Are school uniforms associated with gender inequalities in physical activity? A pooled analysis of population-level data from 135 countries/regions.

PURPOSE: It is aimed to assess whether school uniforms are associated with population-level gender inequalities in physical activity, and whether associations differ by school level, country/region income, and assessment method. METHODS: An ecological study design was employed. We collected data about global uniform practices using an online survey. We searched for country/region-level estimates of school-aged youth meeting physical activity guidelines from international surveillance studies. Study selection was conducted in duplicate using a systematic process, and a random sample of all data was checked to ensure extraction and pooling processes were accurate. We calculated absolute and relative gender inequalities in physical activity for each country. Linear regression examined associations between country/region-level uniform practices (binary yes/no exposure variable) and country/region-level gender inequalities in physical activity guideline compliance (absolute and relative inequalities). We investigated moderation by school level, stratified analyses by income group, and repeated primary analyses using device-measured data. RESULTS: Pooling data from 135 countries/regions (n = 1,089,852), we found no association between population-level uniform practices and gender inequalities in physical activity across all ages (absolute: ß = -0.2; 95% confidence interval (95%CI): -1.7 to 1.3, p = 0.74; relative: ß = 0.1; 95%CI: -0.1 to 0.2, p = 0.51). Subgroup analysis suggested a positive association in primary school settings (absolute: ß = 4.3; 95%CI: -0.0 to 8.6, p = 0.05). Among high-income countries, absolute inequalities were significantly greater in countries/regions with uniform practices (N = 37) compared to those without (N = 48) (9.1 (SD = 3.6) vs. 7.8 percentage points (SD = 4.3)). Repeating analyses using device-measured data (n = 32,130; N = 24) did not alter our primary finding. From initial descriptive statistics, we found that in countries/regions where a majority of schools (>50%) reportedly use uniforms, there was lower compliance with physical activity guidelines among all genders (median: 16.0%, interquartile range: 13.2%-19.9%, N = 103) compared to generally non-uniform countries/regions (median: 19.5%, interquartile range: 16.4%-23.5%, N = 32) (z = 3.04, p = 0.002). (N = countries, regions and studies represented; n = sample size or participants included). CONCLUSION: School uniforms are associated with greater gender inequalities in physical activity in primary school settings and in high-income countries. Our population-level findings warrant testing using individual-level data across contexts.

Incomplete reporting of complex interventions: a call to action for journal editors to review their submission guidelines.

Reporting of intervention research has been inadequate for many years. The development and promotion of freely available checklists aims to address this problem by providing researchers with a list of items that require reporting to enable study interpretation and replication. In this commentary, we present evidence from a recent systematic review of 51 randomised controlled trials published 2015-2020 that inadequate intervention reporting remains a widespread issue and that checklists are not being used to describe all intervention components. In 2022, we assessed the submission guidelines of 33 journals that published articles included in our review and found that just one at the time encouraged the use of reporting checklists for all intervention components. To drive progress, we contacted the editors of the other 32 journals and requested that they update their submission guidelines in response. We conclude by highlighting the waste associated with current practices and encourage journals from all fields to urgently review their submission guidelines. Only through collective action can we build an evidence base that is fit for purpose.

Features of effective staff training programmes within school-based interventions targeting student activity behaviour: a systematic review and meta-analysis.

BACKGROUND: Evaluations of school-based activity behaviour interventions suggest limited effectiveness on students' device-measured outcomes. Teacher-led implementation is common but the training provided is poorly understood and may affect implementation and student outcomes. We systematically reviewed staff training delivered within interventions and explored if specific features are associated with intervention fidelity and student activity behaviour outcomes. METHODS: We searched seven databases (January 2015-May 2020) for randomised controlled trials of teacher-led school-based activity behaviour interventions reporting on teacher fidelity and/or students' device-measured activity behaviour. Pilot, feasibility and small-scale trials were excluded. Study authors were contacted if staff training was not described using all items from the Template for Intervention Description and Replication reporting guideline. Training programmes were coded using the Behaviour Change Technique (BCT) Taxonomy v1. The Effective Public Health Practice Project tool was used for quality assessment. Promise ratios were used to explore associations between BCTs and fidelity outcomes (e.g. % of intended sessions delivered). Differences between fidelity outcomes and other training features were explored using chi-square and Wilcoxon rank-sum tests. Random-effects meta-regressions were performed to explore associations between training features and changes in students' activity behaviour. RESULTS: We identified 68 articles reporting on 53 eligible training programmes and found evidence that 37 unique teacher-targeted BCTs have been used (mean per programme = 5.1 BCTs; standard deviation = 3.2). The only frequently identified BCTs were 'Instruction on how to perform the behaviour' (identified in 98.1% of programmes) and 'Social support (unspecified)' (50.9%). We found moderate/high fidelity studies were significantly more likely to include shorter (≤6 months) and theory-informed programmes than low fidelity studies, and 19 BCTs were independently associated with moderate/high fidelity outcomes. Programmes that used more BCTs (estimated increase per additional BCT, d: 0.18; 95% CI: 0.05, 0.31) and BCTs 'Action planning' (1.40; 0.70, 2.10) and 'Feedback on the behaviour' (1.19; 0.36, 2.02) were independently associated with positive physical activity outcomes (N = 15). No training features associated with sedentary behaviour were identified (N = 11). CONCLUSIONS: Few evidence-based BCTs have been used to promote sustained behaviour change amongst teachers in school-based activity behaviour interventions. Our findings provide insights into why interventions may be failing to effect student outcomes. TRIAL REGISTRATION: PROSPERO registration number: CRD42020180624.

