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OBJECTIVES: Leadership knowledge and skills are known to be developed by health professionals during global health experiences overseas. However, volunteers struggle to recognise and use these new skills on return to their workplace. A series of bespoke leadership workshops were designed, delivered and evaluated by leadership experts to help enhance the transferability of leadership skills back to the UK National Health Service. DESIGN: A mixed-methods participatory action research methodology was employed to explore the impact of the workshops. This approach lends itself to a complex, situated project involving multiple partners. Quantitative and qualitative descriptive data were collected via online survey (n=29 participants) and focus groups (n=18 focus groups) and thematically analysed. SETTING: The authors delivered the tailored leadership workshops online to globally engaged National Health Service (NHS) healthcare professionals based in England who had all worked overseas within the past 5 years. PARTICIPANTS: 29 participants attended: 11 medical doctors; 6 nurses/midwives; 10 allied health professionals; 1 NHS manager and 1 student nurse (who was also working as a healthcare assistant). RESULTS: Participants were able to network both during the large group discussions and while in smaller breakout groups. Data highlighted the substantial benefits obtained from this networking, with 91% of participants reporting it enriched their learning experience, particularly within a multi-disciplinary context, and by having the time and space for facilitated reflection on leadership. Furthermore, 78% agreed that they learned new skills for influencing change beyond their position and 76% reported they could maximise the impact of this change for themselves and their employer. Participants also reported the development of systems and ethical leadership knowledge that they felt they could transfer to their NHS roles. CONCLUSIONS: This study extends explorations of global health experiences by moving beyond the skills gained while working in low-income and middle-income countries. The innovative online leadership workshops gave agency to individuals to recognise and use the skills gained from global health placements on return to the NHS.

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PURPOSE: This paper reports on trainees' perceptions of leadership and leadership development, to inform the support that may be provided to them. It draws on a formative evaluation of the new role of clinical leadership mentor (CLM), introduced by Health Education England South-West in 2018. CLMs are responsible for 'overseeing the process and progress of leadership development among the trainees within their Trust/Local Education Provider'. METHODS: The evaluation was a formative evaluation, based on interviews with CLMs, trainees and trainers and a survey of trainees and trainers. Recruitment was through 8 of the 19 CLMs in the South West. A report for each participating CLM was available to support the development of their individual role. In exploring trainees' perceptions of leadership and leadership development, this paper draws on data from trainees: 112 survey returns which included over 7000 words of free text data and 13 interviews. FINDINGS: Our findings suggest a more nuanced understanding of leadership in medical trainees than was previously reported in the literature, and a wider acceptance of their leadership role. We highlight the problem of considering postgraduate doctors as a homogeneous group, particularly with reference to specialty. We also highlight that the organisational context for leadership development can be supportive or non-supportive. Leadership learning through genuine leadership experience with appropriate support from trainers and the wider Trust offers opportunities for both trainees and Trusts. PRACTICAL IMPLICATIONS: Trainees are accepting of their roles as leaders. The value of leadership learning through genuine leadership experience was highlighted. Improving the environment for leadership development offers Trusts and trainees opportunities for genuine service improvement.

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Motor competence (MC) has been extensively examined in children and adolescents, but has not been studied among adults nor across the lifespan. The Test of Motor Competence (TMC) assesses MC in people aged 5-85 years. Among Iranians, aged 5-85 years, we aimed to determine the construct validity and reliability of the TMC and to examine associations between TMC test items and the participants' age, sex, and body mass index (BMI). We conducted confirmatory factor analysis (CFA) to evaluate the TMC's factorial structure by age group and for the whole sample. We explored associations between the TMC test items and participant age, sex, and BMI using a network analysis machine learning technique (Rstudio and qgraph). CFA supported the construct validity of a unidimensional model for motor competence for the whole sample (RMSEA = 0.003; CFI = 0.998; TLI = 0.993) and for three age groups (RMSEA <0.08; CFI and TLI >0.95). Network analyses showed fine motor skills to be the most critical centrality skills, reinforcing the importance of fine motor skills for performing and participating in many daily activities across the lifespan. We found the TMC to be a valid and reliable test to measure MC across Iranians' lifespan. We also demonstrated the advantages of using a machine learning approach via network analysis to evaluate associations between skills in a complex system.

