The Exeter Activity Unlimited statement on physical activity and exercise for cystic fibrosis: methodology and results of an international, multidisciplinary, evidence-driven expert consensus.

BACKGROUND: The roles of physical activity (PA) and exercise within the management of cystic fibrosis (CF) are recognised by their inclusion in numerous standards of care and treatment guidelines. However, information is brief, and both PA and exercise as multi-faceted behaviours require extensive stakeholder input when developing and promoting such guidelines. METHOD: On 30th June and 1st July 2021, 39 stakeholders from 11 countries, including researchers, healthcare professionals and patients participated in a virtual conference to agree an evidence-based and informed expert consensus about PA and exercise for people with CF. This consensus presents the agreement across six themes: (i) patient and system centred outcomes, (ii) health benefits, iii) measurement, (iv) prescription, (v) clinical considerations, and (vi) future directions. The consensus was achieved by a stepwise process, involving: (i) written evidence-based synopses; (ii) peer critique of synopses; (iii) oral presentation to consensus group and peer challenge of revised synopses; and (iv) anonymous voting on final proposed synopses for adoption to the consensus statement. RESULTS: The final consensus document includes 24 statements which surpassed the consensus threshold (>80% agreement) out of 30 proposed statements. CONCLUSION: This consensus can be used to support health promotion by relevant stakeholders for people with CF.

Children's perspectives and experiences of the COVID-19 pandemic and UK public health measures.

BACKGROUND: The COVID-19 pandemic has had profound impacts on how we live our lives; yet, the implications for children and the effects on children's everyday lives have been relatively underacknowledged. Understanding children's views on COVID-19 and related restrictions on their lives provides an important opportunity to understand how children have responded to the pandemic, including the impacts on their social and emotional well-being. OBJECTIVE: This study explored the experiences and perspectives of children in relation to the COVID-19 pandemic and related restrictions on everyday life. METHOD: A qualitative study using semistructured online interviews with participatory drawings was undertaken between May and July 2020. Eighteen children from England and Wales, aged 7-11 years, participated in interviews. FINDINGS: Themes included children's reflections on (1) COVID-19 as a deadly contagion; (2) fears and sadness and (3) social responsibility and opportunities to respond positively. CONCLUSIONS: Young children offer insightful reflections on their experiences during the first wave of the COVID-19 pandemic in the United Kingdom. Children and young people's perspectives must be considered in future public health discourse. PATIENT OR PUBLIC CONTRIBUTION: This work was informed by conversations with my own three primary school-aged children and the children of friends. A formal Patient and Public Involvement (PPI) group was not established due to the speed with which the project was undertaken. Any future research in this area would benefit from formal PPI in the design, methods and questions.

Creating play opportunities on the school playground: Educator experiences of the Sydney playground project.

INTRODUCTION: Children with disabilities often experience unsupportive environments that restrict their play opportunities and inclusion on the school playground. This exclusion can perpetuate inequities for children with disabilities, with lifelong implications. The Sydney Playground Project uses a simple, innovative intervention consisting of placing recycled materials on the playground and engaging parents and educators in risk reframing sessions to create increased playground choice, control, independence and inclusion for all children. METHODS: The purpose of this study was to learn from participants about the utility of the intervention for promoting choice and control among children with disability on the school playground. Data included evaluative interviews with 27 school staff (teaching assistants, teachers, therapists, school leadership) across five participating schools after completing of the intervention. Analysis was thematic and explored prominent ideas first within schools, and then between schools. RESULTS: Prior to the intervention, participating school staff focused on active supervision to support play and student needs. During the intervention, school staff experienced role shift and confusion as they allowed the children increased independence while using the recycled materials and learned to navigate how much independence to give the children. Children engaged in increased imaginative and social play, and school staff adopted higher expectations of children's capabilities. CONCLUSION: Interventions such as the Sydney Playground Project that collaboratively shift adult perceptions to focus on the capabilities of children with disabilities and increase the supportiveness of the physical environment have great promise in increasing play choice and inclusion on the school playground.

