recommended. National (UK) School Food Standards (SFS) are in place but are not mandatory in all schools, and their impact on the diets of secondary school pupils is unknown. We aim to evaluate how SFS and wider healthy eating recommendations (from the national School Food Plan (SFP)) are implemented in secondary schools and how they influence pupils' diets and dental health. METHODS AND ANALYSIS: Secondary-level academies/free schools in the West Midlands, UK were divided into two groups: SFS mandated and SFS non-mandated. Using propensity scores to guide sampling, we aim to recruit 22 schools in each group. We will compare data on school food provision and sales, school food culture and environment, and the food curriculum from each group, collected through: school staff, governor, pupil, parent surveys; school documents; and observation. We will explore the implementation level for the SFS requirements and SFP recommendations and develop a school food typology. We aim to recruit 1980 pupils aged 11-15 years across the 44 schools and collect dietary intake (24-hour recall) and dental health data through self-completion surveys. We will compare free sugar/other dietary intake and dental health across the two SFS groups and across the identified school types. School type will be further characterised in 4-8 case study schools through school staff interviews and pupil focus groups. Evaluation of economic impact will be through a cost-consequence analysis and an exploratory cost-utility analysis. ETHICS AND DISSEMINATION: Ethical approval was obtained from the University of Birmingham Ethical Review Committee (ERN_18-1738). Findings will be disseminated to key national and local agencies, schools and the public through reports, presentations, the media and open access publications. TRIAL REGISTRATION NUMBER: ISRCTN 68757496 (registered 17 October 2019).

Cultural adaptation of an existing children's weight management programme: the CHANGE intervention and feasibility RCT.

BACKGROUND: Excess weight in children is a continuing health issue. Community-based children's weight management programmes have had some effect in promoting weight loss. Families from minority ethnic communities are less likely to complete these programmes but, to date, no programmes have been culturally adapted to address this. OBJECTIVES: We aimed to (1) culturally adapt an existing weight management programme for children aged 4-11 years and their families to make it more suited to Pakistani and Bangladeshi communities but inclusive of all families and (2) evaluate the adapted programme to assess its feasibility and acceptability, as well as the feasibility of methods, for a future full-scale trial. DESIGN: In phase I, a cultural adaptation of a programme that was informed by formative research and guided by two theoretical frameworks was undertaken and in phase II this adapted programme was delivered in a cluster-randomised feasibility study (for which the clusters were the standard and adapted children's weight management programmes). SETTING: Birmingham: a large, ethnically diverse UK city. PARTICIPANTS: In phase I, Pakistani and Bangladeshi parents of children with excess weight, and, in phase II, children aged 4-11 years who have excess weight and their families. INTERVENTIONS: A culturally adapted children's weight management programme, comprising six sessions, which was delivered to children and parents, targeting diet and physical activity and incorporating behaviour change techniques, was developed in phase I and delivered in the intervention arm to 16 groups in phase II. The eight groups in the comparator arm received the standard (unadapted) children's weight management programme. MAIN OUTCOME MEASURES: The primary outcome was the proportion of Pakistani and Bangladeshi families completing (attending ≥ 60% of) the adapted programme. Secondary outcomes included the proportion of all families completing the adapted programme, the feasibility of delivery of the programme, the programme's acceptability to participants, the feasibility of trial processes and the feasibility of collection of outcome and cost data. RESULTS: The proportion of Pakistani and Bangladeshi families and all families completing the adapted programme was 78.8% [95% confidence interval (CI) 64.8% to 88.2%] and 76.3% (95% CI 67.0% to 83.6%), respectively. The programme was feasible to deliver with some refinements and was well received. Ninety-two families participated in outcome data collection. Data collection was mostly feasible, but participant burden was high. Data collection on the cost of programme delivery was feasible, but costs to families were more challenging to capture. There was high attrition over the 6-month follow-up period (35%) and differential attrition in the two study arms (29% and 52% in the intervention and comparator arms, respectively). LIMITATIONS: The study was not designed to address the issue of low participant uptake of children's weight management programmes. The design of a future trial may include individual randomisation and a 'minimal intervention' arm, the acceptability of which has not been evaluated in this study. CONCLUSIONS: The theoretically informed, culturally adapted children's weight management programme was highly acceptable to children and families of all ethnicities. Consideration should be given to a future trial to evaluate clinical effectiveness and cost-effectiveness of the adapted programme, but the design of a future trial would need to address the logistics of data collection, participant burden and study attrition. TRIAL REGISTRATION: Current Controlled Trials ISRCTN81798055. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 23, No. 33. See the NIHR Journals Library website for further project information. Kate Jolly is part-funded by the Collaboration for Leadership in Applied Health Research and Care West Midlands.

