Flexible bronchoscopy in pediatric lung transplantation.

Pediatric lung transplantation represents a treatment option for children with advanced lung disease or pulmonary vascular disorders who are deemed an appropriate candidate. Pediatric flexible bronchoscopy is an important and evolving field that is highly relevant in the pediatric lung transplant population. It is thus important to advance our knowledge to better understand how care for children after lung transplant can be maximally optimized using pediatric bronchoscopy. Our goals are to continually improve procedural skills when performing bronchoscopy and to decrease the complication rate while acquiring adequate samples for diagnostic evaluation. Attainment of these goals is critical since allograft assessment by bronchoscopic biopsy is required for histological diagnosis of acute cellular rejection and is an important contributor to establishing chronic lung allograft dysfunction, a common complication after lung transplant. Flexible bronchoscopy with bronchoalveolar lavage and transbronchial lung biopsy plays a key role in lung transplant graft assessment. In this article, we discuss the application of bronchoscopy in pediatric lung transplant evaluation including historical approaches, our experience, and future directions not only in bronchoscopy but also in the evolving pediatric lung transplantation field. Pediatric flexible bronchoscopy has become a vital modality for diagnosing lung transplant complications in children as well as assessing therapeutic responses. Herein, we review the value of flexible bronchoscopy in the management of children after lung transplant and discuss the application of novel techniques to improve care for this complex pediatric patient population and we provide a brief update about new diagnostic techniques applied in the growing lung transplantation field.

A systematic review of the use of the concept family resilience in interventions with families with children and young people.

OBJECTIVE: To review the evidence on using family resilience as a concept in interventions by public health nurses/health visitors with families with children and young people as part of an evaluation of the evidence base for the Family Resilience Assessment Instrument and Tool (FRAIT). FRAIT was developed by University faculty with Health Visitors and a Community of Practice in Wales, and is used by Health Visitors in Wales with families with children under 5 years to assess family resilience. METHOD: A standard Cochrane Systematic Review methodology was used to review published literature. A protocol (crd.york.ac.uk/PROSPERO/display_record.php?RecordID = 230845) was submitted to Prospero in September 2021, and reviewing began in January 2022. Title and abstract searching were undertaken 12 databases and results were captured using PRISMA and Excel spreadsheet. Second reviewers reviewed title and abstract screening, and full-text extraction. RESULTS: Initial title screening brought back 1350 papers across 12 databases. Titles and abstract screening reduced these to 106, 44 papers were considered for full-text extraction, with 25 papers included for review. DISCUSSION: Results demonstrated a focus on specific demographics, and use of family resilience with families living with specific health problems. Existing family resilience scales showed improved results in selected specific demographic groups, albeit in a reactive way. FRAIT has originality within the literature as it is used in a universal, preventative way with all families regardless of demographic or health issues. There is evidence to show that using a family resilience program in this way has originality and implications for the physical and mental health of children and young people. NO PATIENT OR PUBLIC CONTRIBUTION: This was a systematic review of existing literature so public or patient contribution would not have been appropriate.

Identifying barriers and facilitators to the inclusion of older adults living in UK care homes in research: a scoping review.

BACKGROUND: With an ageing population, older adults will have more complex health and social care needs and many of these older adults will be living in care homes. Despite the growth in care home populations, care home residents are often excluded from research that could potentially benefit their care. The purpose of this scoping review is to explore resident-related barriers and facilitators to including older people living in UK care homes in research and to identify potential approaches to modify such barriers. METHOD: The 6-stage scoping review methodology framework proposed by Arksey and O'Malley guided this review. Five electronic databases (MedLine, PsychINFO, Scopus, Web of Science, CINAHL) and grey literature were searched. Identified articles went through two levels of screening, and those deemed relevant were collated, summarised and reported using a thematic analysis approach. RESULTS: 90 reports were eligible for inclusion and were synthesised into 7 themes and related subthemes: (1) research design; (2) understanding and beliefs about research (resident and care home staff); (3) communication; (4) relationships; (5) eligibility criteria (resident and care home); (6) preference-based decisions; and (7) care home staff and environment. Given the complex interplay of the factors identified, both direct and indirect factors were included. CONCLUSIONS: A number of recurring barriers and facilitators to the inclusion of care home residents in research are reported. However, isolating resident-related barriers was complex as both direct and indirect factors must be considered as influential. Understanding the barriers and facilitators to inclusion will enable these factors to be addressed and increase the evidence-base for care provided to older people living in care homes.