Sustainable development goals for health promotion: a critical frame analysis.

The Sustainable Development Goals (SDGs) lay the foundations for supporting global health and international development work for the next 15 years. Thirty years ago, the Ottawa Charter defined health promotion and outlined key principles for global action on health, including the importance of advocating, enabling and mediating for health equity. Advocacy underscores a human right to health and suggests political action to support its attainment. Enabling speaks to health promotion's focus on the empowerment of people and communities to take control over their health and aspirations. Mediation draws attention to the critical intersectoral partnerships required to address health and social inequities. Underpinned by this approach, the aim of this paper is to consider how key health promotion principles, namely, rights, empowerment and partnership feature (and are framed) within the SDGs and to consider how these framings may shape future directions for health promotion. To that end, a critical frame analysis of the Transforming Our World document was conducted. The analysis interrogated varying uses and meanings of partnerships, empowerment and rights (and their connections) within the SDGs. The analysis here presents three framings from the SDGs: (1) a moral code for global action on (in)equity; (2) a future orientation to address global issues yet devoid of history; and (3) a reductionist framing of health as the absence of disease. These framings raise important questions about the underpinning values of the SDGs and pathways to health equity - offering both challenges and opportunities for defining the nature and scope of health promotion.

The Sydney playground project--levelling the playing field: a cluster trial of a primary school-based intervention aiming to promote manageable risk-taking in children with disability.

BACKGROUND: Providing children and adults with opportunities to engage in manageable risk taking may be a stepping stone toward closing the gap in life conditions currently experienced by young people with disabilities. We aim to demonstrate the effectiveness of a simple, innovative program for 1) changing the way parents and teachers view manageable risk-taking for children with disabilities and 2) increasing the level of responsibility that children take for their own actions, as seen on the school playground. METHODS/DESIGN: We will employ a cluster repeated measures trial with six Sydney-area primary-school-based programs for children with disabilities. The intervention comprises two arms. 1) Risk-reframing--teachers and parents will participate together in small group intervention sessions focusing on the benefits of manageable risk-taking; 2) Introduction of play materials--materials without a defined purpose and facilitative of social cooperation will be introduced to the school playground for children to use at all break times. A control period will be undertaken first for two school terms, followed by two terms of the intervention period. Outcome measures will include playground observations, The Coping Inventory, qualitative field notes, and The Tolerance of Risk in Play Scale. DISCUSSION: New national programs, such as Australia's National Disability Insurance Scheme, will place increasing demands on young people with disabilities to assume responsibility for difficult decisions regarding procuring services. Innovative approaches, commencing early in life, are required to prepare young people and their carers for this level of responsibility. This research offers innovative intervention strategies for promoting autonomy in children with disabilities and their carers. TRIAL REGISTRATION: Australian and New Zealand Clinical Trials Registration Number ACTRN12614000549628 (registered 22/5/2014).

'Troubling' moments in health promotion: unpacking the ethics of empowerment.

ISSUE ADDRESSED: Concepts of empowerment feature strongly in global health discourses. Empowerment is frequently advocated as a positive approach to addressing individual and community-level health needs. Despite its popularity, relatively little has been said about the unintended consequences of empowerment, which may give rise to some troubling ethical issues or, indeed, result in outcomes that may not be considered health promoting. METHODS: Drawing on current uses of empowerment within health promotion, along with insights from an ethnographic study on young people's health, this paper raises some critical questions about the ethics of empowerment. By doing so, the paper troubles the idea that empowerment is a 'good thing' without some careful attention to the varying ways in which the ethics of empowerment may unfold in practice. RESULTS: Findings revealed young people's different perspectives on health and priorities for health promotion. The present analysis highlights how these alternative framings prompt a number of ethical tensions for understanding and operationalising empowerment. CONCLUSIONS: In conclusion, the findings underscore the importance of promoting ethical reflexivity in health promotion and, crucially, attending to the unintended and potentially ethically problematic consequences of empowerment. So what? This paper raises some critical questions about the ethics of empowerment and calls for a more thorough engagement with the unintended consequences of empowerment within health promotion.