Many programmes have been designed for children with excess weight and their families to help them try and lose weight. Often families start going to these programmes but do not complete them. This has been noted to be an issue in families from ethnic minority communities. We aimed to adapt an existing programme for families of primary school children with excess weight to make it more suitable for Pakistani and Bangladeshi families. We asked parents from these communities who had experience of the existing programme what they thought about it and what they would like to change. We used this information to help us adapt the existing programme. We also aimed to make the programme acceptable to families of all ethnicities. We then aimed to (1) test delivery of the adapted programme, (2) see whether or not it was acceptable to Pakistani and Bangladeshi families and families of other ethnicities and (3) test methods to be used in a future research study to determine whether or not the adapted programme helps children to lose weight and provides value for money. We asked parents and children who attended and the staff delivering the new programme for their views. A panel of Pakistani and Bangladeshi parents helped us to plan our study methods. The programme was successfully delivered and the parents, children and staff all enjoyed it. Overall, 76% of families from all ethnic backgrounds who started attending the programme completed it. This was substantially higher than the 58% of families who completed the standard (unadapted) programme. We identified several issues that we would need to take into account when designing a future study. These include making sure that the families taking part are not overburdened and that we take steps to make sure that as many families as possible are followed up until the end of the study.

Barriers to implementation of stratified care in primary biliary cholangitis: a scoping exercise.

Patients with primary biliary cholangitis (PBC) can be stratified into low-risk and high-risk groups based on their response to treatment. Newly published guidelines from the British Society of Gastroenterology suggest low-risk patients can be managed substantially in primary care. This represents a shift from existing practice and makes assumptions about service capacity and the willingness of both patients and health care practitioners (HCPs) to make this change. The aim of this paper is to identify possible barriers to the implementation of these new care pathways through review of the PBC-specific literature and by identifying the experiences of patients and HCPs managing a different condition with comparable patients and disease characteristics. Searches of MEDLINE, CINAHL and EMBASE were undertaken. Within the existing PBC literature there is little data surrounding stakeholder perspectives on place of care. Review of the breast cancer literature highlights a number of barriers to change including primary care practitioner knowledge and work load, communication between healthcare settings, and the significance of the established doctor-patient relationship. Further research is needed to establish the extent to which these barriers may surface when changing PBC care pathways, and the actions required to overcome them.

Cultural adaptation of a children's weight management programme: Child weigHt mANaGement for Ethnically diverse communities (CHANGE) study.

BACKGROUND: Childhood obesity prevalence continues to be at high levels in the United Kingdom (UK). South Asian children (mainly Pakistani and Bangladeshi origin) with excess adiposity are at particular risk from the cardiovascular consequences of obesity. Many community-based children's weight management programmes have been delivered in the UK, but none have been adapted for diverse cultural communities. The aim of the Child weigHt mANaGement for Ethnically diverse communities (CHANGE) study, was to culturally adapt an existing children's weight management programme for children aged 4-11 years so that the programme was more able to meet the needs of families from South Asian communities. METHODS: The adaptation process was applied to First Steps, an evidence informed programme being delivered in Birmingham (a large, ethnically diverse city). A qualitative study was undertaken to obtain the views of South Asian parents of children with excess weight, who had fully or partially attended, or who had initially agreed but then declined to attend the First Steps programme. The resulting data were integrated with current research evidence and local programme information as part of a cultural adaptation process that was guided by two theoretical frameworks. RESULTS: Interviews or focus groups with 31 parents in their preferred languages were undertaken. Themes arising from the data included the need for convenient timing of a programme in a close familiar location, support for those who do not speak English, the need to focus on health rather than weight, nutritional content that focuses on traditional and Western diets, more physical activity content, and support with parenting skills. The data were mapped to the Behaviour Change Wheel framework and Typology of Cultural Adaptation to develop an intervention programme outline. The research evidence and local programme information was then used in the detailed planning of the programme sessions. CONCLUSIONS: The process of cultural adaptation of an existing children's weight management programme resulted in a theoretically underpinned programme that is culturally adapted at both the surface and deep structural levels. TRIAL REGISTRATION: ISRCTN81798055 , registered: 13/05/2014.