Primary health care in the Amazon and its potential impact on health inequities: a scoping review.

INTRODUCTION: Health studies of the Amazon often focus on diseases and infections prevalent in the region, and few studies address health organizations and services. In this sense, this study fills a gap by reviewing the studies aimed at primary healthcare (PHC) implementation in the nine Amazonian countries. This review addresses a need to explore the forms in which PHC is implemented in the Amazon areas outside the urban centers and its potential to reduce health inequities. This study contributes to improvements in the practices of managers and health professionals and research on the topic. METHODS: Scoping review methodology was applied to peer-reviewed articles. The databases searched were PubMed, Scopus, Lilacs, Embase and Web of Science. Selected studies included peer-reviewed publications, published between January 2000 and November 2019, that focused on PHC or one of its components in the Amazon, and were published in English, Spanish and Portuguese. The study used Arksey and O'Malley's scoping review guidelines, supported by Levac, and included five steps: (i) identification phase, where search queries were applied to the databases followed by the removal of duplicates; (ii) screening phase, where titles and abstracts of articles were screened to exclude irrelevant articles; (iii) eligibility phase, where the full texts of articles were read to assess their relevancy to this study; (iv) data extraction, using a spreadsheet designed to capture relevant information required in this review, using an iterative process; (v) summarizing and classification of each article according to content. The second and third phases were conducted independently by two reviewers. If a disagreement arose between the reviewers, a third reviewer was consulted to help decide whether to include or exclude a study. RESULTS: This review included 25 studies. Of these, 11 presented promising results regarding PHC functioning in the Amazon region, and 14 presented challenges and difficulties in its functioning. Some PHC strategies implemented in the Amazon showed the potential to reduce inequities, mostly when they involved actions that increased access to PHC in the region when they developed a culturally adapted role and engaged community members in the decision-making and in the collaborative construction of health services. Actions that exposed challenges and difficulties were related to ill-prepared healthcare professionals, inadequate service approach and the inability to adapt to cultural issues. CONCLUSION: The findings reveal information about PHC implementations that have had promising results in the Amazon region and, at the same time, show the challenges and difficulties of the PHC actions. The findings also highlight and synthesize knowledge about the potential that PHC strategies have to affect existing inequities in the Amazon region and gaps in the studies that have been undertaken, or at least published, including a lack of studies of PHC implementation and examination of strategies aimed at health determinants.

Training in health coaching skills for health professionals who work with people with progressive neurological conditions: A realist evaluation.

BACKGROUND: Supporting people to self-manage their long-term conditions is a UK policy priority. Health coaching is one approach health professionals can use to provide such support. There has been little research done on how to train clinicians in health coaching or how to target training to settings where it may be most effective. OBJECTIVE: To develop theories to describe how training health professionals in health coaching works, for whom and in what circumstances, with a focus on those working with people with progressive neurological conditions. DESIGN: Realist evaluation using mixed methods (participant observation, pre- and post-training questionnaires, and telephone interviews with participants and trainers). Realist data analysis used to develop and refine theories. INTERVENTION: Two 1-day face-to-face training sessions in health coaching with 11 weeks between first and second days. SETTING AND PARTICIPANTS: Twenty health-care professionals who work with people with neurological conditions in the UK, two training facilitators. RESULTS: Four theories were developed using context-mechanism-outcome configurations to describe how training triggers critical reflection; builds knowledge, skills and confidence; how participants evaluate the relevance of the training; and their experiences of implementing the training. Some participants reported a major shift in practice, and others implemented the training in more limited ways. DISCUSSION: Fully embracing the role of coach is difficult for health professionals working in positions and settings where their clinical expertise appears most highly valued. CONCLUSIONS: Training should address the practicality of using coaching approaches within existing roles, while organizations should consider their role in facilitating implementation.