The Health Experiences of Young Internal Migrants in Ghana-Identifying Priorities for Sustainable Health Promotion.

The Sustainable Development Goals underscore the importance of migration to the achievement of health, and global migration presents both opportunities and challenges for the development of health promotion. Despite such recognition, very little work has focused on health promotion with young migrants, including how migration shapes opportunities for positive health. This paper reports findings from a qualitative study that sought to advance knowledge of the health experiences of young internal migrants in Ghana (n = 14) and considers ways to harness these perspectives in the development of sustainable health promotion solutions. Methods included community consultations, participatory workshops and interviews with young migrants aged 14-21 years. Findings highlighted how the social determinants of health affected young migrants' opportunities to support their health. Our analysis highlights how a lack of access to adequate food, shelter and health services often resulted in the adoption of alternative health practices, including the use of herbal remedies. Supporting positive livelihoods as part of tackling the social determinants of health is crucial to mitigate the impacts of poverty and inequalities on young migrants' health practices and outcomes. We conclude by considering how to advance relevant health promotion with young migrants living in contexts of vulnerability.

A process evaluation of the Mind Your Back trial examining psychologically informed physical treatments for chronic low back pain.

BACKGROUND: In chronic conditions, such as back pain, the use of interventions that address physical, social and psychological aspects within a biopsychosocial framework are encouraged, however, applying this holistic multimodal approach in physical therapy practice (i.e., chiropractic and physiotherapy) is challenging. To explore the problem of delivering a biopsychosocially informed package of care in physical therapy practice a recent randomised control trial (RCT) called 'Mind Your Back' was conducted to evaluate the effectiveness of a combined physical and internet-delivered psychological intervention (psychologically informed physical treatments) compared to standard treatment for improving disability and self-efficacy in people with chronic LBP. The results of the trial indicated no difference between the two intervention groups. Although high-quality RCTs are considered gold standard for effectiveness of interventions, qualitative research methods embedded within a process evaluation framework are also used to reveal other issues and important information that help to explain clinical trial results, and to further the field of digital health interventions research. Therefore, within a process evaluation framework, the aim is to explore participants experiences of the interventions received throughout the Mind Your Back trial which led to a null result. METHODS: In-line with recommendations for a process evaluation this study used in-depth interviews and qualitative thematic analysis with participants of both arms of the trial 5-6 months after study completion. Semi-structured telephone interviews were conducted with twenty-five participants to explore their experiences of taking part in the Mind Your Back trial. Interviews were conducted in November 2017, transcribed verbatim and data analysed thematically. RESULTS: Two main themes were identified: (1) Personalised support and therapeutic alliance are important, and (2) MoodGYM lacked relevant, personalised and tailored support. CONCLUSION: It is important to deliver tailored digital health supports that is personalised and fosters a therapeutic alliance.

The agentic Self and uncontrollable body: Young people's management of chronic illness at university.

Young people's experiences of living with a long-term health condition have been largely investigated from the perspective of developing autonomy and optimal self-management of treatment regimens. Little existing research explores how young people adjust to the experience of chronic illness within everyday social contexts. Drawing on sociocultural theories of healthism, in this article, we examine the everyday strategies students employed to manage their health condition at university. Data were drawn from a qualitative study with 16 undergraduate students in Australia. Findings from interviews highlight how participants took up discourses of the (hard-working, diligent) Self to discursively position themselves as 'health conscious' and 'in control'. This positioning was maintained through separating the controlled Self from the (uncontrollable) body. The unpredictability of the body posed a threat to young people's abilities to maintain control and denied them opportunities to exercise personal agency. Yet, participants also described a number of subversive strategies in order to take back control and resist the experience of ill health. These potential agentic practices often held unintended consequences, including loss of optimal medical control or (self) exclusion from university life - offering new insights into the differing ways young people concomitantly take-up, rework and resist the pursuit of healthism to 'successfully' manage their health conditions.