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Policies supporting caregivers ("caregiver policies") are limited in the extent to which they meet the needs of those who care for others. Where policies do exist, they focus on relieving the burdens associated with caring or the needs of the person they care for, rather than consider the holistic needs of the caregiver that would enable them to flourish. We argue that the established approach to caregiver policies reflects a policy failure, requiring a reassessment of current practice related to caregiver support. Often, caregiver policies target the care recipient rather than the caregiver's needs. Through a consultative exercise, we identified five areas of need that existing caregiver policies touch upon. Yet current approaches remain piecemeal and inadequate in a global context. Caregiver policies should not just relieve burden to the extent that caregivers can continue in the role, but they should support caregivers to flourish, and future work may benefit from drawing on related frameworks from positive psychology, such as the PERMA™ model; this is important for both policymakers and researchers.

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PURPOSE: To determine the effect of a 12-week fundamental motor skill (FMS) program on FMS and physical activity (PA) on preschool-aged children. METHOD: A cluster randomized controlled trial. The intervention (PhysicaL ActivitY and Fundamental Motor Skills in Pre-schoolers [PLAYFun] Program) was a 12-week games-based program, delivered directly to the children in childcare centers by exercise physiologists. Children in the control arm received the usual preschool curriculum. Outcomes included FMS competence (Test of Gross Motor Development-2) and PA (accelerometer) assessed at baseline, 12 weeks, and 24 weeks (12-wk postintervention). RESULTS: Fifty children (mean age = 4.0 [0.6] y; 54% male) were recruited from 4 childcare centers. Two centers were randomized to PLAYFun and 2 centers were randomized to the waitlist control group. Children attended on average 2.0 (1.0) 40-minute sessions per week. The PLAYFun participants demonstrated significant increases in object control (P < .001) and total FMS (P = .010) competence at week 12, compared with controls in a group × time interaction. Girls, but not boys, in PLAYFun significantly increased moderate to vigorous PA after the intervention (P = .004). These increases were not maintained 12-week postcompletion of PLAYFun. CONCLUSIONS: The PLAYFun Program is effective at improving FMS competence in boys and girls and increasing PA in girls. However, improvements are not maintained when opportunities to practice are not sustained.

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OBJECTIVES: To determine the prevalence of fundamental movement skill (FMS) proficiency among a sample of Iranian children. DESIGN: Cross sectional, representative sample of 2200 children aged 2.5-14 years (50% girls), living in Tehran in 2018. METHODS: Trained field staff assessed 7 locomotor and 4 object control skills in educational settings using the Ohio State University Scale of Intra-Gross Motor Assessment (OSU-SIGMA). Scores for levels 1-3 represent immature performance and level 4 represents proficiency. Data were analyzed by age and sex. RESULTS: Overall, proficiency prevalences were higher in boys than girls. Proficiency in walking and running emerged in children from age 2.5 years, and proficiency in more complex locomotor skills (i.e., jumping, skipping, hopping, ladder-climbing) and object control skills emerged at age 6 years. The prevalence of proficiency in hopping, jumping, skipping and all object control skills were low in children aged <9 years. All children aged ≥9 years were proficient in all locomotor skills. At age 9 years, the prevalence of object control proficiency were high for throwing (boys 100%, girls 89%), catching (boys 89%, girls 65%), striking (boys 69%, girls 53%) and low for kicking (boys 45%, girls 41%). All children ≥11 years were proficient in all FMS except kicking (boys 61%, girls 55%). CONCLUSIONS: FMS proficiency were age and sex related with proficiency in most skills emerging around age 6 years. All children aged ≥11 years were proficient in all FMS, except kicking. The findings may be useful to guide the development of intervention programs in Iranian children aged 2.5-10 years.