Collaboration with community connectors to improve primary care access for hardly reached people: a case comparison of rural Ireland and Australia.

BACKGROUND: This study presents a way for health services to improve service access for hardly reached people through an exploration of how staff can find and collaborate with citizens (referred to as connectors) who span socio-cultural boundaries in their community. The study explored the local socio-cultural contexts of connectors' boundary spanning activities and if they are health related; boundary spanning occurring between connectors and health professionals at the interface of health systems and community; and the opportunities and barriers to actively seeking out and collaborating with community connectors to access marginalised and hardly reached people. METHODS: We conducted a qualitative case comparison from rural Ireland and Australia. Following purposive snow-ball sampling techniques to recruit participants, semi-structured interviews were conducted with 34 community informants, 21 healthcare staff and 32 connectors. Transcripts were coded and analysed using an inductive approach to ascertain categories and overall themes. RESULTS: We found a diverse sample of connectors relating to heterogenous, small and locally distinct groups of hardly reached people. Overall 26 connectors were active at the interface between health services and the community, with variation in how this occurred between cases. The majority (21) described one or more health related activities with hardly reached people. All connectors expressed a willingness to develop a relationship with local health services on issues they identified as relevant. Barriers to collaborations between connectors and health services related to bureaucracy, workload, and burnout. CONCLUSIONS: Collaborating with connectors has potential as one strategy to improve access to health services for hardly reached people. To enact this, health staff need to identify local socio-cultural boundaries and associated connectors, facilitate two-way connections at the boundary between health services and community and enable collaboration by attending to activities in the community, at the interface between health services and community, and within the health system.

Community boundary spanners as an addition to the health workforce to reach marginalised people: a scoping review of the literature.

BACKGROUND: Health services in high-income countries increasingly recognise the challenge of effectively serving and engaging with marginalised people. Effective engagement with marginalised people is essential to reduce health disparities these populations face. One solution is by tapping into the phenomenon of boundary-spanning people in the community-those who facilitate the flow of ideas, information, activities and relationships across organisation and socio-cultural boundaries. METHODS: A scoping review methodology was applied to peer-reviewed articles to answer the question: "How do health services identify, recruit and use boundary spanners and what are the outcomes?" The review was conducted in seven databases with search terms based on community-based boundary spanning, marginalised people and health services. FINDINGS: We identified 422 articles with the screening process resulting in a final set of 30 articles. We identified five types of community-based boundary spanning: navigators, community health workers, lay workers, peer supporters and community entities. These range from strong alignment to the organisation through to those embedded in the community. We found success in four domains for the organisation, the boundary spanner, the marginalised individuals and the broader community. Quantifiable outcomes related to cost-savings, improved disease management and high levels of clinical care. Outcomes for marginalised individuals related to improved health knowledge and behaviours, improved health, social benefits, reduced barriers to accessing services and increased participation in services. We identified potential organisational barriers to using boundary spanners based on organisational culture and staff beliefs. CONCLUSIONS: Community boundary spanners are a valuable adjunct to the health workforce. They enable access to hard to reach populations with beneficial health outcomes. Maintaining the balance of organisational and community alignment is key to ongoing success and diffusion of this approach.

Shifting mindsets: a realist synthesis of evidence from self-management support training.