Professional learning, organisational change and clinical leadership development outcomes.

INTRODUCTION: The aim of this study is to develop a conceptually sound outcome model for clinical leadership (CL) development in healthcare, linking individual professional learning and organisational change. Frontline doctors' CL is often offered as a solution to healthcare challenges worldwide. However, there is a paucity of rigorous evidence of effectiveness of CL development, or theories supporting it. Importantly, the literature currently lacks robust outcome models for CL development, impeding robust impact evaluations. METHODS: This multi-source, sequential integrated mixed-methods study draws on systematic content analysis of NHS policy documents and empirical data from a CL programme evaluation study: exploratory factor analysis (EFA) of 142 participants' survey responses and thematic qualitative analysis of 30 in-depth participant interviews across six cohorts. Through integrating findings from the three analyses we examine: (a) the expected organisational outcomes of CL, (b) individual learning outcomes of CL development, and (c) the mechanisms linking the two. RESULTS: The policy analysis identified three desired solutions to key healthcare problems which CL is expected to offer: Speeding up good practice, Inter-professional collaboration and dialogue, and Change and transformation. Triangulating the EFA results with the qualitative analysis produced five individual outcome constructs: Self-efficacy, Engaging stakeholders, Agency, Boundary-crossing expertise, and Willingness to take risks and to learn from risks and failures. Further qualitative analysis uncovered key mechanisms linking the individual outcomes with the desired organisational changes. DISCUSSION: Despite significant investments into CL development in the UK and worldwide, the absence of conceptually robust and operationally specific outcome models linking individual and organisational impact impedes rigorous evaluations of programme effectiveness. Our study developed a novel individual and organisational outcome model including a theory of change for clinical leadership. Our findings further contribute to professional learning theory in medical settings by conceptualising and operationalising the mechanisms operating between individual and organisational learning outcomes.

Stereoscopic Three-Dimensional Neuroanatomy Lectures Enhance Neurosurgical Training: Prospective Comparison with Traditional Teaching.

OBJECTIVE: Stereoscopic three-dimensional (3D) imaging is increasingly used in the teaching of neuroanatomy and although this is mainly aimed at undergraduate medical students, it has enormous potential for enhancing the training of neurosurgeons. This study aims to assess whether 3D lecturing is an effective method of enhancing the knowledge and confidence of neurosurgeons and how it compares with traditional two-dimensional (2D) lecturing and cadaveric training. METHODS: Three separate teaching sessions for neurosurgical trainees were organized: 1) 2D course (2D lecture + cadaveric session), 2) 3D lecture alone, and 3) 3D course (3D lecture + cadaveric session). Before and after each session, delegates were asked to complete questionnaires containing questions relating to surgical experience, anatomic knowledge, confidence in performing procedures, and perceived value of 3D, 2D, and cadaveric teaching. RESULTS: Although both 2D and 3D lectures and courses were similarly effective at improving self-rated knowledge and understanding, the 3D lecture and course were associated with significantly greater gains in confidence reported by the delegates for performing a subfrontal approach and sylvian fissure dissection. CONCLUSIONS: Stereoscopic 3D lectures provide neurosurgical trainees with greater confidence for performing standard operative approaches and enhances the benefit of subsequent practical experience in developing technical skills in cadaveric dissection.

Methodological shortcomings in the literature evaluating the role and applications of 3D training for surgical trainees.

AIM: There has been an increased interest in the use of three-dimensional (3D) technology in surgical training. We wish to appraise the methodological rigor applied to evaluating the role and applications of 3D technology in surgical training, in particular, on the validity of these models and assessment methods in simulated surgical training. METHODS: Literature search was performed using MEDLINE with the following terms: "3D"; "surgery"; and "training". Only studies evaluating the role of 3D technology in surgical training were eligible for inclusion and assessed for the level of evidence, validity of the simulation model, and assessment method used. RESULTS: A total of 93 studies were analyzed, and majority of reviewed articles focused on 3D displays (36) and 3D printing (35). Most of these studies were case series, the most common assessment was subjective (69), with objective assessment used by 57 studies. Very few studies provided evidence for validity of the model or the assessment methods used. CONCLUSIONS: 3D technology has a great potential in simulated surgical training. However, the validity of this technology and strong evidence for its beneficial effects in surgical training is lacking. Further work on validation of 3D technology and assessment tools is needed.

The Effect of 3-Dimensional Simulation on Neurosurgical Skill Acquisition and Surgical Performance: A Review of the Literature.

OBJECTIVE: In recent years, 3-dimensional (3D) simulation of neurosurgical procedures has become increasingly popular as an addition to training programmes. However, there remains little objective evidence of its effectiveness in improving live surgical skill. This review analysed the current literature in 3D neurosurgical simulation, highlighting remaining gaps in the evidence base for improvement in surgical performance and suggests useful future research directions. DESIGN: An electronic search of the databases was conducted to identify studies investigating 3D virtual reality (VR) simulation for various types of neurosurgery. Eligible studies were those that used a combination of metrics to measure neurosurgical skill acquisition on a simulation trainer. Studies were excluded if they did not measure skill acquisition against a set of metrics or if they assessed skills that were not used in neurosurgical practice. This was not a systematic review however, the data extracted was tabulated to allow comparison between studies RESULTS: This study revealed that the average overall quality of the included studies was moderate. Only one study assessed outcomes in live surgery, while most other studies assessed outcomes on a simulator using a variety of metrics. CONCLUSIONS: It is concluded that in its current state, the evidence for 3D simulation suggests it as a useful supplement to training programmes but more evidence is needed of improvement in surgical performance to warrant large-scale investment in this technology.