A conceptual framework for understanding the mechanism of action of community health workers services: the centrality of social support.

OBJECTIVE: To propose an empirically derived and theoretically-informed mechanism to explain how Community Health Workers (CHWs) bring about health gain in clients in England. METHODS: We undertook in-depth interviews (n = 43) with CHWs and service staff working in four case studies selected using maximum variation sampling. Interviewees were encouraged to talk about the service, how they had become involved with the service, the CHW role and relationship with clients. FINDINGS: We identified the provision of social support to be central to the mechanism of CHW-mediated health gain. Appropriate social support provision comprised three inter-related elements; needs assessment, social support delivery and client engagement. This mechanism is dependent on the personal characteristics of CHWs and of the roles they are employed or volunteer to carry out. CONCLUSION: A range of CHW characteristics can influence the social support process, but these are context-dependent and move beyond simple notions of CHW similarity to the client. This finding has important policy implications for the development and implementation of CHW services in high income countries with super-diverse populations.

A cluster-randomised feasibility trial of a children's weight management programme: the Child weigHt mANaGement for Ethnically diverse communities (CHANGE) study.

BACKGROUND: Community-based programmes for children with excess weight are widely available, but few have been developed to meet the needs of culturally diverse populations. We adapted an existing children's weight management programme, focusing on Pakistani and Bangladeshi communities. We report the evaluation of this programme to assess feasibility of programme delivery, acceptability of the programme to participants from diverse communities, and feasibility of methods to inform a future trial. METHODS: A cluster-randomised feasibility trial was undertaken in a large UK city. Children's weight management programmes (n = 24) were randomised to be delivered as the adapted or the standard programme (2:1 ratio). Routine data on participant attendance (n = 243) at the sessions were used to estimate the proportion of families completing the adapted and standard programmes (to indicate programme acceptability). Families planning to attend the programmes were recruited to participate in the feasibility study (n = 92). Outcome data were collected from children and parents at baseline, end of programme, and 6 months post-programme. A subsample (n = 24) of those attending the adapted programme participated in interviews to gain their views of the content and delivery and assess programme acceptability. Feasibility of programme delivery was assessed through observation and consultation with facilitators, and data on costs were collected. RESULTS: The proportion of Pakistani and Bangladeshi families and families of all ethnicities completing the adapted programme was similar: 78.8% (95% CI 64.8-88.2%) and 76.3% (95% CI 67.0-83.6%) respectively. OR for completion of adapted vs. standard programme was 2.40 (95% CI 1.32-4.34, p = 0.004). The programme was feasible to deliver with some refinements, and participant interview data showed that the programme was well received. Study participant recruitment was successful, but attrition was high (35% at 6 months). Data collection was mostly feasible, but participant burden was high. Data collection on cost of programme delivery was feasible, but costs to families were more challenging to capture. CONCLUSIONS: This culturally adapted programme was feasible to deliver and highly acceptable to participants, with increased completion rates compared with the standard programme. Consideration should be given to a future trial to evaluate its clinical and cost-effectiveness. TRIAL REGISTRATION: ISRCTN81798055, registered: 13/05/2014.

Effectiveness of a childhood obesity prevention programme delivered through schools, targeting 6 and 7 year olds: cluster randomised controlled trial (WAVES study).