CONTEXT: Accompanying the growing expectation of patient self-management is the need to ensure health care professionals (HCPs) have the required attitudes and skills to provide effective self-management support (SMS). Results from existing training interventions for HCPs in SMS have been mixed and the evidence base is weaker for certain settings, including supporting people with progressive neurological conditions (PNCs). We set out to understand how training operates, and to identify barriers and facilitators to training designed to support shifts in attitudes amongst HCPs. METHODS: We undertook a realist literature synthesis focused on: (i) the influence of how HCPs, teams and organisations view and adopt self-management; and (ii) how SMS needs to be tailored for people with PNCs. A traditional database search strategy was used alongside citation tracking, grey literature searching and stakeholder recommendations. We supplemented PNC-specific literature with data from other long-term conditions. Key informant interviews and stakeholder advisory group meetings informed the synthesis process. Realist context-mechanism-outcome configurations were generated and mapped onto the stages described in Mezirow's Transformative Learning Theory. RESULTS: Forty-four original articles were included (19 relating to PNCs), from which seven refined theories were developed. The theories identified important training elements (evidence provision, building skills and confidence, facilitating reflection and generating empathy). The significant influence of workplace factors as possible barriers or facilitators was highlighted. Embracing SMS often required challenging traditional professional role boundaries. CONCLUSION: The integration of SMS into routine care is not an automatic outcome from training. A transformative learning process is often required to trigger the necessary mindset shift. Training should focus on how individual HCPs define and value SMS and how their work context (patient group and organisational constraints) influences this process. Proactively addressing potential contextual barriers may facilitate implementation. These findings could be applied to other types of training designed to shift attitudes amongst HCPs.

Developing the health visitor concept of family resilience in Wales using Group Concept Mapping.

INTRODUCTION: A health visitor's ability to assess and analyse aspects of family resilience in daily practice is essential to enable practitioners to support families and facilitate positive lifestyle choices, and improve child health and developmental outcomes. The purpose of this research was to undertake an in-depth exploration of the concept of family resilience as understood by health visitors in Wales and to develop a concept map. This knowledge has been used to develop the Family Resilience Assessment Instrument Tool (FRAIT). This is a standardised form of assessment, measuring instrument, guidance, training package and community of practice for use in health visitor daily practice. This article presents the first stage of the FRAIT research study, that of identifying the clusters within the concept map of what health visitors perceive as 'family resilience'. METHODS: A structured Group Concept Mapping (GCM) methodology using Concept Systems' Global Max online software was used to gain a consensus of the understanding of the concept of family resilience from 62 invited health visitors practising across Wales. This is an integrated qualitative and quantitative approach to brainstorming, idea synthesis, idea sorting, idea rating and group analysis. GCM has six clear steps, with four steps described in the method: 'preparing for concept mapping', 'generating ideas', 'structuring the statements' and 'concept mapping analysis'. Steps 5 and 6, 'interpreting the maps' and 'utilisation', are considered in the results section. RESULTS: Use of multi-dimensional scaling and hierarchical cluster analysis enabled point, cluster, rating and pattern matching maps to be presented to the study group. These were then interpreted, understood and consensus gained on how the concept of family resilience was constructed from both the study group and the health visitor participants. Family resilience understood by health visitors in Wales comprises five clusters: 'family health', 'responsive parenting', 'engagement', 'family support' and 'socioeconomic factors'. Each of the clusters has an identified number of underpinning statements from a total number of 117 statements. CONCLUSION: Family resilience as understood by health visitors is a multidimensional concept. Using online software such as Concept Systems' Global Max enabled health visitors working across Wales to achieve a consensus and generate the data in preparation for building FRAIT for use in their daily practice as required by Welsh Government policy.

Mixed-methods study to develop a patient complexity assessment instrument for district nurses.

