Responsibility driven learning in primary care: a qualitative evaluation of a medical student COVID-19 volunteering programme.

BACKGROUND: During the first wave of the pandemic when clinical placements were suspended, a UK medical student volunteering programme was developed to support local GP practices. This study aimed to explore the impact that volunteering in primary care had on students' learning and professional development to inform the design of future service-learning curricula innovations. METHODS: Seventy medical students across all years volunteered across forty-five GP practices in north-west London. Ten volunteer students and six GPs who had hosted students volunteered to participate in remotely conducted, semi-structured interviews with a researcher. Transcriptions were independently coded by two researchers and analysed by thematic analysis using service learning and communities of practice as sensitising concepts. RESULTS: Analysis showed a strong alignment between the views of students and GPs in terms of perceived learning. Our analysis of both sets of interviews resulted in five themes describing student outcomes from the volunteering scheme: developing as a doctor, understanding the complexity of medicine, responsibility driven learning, a meaningful role in a community of practice, and seeing behind the scenes in primary care. DISCUSSION AND CONCLUSION: Results from this study highlighted how a meaningful service-led role and responsibility in primary care can empower and motivate students to learn beyond the traditional medical curriculum and assessments. Adopting these new 'pro-active' roles within general practices led volunteers, particularly those in the early years of study, to develop a better understanding of primary care and medical complexity. It also enhanced their professional skills, attitudes and behaviours, while having a beneficial impact on patient care during the pandemic.

The impact of Covid-19 on professional identity formation: an international qualitative study of medical students' reflective entries in a Global Creative Competition.

INTRODUCTION: The Covid-19 pandemic, which affected medical students globally, could be viewed as a disorientating dilemma with the potential to offer opportunities for transformative learning. In 2021 the Medical Education Innovation and Research Centre at Imperial College London launched a Global Creative Competition as a platform for medical students to reflect on their experiences during the pandemic. METHODS: Six hundred forty-eight creative pieces with written reflections were submitted by medical students from 52 countries. 155 students from 28 countries consented for their entries to be included in this study. The reflections were analysed thematically and independently by three reviewers to explore how the pandemic impacted students' professional identity formation (PIF). RESULTS: The pandemic increased students' awareness of the social and global role of doctors in addressing health inequities. Students felt part of a wider healthcare community and showed greater appreciation towards person-centred care. Students also became more aware of their personal needs, priorities, and the importance of self-care. DISCUSSION: In agreement with Mezirow's theory of transformative learning (2003), the pandemic led students to re-examine pre-existing epistemic and sociocultural assumptions concerning the role of doctors and explore new perspectives of what it means to be a doctor. In accordance with Cheng's theory of coping flexibility (2021), students developed both emotion-focused coping strategies (e.g., arts engagement) and problem-solving strategies (e.g., volunteering), suggesting they were able to adjust psychologically and develop agency. However, students experienced tension between their sense of duty and sense of wellbeing, highlighting the need for medical educators to design into programmes formal support systems where medical students have the space and time they need to reflect on their emergent identities as a doctor. CONCLUSION: Medical educators should encourage students to reflect on their identity formation while encountering disorientating dilemmas. The inclusion of arts and humanities within the medical curriculum is strongly recommended to provide an avenue for students to access and express complex emotions and experiences.

Public health for paediatricians: 15-minute guide to identify and address food insecurity.

Food insecurity is a major problem in the UK. It has been both highlighted and exacerbated by the COVID-19 pandemic, and particularly affects children and young people (CYP). The effects of inadequate nutrition manifest themselves in all stages of child development and adversely affect health and educational outcomes. Healthcare professionals working with CYP can address food insecurity at individual, local community, organisational and national levels. The government plays an important role in monitoring and responding to food insecurity, supporting CYP most in need.This paper summarises how food insecurity can be identified and approached by healthcare professionals in clinical consultations, including the use of screening tools and awareness of risk factors that signpost family food insecurity. Examples of services and clinician-assisted referrals to support vulnerable patients are provided, alongside suggested methods to implement further education for the multidisciplinary healthcare team.

'I sound different, I look different, I am different': Protecting and promoting the sense of authenticity of ethnically minoritised medical students.