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The continuing high prevalence of child overweight and obesity globally means that it remains the most common chronic health condition in children. Population-based child obesity surveillance systems are critical for monitoring trends in obesity and related behaviours, and determining the overall effect of child obesity prevention strategies. Effective surveillance systems may vary in methods, scope, purpose, objectives, and attributes, and our aim was to provide an overview of child obesity surveillance systems globally, and to highlight main components and other types of survey data that can enhance our understanding of child obesity. Measures of adiposity, including body mass index and waist circumference are essential, but effective surveillance must also include measures of weight-related behaviours, including diet, physical activity, sedentary time, and sleep. While objective measures are desirable, the variability in psychometrics and rapid evolution of wearable devices is potentially problematic for examining long-term trends over time and how behaviours may change. Questionnaires on self-reported behaviours are often used but also have limitations. Because the determinants of obesity are not only functioning at the individual level, some measures of the broader environmental and commercial determinants, including the built and food environments, are useful to guide upstream policy decisions.

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OBJECTIVES: To examine the relationship between school playground size and total physical activity (PA), fitness and fundamental movement skills (FMS) of primary school students. DESIGN: Cross-sectional ecological analysis. SETTING: 43 primary schools in New South Wales, Australia. PARTICIPANTS: Data were from 5238 students, aged 5 to 12 years, participating in the Schools Physical Activity and Nutrition Survey. OUTCOME MEASURES: Self (for age ≥11 years) and parent (for age <11 years) report of PA (meeting PA recommendations and number of days meeting recommendations), objectively measured FMS and cardiorespiratory and muscular fitness. RESULTS: Associations between playground space and measures of PA and fitness were mostly non-linear and moderated by loose equipment. Students in schools with no loose equipment showed a weak association between space and meeting PA recommendations (self-report). In schools with equipment, students' predicted probability of meeting PA recommendations increased sharply between 15 m2 and 25 m2 per student from 0.04 (95% CI: 0.01 to 0.08) to 0.30 (95% CI: 0.14 to 0.46), but at 30 m2 returned to levels comparable to students in schools with no equipment (0.18, 95% CI: 0.07 to 0.28). For cardiorespiratory fitness, in schools with no loose equipment, probabilities for being in the healthy cardiovascular fitness zone varied between 0.66 and 0.77, showing no consistent trend. Students in schools with loose equipment had a predicted probability of being in the healthy fitness zone of 0.56 (95% CI: 0.41 to 0.71) at 15 m2 per student, which rose to 0.75 (95% CI: 0.63 to 0.86) at 20 m2 per student. There was no relationship between space and FMS. CONCLUSIONS: School space guidelines need to incorporate sufficient playground space for students. Our study provides evidence supporting better PA outcomes with increasing space up to 25 m2 per student, and access to loose equipment, however further research is required to determine precise thresholds for minimum space. Intersectoral planning and cooperation is required to meet the needs of growing school populations.

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BACKGROUND: Since 2006 there has been substantial long-term investment in school-based child obesity prevention programs in New South Wales (Australia). Whether these programs have led to population level improvements in children's weight status and weight-related behaviors are yet to be determined. The purpose of this study was to describe changes in children's weight status and weight-related behaviors, including Indigenous children, who are at greater risk of poorer health outcomes than non-Indigenous children. METHODS: Representative cross-sectional population surveys conducted in 2010 and 2015 among children age 5-16 years (n = 15,613). Objective measurements included height, weight, waist circumference, cardiorespiratory fitness, and fundamental movement skills. Indigenous status and indicators of weight-related behavior (i.e., diet, physical activity, school travel, screen-time) were measured by questionnaire with parents responding for children age <10 years and self-report by children age ≥10 years. RESULTS: The prevalences of overweight/obesity, obesity and abdominal obesity were higher in 2015, than 2010, and higher among Indigenous than non-Indigenous children at both timepoints. There were some small positive changes towards healthier weight-related behaviors between surveys among all children, but many unhealthy weight-related behaviors remain highly prevalent. The magnitude of changes and the 2015 prevalences of weight-related behaviors were generally similar for Indigenous and non-Indigenous children. CONCLUSIONS: Schools play an important role in health promotion, but our findings suggest the current approaches need re-thinking. Upstream factors that shape weight-related behaviors such as the regulation of the food industry and food environment, urban, neighborhood and public transport planning must be including in solutions to ensure populations can eat healthily and be physical active.