Expectations and Assumptions: Examining the Influence of Staff Culture on a Novel School-Based Intervention to Enable Risky Play for Children with Disabilities.

Risky play is challenging, exciting play with the possibility of physical, social, or emotional harm. Through risky play, children learn, develop, and experience wellbeing. Children with disabilities have fewer opportunities than their typically developing peers to engage in this beneficial type of play. Our team designed a novel, school-based intervention to address this disparity; however, our intervention yielded unexpected quantitative results. In the present study, we qualitatively examined divergent results at two of the five schools that participated in the intervention. Specifically, we aimed to explore how staff culture (i.e., shared beliefs, values, and practices) influenced the intervention. To explore this relationship, we employed a retrospective, qualitative, multiple case study. We used thematic analysis of evaluative interviews with staff members to elucidate the cultures at each school. Then, we used cross-case analysis to understand the relationships between aspects of staff culture and the intervention's implementation and results. We found that staff cultures around play, risk, disability influenced the way, and the extent to which, staff were willing to let go and allowed children to engage in risky play. Adults' beliefs about the purpose of play and recess, as well as their expectations for children with disabilities, particularly influenced the intervention. Furthermore, when the assumptions of the intervention and the staff culture did not align, the intervention could not succeed. The results of this study highlight the importance of (1) evaluating each schools' unique staff culture before implementing play-focused interventions and (2) tailoring interventions to meet the needs of individual schools.

Promoting the health of children and young people who migrate: reflections from four regional reviews.

Calls to enhance the health of migrant population sub-groups are strengthening, with increasing evidence documenting the relationship between migration and health outcomes. Despite the importance of migration to global health promotion, little research has focused on the health experiences of young migrants. As part of a Worldwide University Network project, we completed four systematic reviews examining the existing evidence base on the health experiences of children and young people who migrate. In this commentary, we share commonalities with the international evidence but also reflect on some of the challenges, omissions and limitations. These insights expose significant gaps and methodological shortcomings in the evidence - providing space for new research that seeks to identify the influences on migrant children's health.

Young people and health: towards a new conceptual framework for understanding empowerment.

In recent times, empowerment has become the focus of much work with young people amidst increasing concerns about their health. Empowerment is often offered as a 'solution' to such concerns, with the uncritical assumption being made that empowerment unproblematically results in positive health outcomes. While much of the health promotion literature advocates 'empowerment', it often does so without offering a clear conceptualisation of the word itself or indeed addressing the thorny theoretical tensions surrounding the concept's root word of power. In light of this omission, this article offers a more theoretically informed conceptualisation of empowerment and considers the relationship to young people's health. This article outlines a more dynamic and generative conceptualisation of empowerment than hitherto articulated in the literature, informed by Lukes' multidimensional perspective of power. Drawing on findings from an ethnographic study on empowerment and young people's health, this article develops six conceptually distinct forms of empowerment (impositional, dispositional, concessional, oppositional, normative and transformative). Data were collected from 55 young men and women aged 15-16 years through group discussions, individual interviews and observational work in a school and surrounding community settings in England. Crucially, these six new forms of empowerment capture and synthesise individual, structural and ideological elements of power that differentially, and sometimes inconsistently, shape the possibilities for young people's empowerment. Of significance is the way in which these different forms of empowerment intersect to (re)produce relations of power and may offer different possibilities for health promotion.

Ethical and epistemological insights: a case study of participatory action research with young people.

Debates over how to determine age of consent for youth to participate in research feature prominently in the practice of researchers, research ethics boards (REBs), and community decision makers working with youth. In particular, tensions can arise over how the ethical principles of beneficence, autonomy, and justice are interpreted and applied in research involving young people. We discuss our experiences obtaining ethical approval to conduct a participatory action research project involving youth and the differences of opinion we encountered regarding underage youth's capability to make informed consent. We suggest that researchers, REBs, and community decision makers all share a responsibility to conduct proactive outreach to youth participants, so that they are adequately informed of their rights related to research.