BACKGROUND: Being authentic can improve students' well-being and enhance the medical student-patient communication and patient safety. However, the underrepresentation of ethnically minoritised students in medical education can result in identity suppression, interfering with students' ability to succeed academically and professionally. METHODS: We conducted interviews with 20 ethnically minoritised medical students, which were analysed thematically, to explore the following: What facilitates and prevents students from being their authentic self during medical school? What learning and teaching strategies can enable students to be or become their authentic self? FINDINGS: Experiences of discrimination, microaggressions and/or racism were the main barriers to authenticity, leading to fear of being discriminated again if students expressed their true self. Lack of diversity, cultural awareness and staff representation were also fundamental barriers. Being authentic was often perceived as contradictory to being professional and a risk that could damage students' reputation. However, when students could express their true self, they felt happier, safer and developed a stronger sense of belonging. DISCUSSION: To enhance authenticity, students need to see better staff representation, role models they can relate and aspire to, such as Black professors. Equity/Diversity/Inclusion/Belonging (EDIB) training needs to become embedded throughout the curriculum and be delivered by facilitators with lived experiences. Other strategies to promote students' authenticity included mentoring, better signposting to complaints procedure and well-being resources and implementation of 'zero tolerance' policies. To our knowledge, this is one of the first studies on the concept of authenticity in medical education and the first study focusing on ethnically minoritised students.

Building partnerships with local schools.

BACKGROUND: Medical schools have a responsibility to support their students in developing an understanding of the complex concepts of a 'VUCA' (volatile, uncertain, complex and ambiguous) world. To achieve this, service learning approaches have been increasingly successfully employed for students to learn through participating in activities addressing local community priorities. Sharing outcomes and lessons from such programmes is essential for advancing service learning. We present the evaluation of a new service learning module co-designed at Imperial College London with local schools and wider stakeholders. APPROACH: Students partnered with local schoolteachers to design and implement inclusive science-based after-school sessions for secondary school pupils. The module aimed to foster critical reflection on social accountability, power and privilege whilst encouraging aspirations for higher education in school pupils. EVALUATION: Our evaluation draws on the perspectives of stakeholders in the first iteration of the module in 2021. Qualitative data were collected through university student reflections, presentations and debriefs (n = 20); semi-structured interviews with schoolteachers (n = 6); and questionnaires with wider stakeholders (n = 6). The evaluation revealed mutual benefits, as students reflected on their own societal roles, whilst considering the complexities of concepts such as inclusivity, power and privilege. Schoolteachers highlighted students' impact as inspiring role models for pupils, fostering aspirations for higher education. IMPLICATIONS: This module provides a replicable framework for supporting students in developing their reflections on their role in our VUCA world whilst addressing the priorities identified by local schools. The evaluation highlighted the importance of working collaboratively with community stakeholders when embarking on service learning projects.

Qualitative and Arts-Based Evidence from Children Participating in a Pilot Randomised Controlled Study of School-Based Arts Therapies.

(1) Background: There is limited evidence on the impact of arts therapies as a tool for the prevention of mental health difficulties in childhood. This pilot randomised controlled study aimed to investigate the impact of arts therapies on children's mental health and well-being; the qualitative and arts-based evidence is presented in this article. (2) Methods: Sixty-two children (aged 7-10) with mild emotional and behavioral difficulties were recruited across four primary schools and were randomly assigned to either art therapy, music therapy, dance movement therapy, or dramatherapy. All children were interviewed individually after their participation in arts therapies. (3) Results: Children verbally and artistically expressed that they experienced positive changes in their mental health and well-being, such as improved self-expression, safety, empowerment, hope, and optimism for the future. The arts were particularly important for expressing complex emotions and feelings that cannot be easily verbalised. Recommendations are provided to improve the quality of group arts therapies in future interventions, such as through smaller groups, longer sessions, and strategies to protect the therapeutic environment. (4) Conclusions: This study embraced all arts therapies as one research domain and set children's verbal and non-verbal responses at the heart of outcome evaluation. This article highlights the importance of incorporating qualitative and arts-based methods to capture changes in children's mental health well-being in future experimental studies.

A Systematic Review of Arts-Based Interventions Delivered to Children and Young People in Nature or Outdoor Spaces: Impact on Nature Connectedness, Health and Wellbeing.

