Thinking about inequalities in physical activity as an emergent feature of complex systems.

Inequalities in physical activity are well documented, especially between socioeconomic groups. However, progress on reducing these inequalities is proving challenging. In this commentary, we argue that a complex system perspective is needed, specifically to reorient our thinking of inequalities in physical activity to be emergent features of complex systems. Operationalising this perspective involves acknowledging the multiple dynamic and non-linear interactions which take place between system parts and, over time aggregate to become macro patterns such as physical activity inequalities. We argue that this framing will enhance our understanding of the emergence of inequalities in physical activity and, therefore, provide interventions better suited to the subgroups of the population they are designed to help.

Optimising planned medical education strategies to develop learners' person-centredness: A realist review.

CONTEXT: Person-centeredness is a stated aim for medical education; however, studies suggest this is not being achieved. There is a gap in our understanding of how, why and in what circumstances medical education interventions that aim to develop person-centredness are successful. METHODS: A realist review was conducted with a search of Medline, Embase, HMIC and ERIC databases and the grey literature using the terms 'medical education' and 'person-centred' and related synonyms. Studies that involved a planned educational intervention in medical education with data on outcomes related to person-centredness were included. The analysis focused on how and why different educational strategies interact with biomedical learner perspectives to trigger mechanisms that may or may not lead to a change in perspective towards person-centredness. RESULTS: Sixty-one papers representing fifty-three interventions were included in the final synthesis. Nine context-intervention-mechanism-outcome configuration (CIMOc) statements generated from the data synthesis make up our refined programme theory. Where educational interventions focused on communication skills learning or experiences without person-centred theory, learners experienced dissonance with their biomedical perspective which they resolved by minimising the importance of the learning, resulting in perspective endurance. Where educational interventions applied person-centred theory to meaningful experiences and included support for sense making, learners understood the relevance of person-centeredness and felt able to process their responses to learning, resulting in perspective transformation towards person-centredness. CONCLUSION: Our findings offer explanations as to why communication skills-based interventions may be insufficient to develop learners' person-centredness. Integrating experiential person-centred learning with theory on why person-centredness matters to clinical practice and enabling learners to make sense of their responses to learning, may support perspective transformation towards person-centredness. Our findings offer programme and policymakers testable theory to inform the development of medical education strategies that aim to support person-centredness.

Behaviour change practices in exercise referral schemes: developing realist programme theory of implementation.

BACKGROUND: Exercise Referral Schemes have been delivered worldwide in developed countries to augment physical activity levels in sedentary patients with a range of health issues, despite their utility being questioned. Understanding the implementation mechanisms of behaviour change practices is important to avoid inappropriate decommissioning and support future service planning. The aim of this study was to develop initial theories to understand what influences the behaviour change practices of Exercise Referral practitioners within the United Kingdom. METHODS: An eight-month focused ethnography was undertaken, to carry out the first phase of a realist evaluation, which included participant observation, interviews, document analysis, and reflexive journaling. A comprehensive implementation framework (Consolidated Framework for Implementation Research) was adopted providing an extensive menu of determinants. Mechanisms were categorised based on the Theoretical Domains Framework (within the Capability, Opportunity, Motivation, Behaviour model) providing an explanatory tool linking the levels of the framework. RESULTS: Three programme theories are proposed. Firstly, motivation and capability are influenced when behaviour change oriented planning and training are in place. Secondly, motivation is influenced if leadership is supportive of behaviour change practice. Lastly, integration between health professionals and practitioners will influence motivation and capability. The conditions necessary to influence motivation and capability include a person-centred climate, cognizant practitioners, and established communities of practice. CONCLUSIONS: The findings are the first to articulate the necessary elements for the implementation of behaviour change practices in Exercise Referral services. These results outline emerging theories about the conditions, resources, and explanations of behaviour change implementation that can inform service development.

Clarity, conviction and coherence supports buy-in to positive youth sexual health services: focused results from a realist evaluation.

BACKGROUND: There is a call for sexual health services to support young people achieve sexual wellbeing in addition to treating or preventing sexual ill-health. Progress towards realising this ambition is limited. This study aimed to contribute theory and evidence explaining key processes to support local delivery of positive youth sexual health services. METHODS: A realist evaluation was conducted, comprising four research cycles, with a total of 161 data sources, primarily from the UK. Theory was refined iteratively using existing substantive theories, secondary and primary research data (including interviews, documentary analysis, feedback workshops and a literature search of secondary case studies). A novel explanatory framework for articulating the theories was utilised. RESULTS: The results focused on local level buy-in to positive services. Positive services were initiated when influential teams had clarity that positive services should acknowledge youth sexuality, support young people's holistic sexual wellbeing and involve users in design and delivery of services, and conviction that this was the best or right way to proceed. How positive services were operationalised differed according to whether the emphasis was placed on meeting service objectives or supporting young people to flourish. Teams were able to effect change in local services by improving coherence between a positive approach and existing processes and practices. For example, that a) users were involved in decision making, b) multi-disciplinary professional working was genuinely integrated, and c) evidence of positive services' impact was gathered from a breadth of sources. New services were fragile. Progress was frequently stymied due to a lack of shared understanding and limited compatibility between characteristics of a positive approach and the wider cultural and structural systems including medical hegemony and narrow accountability frameworks. These challenges were exacerbated by funding cuts. CONCLUSIONS: This study offers clarity on how positive youth sexual health services may be defined. It also articulates theory explaining how dissonance, at various levels, between positive models of sexual health service delivery and established cultural and structural systems may restrict their successful inception. Future policy and practice initiatives should be theoretically informed and address barriers at societal, organisational and interpersonal levels to stimulate change.

What consultation resources are available to support delivery of integrated sexual and reproductive health services? A scoping review.

BACKGROUND: Contraceptive and sexual healthcare is increasingly delivered in an integrated setting in the UK and worldwide, requiring staff to be competent in differing styles of delivery, and to have a wide knowledge base. OBJECTIVES: We did a scoping review of the literature for evidence of the resources that exist for healthcare professionals to guide or structure the process of conducting an integrated sexual and reproductive health (SRH) consultation. ELIGIBILITY CRITERIA: Articles were included in the review if (1) their primary focus was a consultation resource related to one or more aspects of an SRH consultation and (2) they provided details of the resource and/or its application including evaluation of use. SOURCES OF EVIDENCE: Peer-reviewed articles published in English, published non-peer-reviewed guides, and web-based guidelines addressing the conduct of a contraception or sexual health consultation were included. Date range: 1998-December 2018. Searches were carried out in the databases AMED (Ovid), ASSIA (ProQuest), CINAHL Complete (EBSCO), Cochrane Library (Wiley), HMIC (NHS Evidence), Medline (EBSCO), PsycINFO (Proquest) and Scopus (Elsevier) on 10 February 2017, and incremental searching performed until December 2018. RESULTS: A total of 12 peer-reviewed journal articles, two web-published guidelines from the Faculty of Sexual & Reproductive Healthcare and three published, non-peer-reviewed resources were included. CONCLUSION: Many resources exist to guide either the contraceptive or sexual health consultations, but there is a lack of a comprehensive consultation resource to guide the conduct of an integrated consultation.