BACKGROUND: There is increasing reference to complex patient needs in health care. However, little is known about how to measure patient complexity or the relationship between it and district nursing activity. AIM: To illustrate the use of group concept mapping (GCM) to conceptualise and develop items for a patient complexity assessment instrument to be used by district nurses. DISCUSSION: The first phase of this research used GCM conceptualisation and consensus methodology to identify items for a community-based patient complexity instrument. GCM helped to provide a conceptual understanding of community-based patient complexity through focused exploration of the term. RESULTS: indicated that a number of environmental, sociological, psychological, behavioural, physical and organisational factors needed to be included. This, in turn, showed that an existing taxonomy did not contain the relevant items. Consequently, amendments were made and a new instrument developed. CONCLUSION: GCM is a suitable consensus method for use in nursing theory and developing instruments. It proved successful in achieving consensus with no loss of participants' views. IMPLICATIONS FOR PRACTICE: GCM is a suitable method for nurses to use in research or practice development activities as it is based on a facilitative and engagement-led approach.

Speaking the Same Language - The Development of a Glossary of Terms for Social Prescribing in Wales.

Introduction: Social prescribing can facilitate the integration of health, social care and community support but has a diverse and confusing terminology that impairs cross-sectoral communication and creates barriers to engagement. Methods: To address this issue a mixed-methods approach that incorporated a scoping review, a group concept mapping study and consultation was employed to identify and classify the terminology associated with social prescribing. The findings were then used to inform the development of a glossary of terms for social prescribing. Results: Many terms are used interchangeably to describe the same specific aspects of social prescribing. Much of the terminology originates from the health and social care literature of England. Discussion: The terminology used in the academic literature may not accurately reflect the terminology used by the social prescribing workforce. The innovative and interactive glossary of terms identifies the terminology associated with social prescribing and provides additional contextual information. The process of developing the dual language glossary presented several considerations and challenges. Conclusion: The glossary of terms will facilitate cross-sector communication and reduce barriers to engagement with social prescribing. It takes an important first step to help clarify and standardise the language associated with social prescribing, for professionals and members of the public alike.

A comparison of social prescribing approaches across twelve high-income countries.

BACKGROUND: Social prescribing connects patients with community resources to improve their health and well-being. It is gaining momentum globally due to its potential for addressing non-medical causes of illness while building on existing resources and enhancing overall health at a relatively low cost. The COVID-19 pandemic further underscored the need for policy interventions to address health-related social issues such as loneliness and isolation. AIM: This paper presents evidence of the conceptualisation and implementation of social prescribing schemes in twelve countries: Australia, Austria, Canada, England, Finland, Germany, Portugal, the Slovak Republic, Slovenia, the Netherlands, the United States and Wales. METHODS: Twelve countries were identified through the Health Systems and Policy Monitor (HSPM) network and the EuroHealthNet Partnership. Information was collected through a twelve open-ended question survey based on a conceptual model inspired by the WHO's Health System Framework. RESULTS: We found that social prescribing can take different forms, and the scale of implementation also varies significantly. Robust evidence on impact is scarce and highly context-specific, with some indications of cost-effectiveness and positive impact on well-being. CONCLUSIONS: This paper provides insights into social prescribing in various contexts and may guide countries interested in holistically tackling health-related social factors and strengthening community-based care. Policies can support a more seamless integration of social prescribing into existing care, improve collaboration among sectors and training programs for health and social care professionals.

Developing and implementing the community nursing research strategy for Wales.

In order to obtain the best patient outcomes in community nursing, practice needs to be underpinned by robust research-based evidence. This article describes a Community Nursing Research Strategy developed and implemented in Wales to provide the nursing profession with the evidence to support future organisational and professional change in achieving excellence in the community. This was developed in partnership with education, research, health services, workforce planning and Government using consensus methodology (specifically, a nominal group technique). Consequently, the process was inclusive and included three steps: escalating presentation of ideas, topic debate and topic rating. The result was a strategy with four implementation strands, including a virtual network, research portfolio, application to practice and leadership.

Enhancing Student Wellbeing Through Social Prescribing: A Rapid Realist Review.