Background: The time that children and young people spend in nature and outdoor spaces has decreased significantly over the past 30 years. This was exacerbated with a further 60% decline post-COVID-19. Research demonstrating that natural environments have a positive impact on health and wellbeing has led to prescription of nature-based health interventions and green prescribing, although evidence for its use is predominantly limited to adults. Growing evidence also shows the impact of arts on all aspects of health and wellbeing. However, what has received scant attention in literature is the interconnection between the two: arts and nature. Aims: This review synthesizes the literature surrounding the interconnectedness between arts and nature, and their impact on the health and wellbeing of children and young people. Methods: Eight major electronic databases were systematically searched, while hand-searching included 20 journals, six books, and contact with experts. The review was conducted using the Cochrane handbook for systematic reviews, PRISMA guidelines and TIDieR template. All stages were conducted independently by two researchers and the protocol was published on PROSPERO (Registration no.: CRD42021286574). Results: Although 9,314 records were identified, only 11 records were included as most studies focused either on arts or nature, but not both. Studies were conducted in United Kingdom, United States, Ireland, Australia, and Hong Kong, in a range of spaces such as forests, woodlands, beaches, parks, fields, gardens, and school playgrounds. The review encompasses data from 602 participants in total. Discussion: Arts-in-nature offered an inclusive medium to engage all children and young people, especially those who might otherwise remain disinterested about environmental issues and disengaged with educational programs. Further, arts-in-nature provided stimuli to increase nature connectivity, understand environmental issues and explore ways to prevent environmental disasters. This led to higher environmental awareness and pro-environmental behaviors, and potential decrease in eco-anxiety. Conclusion: Although the quality of qualitative studies was high, the quality of quantitative studies was low or unclear, thus quantitative evidence is still at its infancy. Implications for research, policy, and practice are discussed, such as methods and activities to strengthen future interventions. Scaling-up existing interventions may lead to wider recognition and inclusion of arts-in-nature in future health guidelines, including green prescribing.

Feasibility, acceptability, and effectiveness of school-based dance movement psychotherapy for children with emotional and behavioral difficulties.

Background: Schools have been increasingly employing dance movement psychotherapists to support children cope with daily worries and stress, express and understand their emotions, develop self-awareness and self-esteem. However, evidence on the impact of dance movement psychotherapy as a tool for prevention of mental health difficulties in childhood remains limited. Methods: Sixteen children (aged 7-9) with mild emotional and behavioral difficulties from two primary schools were randomly assigned to a Dance Movement Psychotherapy (DMP) intervention or to a waiting list, within a larger pilot cross-over randomized controlled study which aimed to (a) test whether all elements of study design can work together and run smoothly in a full-scale RCT; and (b) investigate the effectiveness of arts therapies in improving children's health related quality of life (HRQOL; EQ-5D-Y), wellbeing and life functioning (Child Outcome Rating Scale; CORS), emotional and behavioral difficulties (Strengths and Difficulties Questionnaire; SDQ), and duration of sleep (Fitbits). The therapeutic process was also evaluated through interviews with children, participant observations, the Children's Session Rating Scale (CSRS), and ratings of adherence to the therapeutic protocol. Results: The findings indicated that DMP led to improvements in children's life functioning, wellbeing, duration of sleep, emotional and behavioral difficulties, but not in quality of life. The improvements were maintained at the follow-up stages, up to 6 months post-intervention. Interviews with children also suggested positive outcomes, such as self-expression; emotional regulation; mastery and acceptance of emotions; improved self-confidence and self-esteem; reduced stress; and development of positive relationships. However, children would have preferred smaller groups and longer sessions. Conclusion: This study indicated that all outcome measures would be suitable for inclusion in a larger randomized controlled trial, though the EQ-5D-Y is not recommended as a stand-alone measure due to its lack of sensitivity and specificity for young participants. The adherence to the therapeutic protocol ratings differed between children and adults, highlighting the need to include children's voice in future research. Strategies are also proposed of how to conduct randomization of participants in ways that do not hinder the therapeutic process.

A pilot cross-over randomised controlled trial of child-focused process and outcome evaluation of arts therapies at primary mainstream schools: study protocol.

Background: Arts therapies are increasingly being adopted within schools to alleviate and prevent a wide range of children's difficulties. Such therapies help to facilitate personal change and growth through arts media; visual arts, music, drama, dance and movement.Methods: This study aims to investigate the child-focused process and outcomes of an arts therapies intervention through child-reported questionnaires, interviews, participant observations, arts-work and biomarkers. The participants are 64 primary school children with mild emotional and behavioural difficulties.Expected results: To explore a) whether all components of the study (i.e. recruitment, randomisation, follow-up) can work together in a larger trial; b) the children's evaluations of arts therapies;c) the impact on children's wellbeing, quality of life and sleep; d) the sample size calculations and cost evaluations for future research. This is the first study to embrace all arts therapies as one research domain with a clear focus on children's verbal, non-verbal and physical responses.

Making Nature Explicit in Children's Drawings of Wellbeing and Happy Spaces.