OBJECTIVE: To assess the effectiveness of a school and family based healthy lifestyle programme (WAVES intervention) compared with usual practice, in preventing childhood obesity. DESIGN: Cluster randomised controlled trial. SETTING: UK primary schools from the West Midlands. PARTICIPANTS: 200 schools were randomly selected from all state run primary schools within 35 miles of the study centre (n=980), oversampling those with high minority ethnic populations. These schools were randomly ordered and sequentially invited to participate. 144 eligible schools were approached to achieve the target recruitment of 54 schools. After baseline measurements 1467 year 1 pupils aged 5 and 6 years (control: 28 schools, 778 pupils) were randomised, using a blocked balancing algorithm. 53 schools remained in the trial and data on 1287 (87.7%) and 1169 (79.7%) pupils were available at first follow-up (15 month) and second follow-up (30 month), respectively. INTERVENTIONS: The 12 month intervention encouraged healthy eating and physical activity, including a daily additional 30 minute school time physical activity opportunity, a six week interactive skill based programme in conjunction with Aston Villa football club, signposting of local family physical activity opportunities through mail-outs every six months, and termly school led family workshops on healthy cooking skills. MAIN OUTCOME MEASURES: The protocol defined primary outcomes, assessed blind to allocation, were between arm difference in body mass index (BMI) z score at 15 and 30 months. Secondary outcomes were further anthropometric, dietary, physical activity, and psychological measurements, and difference in BMI z score at 39 months in a subset. RESULTS: Data for primary outcome analyses were: baseline, 54 schools: 1392 pupils (732 controls); first follow-up (15 months post-baseline), 53 schools: 1249 pupils (675 controls); second follow-up (30 months post-baseline), 53 schools: 1145 pupils (621 controls). The mean BMI z score was non-significantly lower in the intervention arm compared with the control arm at 15 months (mean difference -0.075 (95% confidence interval -0.183 to 0.033, P=0.18) in the baseline adjusted models. At 30 months the mean difference was -0.027 (-0.137 to 0.083, P=0.63). There was no statistically significant difference between groups for other anthropometric, dietary, physical activity, or psychological measurements (including assessment of harm). CONCLUSIONS: The primary analyses suggest that this experiential focused intervention had no statistically significant effect on BMI z score or on preventing childhood obesity. Schools are unlikely to impact on the childhood obesity epidemic by incorporating such interventions without wider support across multiple sectors and environments. TRIAL REGISTRATION: Current Controlled Trials ISRCTN97000586.

The West Midlands ActiVe lifestyle and healthy Eating in School children (WAVES) study: a cluster randomised controlled trial testing the clinical effectiveness and cost-effectiveness of a multifaceted obesity prevention intervention programme targeted at children aged 6-7 years.

BACKGROUND: Systematic reviews suggest that school-based interventions can be effective in preventing childhood obesity, but better-designed trials are needed that consider costs, process, equity, potential harms and longer-term outcomes. OBJECTIVE: To assess the clinical effectiveness and cost-effectiveness of the WAVES (West Midlands ActiVe lifestyle and healthy Eating in School children) study intervention, compared with usual practice, in preventing obesity among primary school children. DESIGN: A cluster randomised controlled trial, split across two groups, which were randomised using a blocked balancing algorithm. Schools/participants could not be blinded to trial arm. Measurement staff were blind to allocation arm as far as possible. SETTING: Primary schools, West Midlands, UK. PARTICIPANTS: Schools within a 35-mile radius of the study centre and all year 1 pupils (aged 5-6 years) were eligible. Schools with a higher proportion of pupils from minority ethnic populations were oversampled to enable subgroup analyses. INTERVENTIONS: The 12-month intervention encouraged healthy eating/physical activity (PA) by (1) helping teachers to provide 30 minutes of additional daily PA, (2) promoting 'Villa Vitality' (interactive healthy lifestyles learning, in an inspirational setting), (3) running school-based healthy cooking skills/education workshops for parents and children and (4) highlighting information to families with regard to local PA opportunities. MAIN OUTCOME MEASURES: The primary outcomes were the difference in body mass index z-scores (BMI-zs) between arms (adjusted for baseline body mass index) at 3 and 18 months post intervention (clinical outcome), and cost per quality-adjusted life-year (QALY) (cost-effectiveness outcome). The secondary outcomes were further anthropometric, dietary, PA and psychological measurements, and the difference in BMI-z between arms at 27 months post intervention in a subset of schools. RESULTS: Two groups of schools were randomised: 27 in 2011 (n = 650 pupils) [group 1 (G1)] and another 27 in 2012 (n = 817 pupils) [group 2 (G2)]. Primary outcome data were available at first follow-up (n = 1249 pupils) and second follow-up (n = 1145 pupils) from 53 schools. The mean difference (MD) in BMI-z between the control and intervention arms was -0.075 [95% confidence interval (CI) -0.183 to 0.033] and -0.027 (95% CI -0.137 to 0.083) at 3 and 18 months post intervention, respectively. The main analyses showed no evidence of between-arm differences for any secondary outcomes. Third follow-up included data on 467 pupils from 27 G1 schools, and showed a statistically significant difference in BMI-z (MD -0.20, 95% CI -0.40 to -0.01). The mean cost of the intervention was £266.35 per consented child (£155.53 per child receiving the intervention). The incremental cost-effectiveness ratio associated with the base case was £46,083 per QALY (best case £26,804 per QALY), suggesting that the intervention was not cost-effective. LIMITATIONS: The presence of baseline primary outcome imbalance between the arms, and interschool variation in fidelity of intervention delivery. CONCLUSIONS: The primary analyses show no evidence of clinical effectiveness or cost-effectiveness of the WAVES study intervention. A post hoc analysis, driven by findings at third follow-up, suggests a possible intervention effect, which could have been attenuated by baseline imbalances. There was no evidence of an intervention effect on measures of diet or PA and no evidence of harm. FUTURE WORK: A realist evidence synthesis could provide insights into contextual factors and strategies for future interventions. School-based interventions need to be integrated within a wider societal framework and supported by upstream interventions. TRIAL REGISTRATION: Current Controlled Trials ISRCTN97000586. FUNDING: This project was funded by the National Institute for Health Research (NIHR) Health Technology Assessment programme and will be published in full in Health Technology Assessment; Vol. 22, No. 8. See the NIHR Journals Library website for further project information.