Objectives: A Rapid Realist Review of social prescribing in Higher Education (HE) was undertaken to determine what works, for whom, how, why, and within what circumstances. The review resulted in the development of a Realist Programme Theory articulating the way in which social prescribing can be implemented within the HE environment. Methods: Searches of 12 electronic databases were supplemented by citation chaining and grey literature surfaced by the Project Advisory Group. The RAMESES Quality Standards for Realist Review were followed, and the retrieved articles were systematically screened and iteratively analysed to develop Context-Mechanism-Outcome Configurations (CMOCs) and an overarching Realist Programme Theory. Results: A total of 57 documents were included. The overarching programme theory was developed from the analysis of these documents and comprised of a social prescribing pathway with the following components: (1) An Accessible Gateway, (2) A Skilled Peer, (3) Trusted-Safe-Credible Resources, and (4) A Healthy Setting. Conclusion: A Realist Programme Theory was developed-this model and associated principles will provide a theoretical basis for the implementation of social prescribing pathways within higher education. Whilst the direct project outputs are of particular significance to the UK HE audience, the underpinning principles can support practice within the global arena.

Speaking the same language - a scoping review to identify the terminology associated with social prescribing.

AIM: To identify the social prescribing-related terminology within the peer-reviewed literature of the UK and the grey literature from Wales. BACKGROUND: Social prescribing has seen a period of development that has been accompanied by a proliferation of related terminology and a lack of standardisation in the manner in which it is employed. This creates barriers to engagement and impairs communication, both between professionals and members of the public. The Wales School for Social Prescribing Research and Public Health Wales committed to the development of a glossary of terms for social prescribing, to facilitate the clarification and standardisation of the associated terminology. Here, we describe the first step in that process. METHOD: A scoping review of the peer-reviewed UK literature and Welsh grey literature was conducted. The titles and abstracts of 46,242 documents and the full text of 738 documents were screened. Data were charted from 205 documents. Data capture included terminology, the location within the UK of the research or intervention described in the article, and the perspective from which the article was authored. A general inductive approach was used to categorise the terms by theme. FINDINGS: This research serves to highlight the breadth and diversity of the terminology associated with social prescribing. Results demonstrate aspects of shared commonality and clear distinction between the terminology from the two literature sources. The greatest contributions of terms were from articles that examined research and/or interventions in England and that were authored from the perspective of health or health and social care. The research indicates that nation- and sector-specific terms may not be adequately represented in the literature at large. Looking forward, it will be important to ensure that social prescribing terminology within the UK literature is culturally relevant and accurately reflects the terminology used by the workforce who encounter and deliver social prescribing.

Caring for frail patients: best practice.

Frailty has become synonymous with vulnerability and is a state caused by many factors, including disability, recurrent infection and multiple co-morbidities. The Gwent frailty service recognises the importance of an interdisciplinary approach to care, including timely recognition of frailty in patients and referral to the most appropriate services to optimise management and treatment.

Exploring how and why social prescribing evaluations work: a realist review.

OBJECTIVE: The evidence base for social prescribing is inconclusive, and evaluations have been criticised for lacking rigour. This realist review sought to understand how and why social prescribing evaluations work or do not work. Findings from this review will contribute to the development of an evidence-based evaluation framework and reporting standards for social prescribing. DESIGN: A realist review. DATA SOURCES: ASSIA, CINAHL, Embase, Medline, PsycINFO, PubMed, Scopus Online, Social Care Online, Web of Science and grey literature. ELIGIBILITY CRITERIA: Documents reporting on social prescribing evaluations using any methods, published between 1998 and 2020 were included. Documents not reporting findings or lacking detail on methods for data collection and outcomes were excluded. ANALYSIS: Included documents were segregated into subcases based on methodology. Data relating to context, mechanisms and outcomes and the programme theory were extracted and context-mechanism-outcome configurations were developed. Meta-inferences were drawn from all subcases to refine the programme theory. RESULTS: 83 documents contributed to analysis. Generally, studies lacked in-depth descriptions of the methods and evaluation processes employed. A cyclical process of social prescribing evaluation was identified, involving preparation, conducting the study and interpretation. The analysis found that coproduction, alignment, research agency, sequential mixed-methods design and integration of findings all contributed to the development of an acceptable, high-quality social prescribing evaluation design. Context-mechanism-outcome configurations relating to these themes are reported. CONCLUSIONS: To develop the social prescribing evidence base and address gaps in our knowledge about the impact of social prescribing and how it works, evaluations must be high quality and acceptable to stakeholders. Development of an evaluation framework and reporting standards drawing on the findings of this realist review will support this aim. PROSPERO REGISTRATION NUMBER: CRD42020183065.