Previous research on children's wellbeing indicators has focused extensively on adults', rather than children's perspectives, despite there being a broad consensus that children's conceptualisations differ significantly from adults'. In response, this study aimed to explore what constitutes children's wellbeing through their drawings and discussions. Ninety-one seven and eight-year old children from two primary schools in areas of relatively high deprivation in eastern England participated in this study. We identified indicators of wellbeing that were made explicit in children's drawings, such as the need for safety, happiness and positive relationships, but also indicators that remained rather implicit, such as the environment and nature. The drawings in particular illustrated that children's perceptions of wellbeing were subject to the affordances of their favourite spaces for emotional, mental physical and material wellbeing. Access to nature and outdoor spaces was interconnected with all these affordances. We analysed these findings through the theoretical lenses of positive psychology, self-actualisation, social mentality and the human-nature relationship. We argue that making nature explicit, and restoring the interconnectedness between the arts and nature in the current literature, should be a key priority for future research and practice on children's wellbeing indicators.

A Systematic Review of the Contribution of Dance Movement Psychotherapy Towards the Well-Being of Children With Autism Spectrum Disorders.

Background: The present review provides an original examination of published literature on the use of Dance Movement Psychotherapy (DMP) as an intervention for children with an Autism Spectrum Disorder (ASD). Method: The review was systematically conducted using the Preferred Reporting Items for Systematic Review and Meta-Analysis (PRISMA) guidelines. A protocol consisting of four phases: identification; screening and selection; data extraction and synthesis; quality assurance was developed and registered with the PROSPERO. A search strategy was developed using population and intervention as the key concepts and ten databases were searched between 6.1.2018 to 4.4.2018 and 10.07.2021 to 20.07.2021. The intervention characteristics were extracted based on the TIDieR template for intervention description and replication checklist. Quality assessment and level of evidence of all the included studies were evaluated using the Mixed Methods Appraisal Tool (MMAT) and the Centre for Evidence-Based Medicine (CEBM) for treatment criteria. Results: Nine research studies with a total of 133 participants were identified through a systematic search process. There was only one mixed-methods study with the component of randomisation found during the literature search. Collected information was synthesised in relation to (a) ways in which dance movement psychotherapists work with children; (b) data collection methods and findings. Results from the reviewed literature suggest that DMP can potentially promote various aspects of well-being in children with ASD. Eight out of nine studies mentioned the effects of DMP on improving different social and communication skills. However, results from quality assessments and synthesised outcomes indicate that research in DMP is still in its infancy. Conclusions: We conclude that further large-scale, high-quality studies are required to generate further evidence that explains the processes involved in DMP, the effectiveness of DMP, the relationship between therapeutic factors of DMP, and research findings for children on the autism spectrum. Systematic Review Protocol Registration: PROSPERO, identifier: CRD42018087912.

An Investigation of the Effectiveness of Arts Therapies Interventions on Measures of Quality of Life and Wellbeing: A Pilot Randomized Controlled Study in Primary Schools.

BACKGROUND: Over the last decades there has been a change in the way schooling is perceived recognizing that children's learning is closely linked to children's health. Children spend most of their time at school, which is often the place where problems are identified and interventions are offered, not only for treatment but also prevention. Embedding arts therapies into the educational system may help address children's emerging needs and have a positive impact on their wellbeing. METHODS: A pilot cross-over randomized controlled design was employed to investigate the effectiveness of an arts therapies intervention on a series of child- and teacher-reported outcome measures, specifically, health related quality of life (assessed using a HRQOL scale; EQ-5D-Y), wellbeing and life functioning (assessed using the child outcome rating scale; CORS), emotional and behavioral difficulties (assessed using the strengths and difficulties questionnaire; SDQ), as well as duration of sleep (assessed using Fitbits). Sample size calculations for future large-scale studies were also performed, and the sustained impact of the intervention was evaluated at 3, 6, and 12 months follow-up. The pluralistic theoretical and therapeutic framework of this intervention was informed by a systematic review on school-based arts therapies interventions and is presented in detail in the study protocol. Participants were 62 children with mild emotional and behavioral difficulties. RESULTS: Improvements in HRQOL and CORS were greater in those engaged in the arts therapies intervention than the control groups and were maintained at the follow-up stages. Significant improvements were only found for duration of sleep (P = 0.002) and SDQ (P = 0.008). Minimal clinically important differences (MCIDs) as defined in the published protocol were found for CORS, SDQ and duration of sleep, but not HRQOL. DISCUSSION: Findings indicate that the arts therapies interventions were having a clinically significant effect on life functioning, duration of sleep, emotional and behavioral difficulties. Findings also indicate a small effect size for health related quality of life, suggesting the intervention was having a small positive effect on this outcome measure. The study indicates that all outcome measures assessed here would be suitable for inclusion in a larger randomized controlled study utilizing these arts therapies interventions, and that a sample size of 225 participants would be required if these outcome measures were used.