Who are community health workers and what do they do? Development of an empirically derived reporting taxonomy.

Objectives: To develop an empirically-informed reporting taxonomy for Community Health Worker (CHW) services to address concerns about the transparency and consistency of descriptions of these interventions in the existing literature. Methods: We undertook in-depth interviews (n = 43) with CHWs and service staff working in four case studies selected using maximum variation sampling. Interviewees were encouraged to talk about the service, how they had become involved with the service, the CHW role and relationship with clients. Results: Thematic analysis identified recurrent cross-case observations which we classed as 'who CHW are' and 'what CHW do'. CHW's personal characteristics comprised the sub-groups knowledge and skills, personal qualities, similarity to client and voluntary/paid status; role characteristics comprised time and continuity, settings, limited responsibility, core task and enacted philosophies. Conclusions: We have developed a conceptual framework for reporting CHW interventions based on the existing literature and our own empirical work. Compared with existing work in the field, the taxonomy uses nomenclature that minimizes current overlap and confusion, and provides a more complete description of CHW characteristics.

Measuring the impact of Health Trainers Services on health and health inequalities: does the service's data collection and reporting system provide reliable information?

Background: The Health Trainers Service is one of the few public health policies where a bespoke database-the Data Collection and Reporting System (DCRS)-was developed to monitor performance. We seek to understand the context within which local services and staff have used the DCRS and to consider how this might influence interpretation of collected data. Methods: In-depth case studies of six local services purposively sampled to represent the range of service provider arrangements, including detailed interviews with key stakeholders (n = 118). Results: Capturing detailed information on activity with clients was alien to many health trainers' work practices. This related to technical challenges, but it also ran counter to beliefs as to how a 'lay' service would operate. Interviewees noted the inadequacy of the dataset to capture all client impacts; that is, it did not enable them to input information about issues a client living in a deprived neighbourhood might experience and seek help to address. Conclusions: The utility of the DCRS may be compromised both by incomplete ascertainment of activity and by incorrect data inputted by some Health Trainers. The DCRS is also underestimate the effectiveness of work health trainers have undertaken to address 'upstream' factors affecting client health.

Development of a practice framework for improving nurses' responses to intimate partner violence.

AIMS AND OBJECTIVES: The aim of this article is to discuss critically the theoretical concepts of awareness, recognition and empowerment as manifested in intimate partner violence and to show how these can be translated into a practice framework for improving nurses' response. BACKGROUND: Intimate partner violence is a universal problem and is considered a significant public health issue. Nurses are in an ideal position to recognise and respond to intimate partner violence, but many lack confidence in this area of practice. In our previous empirical work, we identified three concepts through which nurses' responses to intimate partner violence can be understood: awareness, recognition and empowerment. In this article, we advance nursing knowledge by showing how these concepts can form a practice framework to improve nurses' responses to intimate partner violence. DESIGN: A discussion paper and development of a practice framework to improve nurses' responses to intimate partner violence. DISCUSSION: The framework comprises three principal needs of women and three related key requirements for nurses to meet these needs. Arising from these are a range of practice outcomes: enhanced understanding of intimate partner violence, increased confidence in recognising intimate partner violence, establishment of trusting relationships, increased likelihood of disclosure and optimised safety. CONCLUSIONS: Nurses sometimes lack confidence in recognising and responding to intimate partner violence. Awareness, recognition and empowerment are important concepts that can form the basis of a framework to support them. When nurses feel empowered to respond to intimate partner violence, they can work together with women to optimise their safety. RELEVANCE TO CLINICAL PRACTICE: Access to adequate and timely intimate partner violence education and training is important in improving nurses' responses to intimate partner violence. Getting this right can lead to enhanced safety planning and better health outcomes for women who experience intimate partner violence. Although difficult to measure as an outcome, nurses' improved responses can contribute to higher rates of referral for help and reduction in intimate partner violence rates.