Enhancing higher education student well-being through social prescribing: a realist evaluation protocol.

INTRODUCTION: UK higher education (HE) student numbers are increasing and students report higher levels of mental health and well-being issues. Social prescribing links individuals to community-based, non-medical support. It is widely implemented throughout the UK, and is supported by the Welsh Government. This protocol presents an evaluation of a new social prescribing service to enhance student well-being, a first for UK HE students. METHODS AND ANALYSIS: A realist evaluation to articulate why, how and to what extent and circumstances social prescribing works for students, using a mixed-methods sequential design of four cycles. Cycle 1 informs the model and programme theory development of how the model works; activities include a Realist Review, Group Concept Mapping and producing bilingual short films about the evaluation and model. Cycle 2 involves secondary analysis of routine service data, and outcome measurements from students receiving a social prescription. Cycle 3 uses reflective diaries and qualitative realist interviews with stakeholders to understand the process and outcome of the model. Cycle 4 concludes with a world café workshop with stakeholders to agree and finalise the framework specification of 'how, why, when and to what extent' the model works. A meta-matrix construction will determine convergence, complementarity or discrepancy across the cycles. An advisory group of key stakeholders informs each cycle. ETHICS AND DISSEMINATION: University of South Wales Life Sciences and Education Ethics Committee and Wrexham Glyndwr University (WGU) Research Ethics Sub-Committee approved secondary data analysis of participant demographics (200 805LRL:USW, id441:WGU), outcome measurement tools (200 902LR:USW, id441:WGU) and qualitative data collection (200 804LR:USW, id449:WGU). The authors will publish findings in peer-reviewed journals, produce an evaluation report to the funder and a short film for dissemination via stakeholders, university networks, United Nations Regional Centre of Expertise in Wales, PRIME Centre Wales, Wales School for Social Prescribing Research, conferences and social media.

Using an integrated competence model to evaluate a health visitor cascade training programme for the Family Resilience Assessment Instrument and Tool (FRAIT).

This paper reports on an evaluation of health visitor trainers' experience of a cascade training programme delivered in Wales, UK. Health visitors used Driscoll's model (What, So What, Now What) to organise their feedback and an integrated competence model developed by Weeks et al. was used to analyse the feedback via category analysis of free text. As well as feedback on the logistics of running the training, the evaluation allowed for cognitive and functional competence to be identified along with personal and meta competence. There was limited scope for identifying ethical competence in the Health Visitor cascade trainer feedback. Suggestions are made for how this may be addressed.

Global developments in social prescribing.

Social prescribing is an approach that aims to improve health and well-being. It connects individuals to non-clinical services and supports that address social needs, such as those related to loneliness, housing instability and mental health. At the person level, social prescribing can give individuals the knowledge, skills, motivation and confidence to manage their own health and well-being. At the society level, it can facilitate greater collaboration across health, social, and community sectors to promote integrated care and move beyond the traditional biomedical model of health. While the term social prescribing was first popularised in the UK, this practice has become more prevalent and widely publicised internationally over the last decade. This paper aims to illuminate the ways social prescribing has been conceptualised and implemented across 17 countries in Europe, Asia, Australia and North America. We draw from the 'Beyond the Building Blocks' framework to describe the essential inputs for adopting social prescribing into policy and practice, related to service delivery; social determinants and household production of health; workforce; leadership and governance; financing, community organisations and societal partnerships; health technology; and information, learning and accountability. Cross-cutting lessons can inform country and regional efforts to tailor social prescribing models to best support local needs.