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BACKGROUND: Authorities recommend that youth undertake at least 60 minutes of daily moderate-to-vigorous physical activity (MVPA), with young people having the opportunity to undertake at least half of this MVPA during school hours. METHODS: In this study, we examined the influence of school-level socioeconomic status (SES) on children's PA, fitness and fundamental movement skill (FMS) levels, and the barriers and enablers of children's PA in 86 Australian schools (41 primary, 45 secondary). School-level SES was based on an Index of Community Socio-Educational Advantage (ICSEA). School representatives reported potential barriers and enablers for children's PA. We used subjective and objectives measures of PA, fitness, and FMS levels. Multiple logistic regression examined the associations of ICSEA category (low or high) with barriers and enablers, and PA outcomes, adjusting for children's language background and residence. RESULTS: Children from high SES schools were more likely to achieve the healthy fitness zone for cardiorespiratory fitness; those from low SES schools consistently reported more barriers and fewer enablers than their high SES counterparts. CONCLUSIONS: Extra efforts may be required to address school-level barriers and enablers to enhance PA, fitness, and FMS levels for schools in disadvantaged areas.

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OBJECTIVE: To report the cross-sectional prevalence and 18-year trends in overweight, obesity and abdominal obesity among Australian children from culturally and linguistically diverse (CALD) backgrounds. SUBJECTS/METHODS: Four cross-sectional population health surveys conducted among children (age 4-16 years; n=26, 449) in 1997-2004-2010-2015 in New South Wales, (NSW) Australia. Adiposity outcomes were measured by trained field staff using standard procedures. Binomial regression models with a robust error variance were used to estimate prevalence ratio (PR) and 95% confidence intervals (CI) for overweight and obesity, obesity, and waist-to-height ratio (WHtR) ≥ 0.5 for children from Asian, European, and Middle Eastern language backgrounds compared with children from English-speaking backgrounds, adjusted for sociodemographic characteristics. RESULTS: Over time, children from Middle Eastern language backgrounds were consistently more likely to be overweight-obese (PR: 1.29-1.42), obese (PR: 1.49-1.65), and have WHtR ≥ 0.5 (PR: 1.42-1.90), compared with children from English-speaking backgrounds. Children from European language backgrounds generally had higher prevalence and children from Asian language backgrounds had lower prevalence, compared with children from English-speaking backgrounds. Between 1997 and 2015, there were significant trends in the prevalence of overweight and obesity combined among children from English-speaking (PR: 1.06, 95%CI: 1.02, 1.09), Middle Eastern (PR: 1.14, 95%CI: 1.05, 1.24), and Asian language backgrounds (PR: 1.14, 95%CI: 1.05, 1.24). The prevalence of WHtr ≥ 0.5 increased among children from English-speaking (PR: 1.21, 95%CI: 1.13, 1.31) and Middle Eastern (PR: 1.35, 95%CI: 1.16, 1.56) language backgrounds. CONCLUSIONS: Overall, the prevalence of overweight and obesity and abdominal obesity is high among NSW children from CALD backgrounds and has increased over time. This suggests that there is a greater scope in understanding, developing, and implementing interventions across the early life-course of children from CALD backgrounds.

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ISSUE ADDRESSED: Intakes of fruit and vegetables in children are inadequate. Our purpose was to examine national data on the proportion of Australian children meeting the fruit and vegetable recommendations in 2011-2012 and 2014-2015, assessing changes over time and differences by age, sex and socio-economic status (SES). METHODS: Secondary analysis of 2011-2012 and 2014-2015 Australian National Health Surveys of Australian children aged 2-18 years. Percentages of children meeting fruit and vegetable recommendations by survey year, age group, sex and SES tertile were calculated using population weights supplied by the Australian Bureau of Statistics (ABS). Chi-squared tests and logistic regression were used to test for the relative influence of each factor. RESULTS: In 2011-2012, 64.6%, 5.1% and 4.6% of children met the recommended intake for fruit, vegetable and fruit-vegetable combined, respectively. In 2014-2015, 68.2%, 5.3% and 5.1% of all children met the recommended intake for fruit, vegetable and fruit-vegetable combined, respectively. There was a large reduction in proportions of children meeting both the fruit and vegetable recommendations between 3 and 4 years of age, which coincides with when most Australian children start pre-school. There were consistent differences by sex for both fruit and vegetables, but we found little evidence that SES is a significant factor predicting the difference in meeting the vegetable recommendations. CONCLUSION: The proportion of Australian children meeting fruit and vegetable recommendations are sub-optimal across all SES groups which suggests that a national approach across demographic strata is warranted. SO WHAT?: Future health promotion interventions should have a refocus on vegetables instead of "fruit and vegetables," particularly in the key transition period when children start pre-school.