Cultural adaptation of a children's weight management programme for Bangladeshi and Pakistani families in the UK: a cluster-randomised feasibility study protocol.

BACKGROUND: Group-based children's weight management programmes are widely available in the UK and evidence shows that these are effective in the short-term. No programmes have been specifically developed to meet the cultural requirements of UK minority ethnic communities. South Asian children are a high-risk group for obesity and its consequences; therefore, the study aim is to adapt an existing weight management programme for children aged 4-11 years and their families to ensure cultural relevance to Pakistani and Bangladeshi communities, and undertake a feasibility study of the adapted programme. METHODS/DESIGN: Pakistani and Bangladeshi families of overweight children who have been offered the existing children's weight management programme in Birmingham, UK, will be invited to interviews and focus groups to explore their experiences and views of the programme. These data, together with existing literature and service provider information, will inform adaptation of the programme to be more culturally relevant to these families. The feasibility study will employ a cluster-randomised design, and will assess success of programme adaptation and feasibility of programme delivery. Planned programmes will be randomised to be delivered as the adapted programme (intervention) or the standard programme (comparator) with a 2:1 ratio. The primary outcome will be the proportion of Pakistani and Bangladeshi families completing the adapted programme. To assess recruitment, retention and data collection methods to inform a future trial, we aim to recruit 80 participants. A range of assessments will be undertaken with participants pre-, post- and 6-months post-intervention. DISCUSSION: This study addresses the identified need to provide children's weight management programmes that are suitable for minority ethnic communities. Whilst the focus of the intervention adaptation is on Pakistani and Bangladeshi communities, the programme will be developed to be flexibly delivered to meet the cultural needs of communities of all ethnic compositions. The feasibility study will directly compare the adapted and existing weight management programmes, and will enable a comprehensive evaluation of the success of the adaptation. Essential information will also be gathered to inform the design and sample size calculation of a future trial to evaluate intervention effectiveness. TRIAL REGISTRATION: ISRCTN81798055, registered: 13/05/2014.

Longitudinal assessment of the impact of the use of the UK clinical aptitude test for medical student selection.

CONTEXT: Medical schools are increasingly using novel tools to select applicants. The UK Clinical Aptitude Test (UKCAT) is one such tool and measures mental abilities, attitudes and professional behaviour conducive to being a doctor using constructs likely to be less affected by socio-demographic factors than traditional measures of potential. Universities are free to use UKCAT as they see fit but three broad modalities have been observed: 'borderline', 'factor' and 'threshold'. This paper aims to provide the first longitudinal analyses assessing the impact of the different uses of UKCAT on making offers to applicants with different socio-demographic characteristics. METHODS: Multilevel regression was used to model the outcome of applications to UK medical schools during the period 2004-2011 (data obtained from UCAS), adjusted for sex, ethnicity, schooling, parental occupation, educational attainment, year of application and UKCAT use (borderline, factor and threshold). RESULTS: The three ways of using the UKCAT did not differ in their impact on making the selection process more equitable, other than a marked reversal for female advantage when applied in a 'threshold' manner. Our attempt to model the longitudinal impact of the use of the UKCAT in its threshold format found again the reversal of female advantage, but did not demonstrate similar statistically significant reductions of the advantages associated with White ethnicity, higher social class and selective schooling. CONCLUSION: Our findings demonstrate attenuation of the advantage of being female but no changes in admission rates based on White ethnicity, higher social class and selective schooling. In view of this, the utility of the UKCAT as a means to widen access to medical schools among non-White and less advantaged applicants remains unproven.