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OBJECTIVES: To offer a user's guide to select appropriate measures of motor competence for children and adolescents. DESIGN: Expert consensus among a working group of the International Motor Development Research Consortium (I-MDRC). METHODS: The guide provides information on objective (motion devices and direct observation) and subjective (self-reports and proxy reports) methods for assessing motor competence among children and adolescents. Key characteristics (age group, sample size, delivery mode, assessment time, data output, data processing) as well as limitations and practical considerations (e.g., cost, sources of error) with regard to each method are included in this paper. We do not recommend specific instruments, rather a guide to assist researchers and practitioners interested in assessing children's motor competence. RESULTS: A decision flow chart was developed to support practitioners and researchers in selecting appropriate methods for measuring motor competence in young people. Real-life scenarios are presented to illustrate the use of different methods in research and practice. CONCLUSIONS: Policy makers, practitioners and researchers should consider the strengths and limitations of each method when measuring motor competence in children and adolescents. This will allow them to choose the most appropriate instrument(s) that meets their needs.

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BACKGROUND: To examine the associations between school-age children's sedentary behavior, screen time, and 3 physical activity attributes: muscular strength, cardiorespiratory endurance (CRE), and fundamental movement skills. METHODS: Cross-sectional survey of 2734 children in years 2 and 4 and 3671 adolescents in years 6, 8, and 10. Total sitting time, 6 screen time behaviors, and physical activity were measured by self-report. Muscular strength was assessed by standing broad jump; CRE by 20-m shuttle run test; and fundamental movement skills by process-oriented checklists. Associations between incremental sitting and screen time (in hours) and meeting the healthy zone of physical activity attributes were examined using logistic regression. RESULTS: After adjusting for covariates and physical activity, children had lower odds of achieving the healthy zone for muscular strength and CRE for each hour of week (but not weekend) screen time. For adolescents, each hour of screen time per day was associated with lower odds of achieving the healthy fitness zone for CRE, locomotor skills, and overall healthy zone, and each hour of weekend screen time was associated with lower odds of achieving the healthy zone for most attributes and overall healthy zone. The associations were slightly stronger among adolescent girls than boys. The findings were similar for total sitting time. CONCLUSIONS: Screen time was associated with a lower likelihood to achieve healthy zones of physical activity attributes, and the effect was more consistent and slightly stronger among adolescents than children. This may suggest that the negative effects of screen time are incremental, emerging during adolescence.

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Childhood obesity is associated with low socioeconomic status in developed countries, and community programs can deliver cost-effective obesity interventions to vulnerable children and adolescents at scale. Evaluating these programs in a low-cost, time-efficient, and culturally appropriate way with valid and reliable measures is essential to determining their effectiveness. We aimed to identify existing valid and reliable short-form instruments (≤50 items for diet, ≤15 items for physical activity) suitable for the assessment of change in diet, physical activity, and sedentary behaviour in an Australian obesity intervention program for children and adolescents aged 7⁻13 years from low socioeconomic groups, with a focus on Aboriginal and Torres Strait Islander children. Relevant electronic databases were searched, with a focus on Australian literature. Validity and/or reliability studies using diet instruments (5), physical activity/sedentary behaviour instruments (12), and diet and physical activity/sedentary behaviour instruments used with Aboriginal and Torres Strait Islander (3) children were identified. Seven questions on diet, one question on physical activity, and no questions on sedentary behaviour were recommended. These questions can be used for evaluation in community-based obesity programs among Australian children and adolescents, including those from low socioeconomic groups and Aboriginal and Torres Strait Islander children.

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BACKGROUND: School-level socioeconomic status (SES) influences on adolescents' lifestyle behaviors is understudied. We examined how school-level SES and sex influence adolescents' health-related lifestyle behaviors and intentions. METHODS: Grade 8 students aged 13-14 years completed an online questionnaire regarding their sociodemographic characteristics, dietary behaviors, physical activity participation and recreational screen-time, and intentions regarding these behaviors. School-level SES, based on an Index of Community Socio-Educational Advantage (ICSEA), was categorized as low or high. Generalized estimating equations estimated individual-level summary statistics, adjusted for clustering. RESULTS: Students (N = 2538; response rate = 79%) from 23 high schools (low ICSEA = 16) participated. Compared with low ICSEA students, high ICSEA students were more likely to report eating breakfast daily (OR 1.9 [95% CI 1.5, 2.4]), not drinking sugar-sweetened beverages (SSBs) daily (2.9 [1.9, 4.3]), and were more likely to have intentions to eat breakfast (1.8 [1.3, 2.3]) and ≥ 5 vegetable serves (1.2 [1.0, 1.5]) daily. Boys were more likely than girls to meet recommendations for breakfast eating, vegetable intake, moderate-to-vigorous physical activity and screen-time, but boys were less likely to meet recommendations regarding SSB intake. CONCLUSIONS: Students from low ICSEA schools would benefit from additional support to improve dietary-related behaviors and intentions. More research is required to identify what targeted approaches will address sex differences in adolescents' lifestyle behaviors.

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OBJECTIVES: Muscular strength is an important component of fitness that enables the execution of a range of daily activities across the lifespan including sport participation. The purpose of this study was to examine changes in children's standing broad jump, an indicator of muscular strength, between 1985 and 2015. DESIGN: Two representative cross-sectional population surveys of Australian children age 9-15 years (n=7051). METHODS: In 1985 and 2015 children's standing broad jump (SBJ; cm) and anthropometry were measured by trained field teams. General linear regression examined the temporal change in SBJ by sex and age adjusting for height, weight, socioeconomic status, and linguistic background. RESULTS: Over a 30-year period, the height, weight, and BMI of children significantly increased and muscular strength decreased. Among boys, the adjusted SBJ distance declined -4.5cms (95%CI -8.8, -0.10) in 9-11 year olds and 7.6cms (95%CI -12.5, -2.7) in 12-15 year olds. Among girls, the adjusted SBJ distance declined 8.5cms (95%CI -12.9, -4.2) in 9-11 year olds and 9.3cms (95%CI -14.1, -4.6) in 12-15 year olds. Larger declines in the distance jumped were observed among children and adolescents from non-English speaking backgrounds, than English speaking peers and children from low socioeconomic neighbourhoods than the declines among children from high SES neighbourhoods. CONCLUSIONS: Overall, the distance children and adolescents jumped in 2015 was lower than the distance their peers jumped in 1985. The declines differed by sex and sociodemographic characteristics, which suggests targeted sub-population interventions to improve children's muscular strength should be considered.

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AIM: Children with obesity have a greater risk of adverse social and physical health outcomes. We examined temporal changes in body mass index (BMI) z-scores and the prevalence obesity and morbid obesity in children from 1985 to 2014. METHODS: Secondary data analysis of BMI data for children aged 7-15 years from five cross-sectional Australian datasets. Changes in age- and gender-adjusted BMI (BMI z-scores) and nutritional status were categorised using the International Obesity Task Force cut-off points. RESULTS: The percentage of children who were obese tripled between 1985 and 1995 from 1.6 to 4.7%, before plateauing between 1995 and 2014. The percentage of morbidly obese children was <1% in 1985 and 1995, increasing to 2% between 1995 and 2007, with no further increase between 2007 and 2014. The proportion of obese children classified as morbidly obese was 12% in 1985-1995, 24% in 2007-2012 and 28% in 2014. Between 1985 and 2012, the mean BMI z-score increased in children categorised as obese from 1.94 (standard deviation 0.15) to 2.03 (0.22), and then plateaued. For morbidly obese children, the mean BMI z-score was 2.4 (0.13) and remained similar over the study period. CONCLUSIONS: Our findings suggest that the relative fatness of children with morbid obesity, as measured by BMI z-score, has remained stable. The proportion of obese and morbidly obese children has also plateaued between 2007 and 2014. However, the prevalence of obesity remains high, and more dedicated resources are required to treat children with obesity to reduce the short- and long-term health impact.

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