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https://www.researchgate.net/profile/Janette-Bobis/publication/237832091_The_Integration_of_Mathematics_and_Music_in_the_Primary_School_Classroom/links/00b7d5282bd17d2560000000/The-Integration-of-Mathematics-and-Music-in-the-Primary-School-Classroom.pdf

# data[].attributes.attachment_link.readable_text
Aim. To examine how celiac children and adolescents on gluten-free diet valued their health-related quality of life, and if age and severity of the disease at onset affected the children's self-valuation later in life. We also assessed the parents' valuation of their child's quality of life. Methods. The DISABKIDS Chronic generic measure, short versions for both children and parents, was used on 160 families with celiac disease. A paediatric gastroenterologist classified manifestations of the disease at onset retrospectively. Results. Age or sex did not influence the outcome. Children diagnosed before the age of five scored higher than children diagnosed later. Children diagnosed more than eight years ago scored higher than more recently diagnosed children, and children who had the classical symptoms of the disease at onset scored higher than those who had atypical symptoms or were asymptomatic. The parents valuated their children's quality of life as lower than the children did. Conclusion. Health-related quality of life in treated celiac children and adolescents was influenced by age at diagnosis, disease severity at onset, and years on gluten-free diet. The disagreement between child-parent valuations highlights the importance of letting the children themselves be heard about their perceived quality of life.

1. Introduction

Celiac disease (CD) is a persistent intolerance to gluten causing a mucosal damage of the small intestine in genetically susceptible individuals. It is one of the most common food-related chronic diseases and it often emerges during childhood. Genetic and environmental factors interact in the pathogenesis, and currently the only treatment is a life-long adherence to a strict gluten-free diet [ 1].

When a disease starts during childhood, the development, growth, self-concept, identity, and mental health of the child may be affected. Chronically ill children are more prone to physical, psychological, and social strains than healthy children, which may influence the child's health-related quality of life (HRQoL) in a negative way [ 2]. The problems are often more pronounced during school age, when it is pertinent for the child not to be deviant from other children [ 3, 4]. The gluten-free diet may cause problems for the child and its family. It can be hard for the child both to accept and comply with the strict diet. Alienation, shame, fear of eating something that contains gluten, and a feeling of being a nuisance are some of the factors related to CD [ 5]. A high incidence of psychological problems, for example, anxiety and depression, has been reported in CD children compliant to a strict gluten-free diet [ 6]. Relatives of CD patients often worry about how the person with CD will manage their everyday life and their social life [ 7]. Parents of children with chronic diseases often describe a large need of professional support, education, and guidance in questions concerning the child's disease [ 8].

There have been several studies concerning the HRQoL of adults with CD [ 5, 7, 9- 12] but only a few studies comprise children [ 13- 15]. In this study, we have examined how children and adolescents with CD valued their present HRQoL, and also if age, sex, and manifestation of the disease at onset affected the children's later valuation of their HRQoL. Furthermore, there are studies showing discrepancies between parents' and children's reports on the HRQoL [ 16, 17]; hence, we also compared the parents' valuation of their child's HRQoL with the corresponding assessment done by their child.

2. Patients and Methods

2.1. Patients

The study comprises children with treated CD and their parents, who visited the pediatric clinics in the south east of Sweden, that is, Linköping, Norrköping, Motala, and Västervik, for their annual follow-up in 2006-2007. A total of 160 families, with CD children 8-18 years of age, were asked to participate and all of them agreed. The children were administered the child's version of the questionnaire and the parents were asked to fill in the proxy version. The questionnaires were both filled in and handed in at the time of the visit at the clinic. Children with both CD and diabetes, with poor understanding of the Swedish language, or with cognitive difficulties were not included in the study. In nine of the participating families, there were two siblings with CD.

2.2. Measures

The study is a cross-sectional study with consecutive selection. The subjective health status of the children during the last four weeks was assessed using the Swedish version of the DISABKIDS Chronic generic measure (DCGM-12, short version) [ 18], a questionnaire where the child estimates its quality of life based on three domains: mental health, social health, and physical health. The questionnaire is constructed to address chronically ill children between 8 and 18 years of age. There is also a proxy version of the questionnaire, where the parents estimate the quality of life of their child. The DISABKIDS questionnaire is a well-validated test, (the child version) and .86 (the proxy version) [ 18], and it is translated into several languages including Swedish [ 19]. The questionnaire is available in both a long and a short version, and the short version was used for this study.

The domain mental health contains four questions about independence, including autonomy and ability to live without restrictions due to the disease, and emotion, including anxiety, anger, and worries. The domain social health contains two questions concerning social community, including acceptance by and good relations to others, and two questions concerning social exclusion, including shame and feeling of exclusion. Two questions in the domain physical health concern functional limitations and subjective physical health status. In this domain, there are also questions concerning medical treatment, which are of no relevance for this study. A 5-graded Likert scale scores each question, where high scoring represents high HRQoL. At the analysis, each question was recoded from 1-5 points to 0-100 points, according to the user's manual for DISABKIDS.

2.3. Manifestation of Disease at Onset

The severity of the disease at onset was estimated retrospectively by an experienced paediatric gastroenterologist. The classification was done according to Fasano and Catassi [ 1], describing three groups of clinical presentations. Classical (typical) form means that the child had the typical celiac symptoms and signs at onset, that is, diarrhea, failure to thrive, loss of weight, great fatigue, enlarged abdomen, recurrent infections, and low serum albumin levels. Atypical form means a less pronounced onset, often with no typical gastrointestinal symptoms. Asymptomatic means that the child had no obvious symptoms and the investigation was prompted when a close relative got the diagnosis of CD. The health estimations were scored as follows: "Classical form" = 1 point, "Atypical form" = 2 points, and "Asymptomatic form" = 3 points.

3. Ethics and Statistics

Informed consent was received from all the participating parents, and the study was approved by the Research Ethics Committee at the Faculty of Health Sciences, Linköping University, Linköping, Sweden.

Since data were not normally distributed, nonparametric tests were used. For analysis of quantitative data (e.g., male/female), the Mann-Whitney -test was used, and Wilcoxon's test was used for comparisons between paired groups (e.g., child/parents). When comparing three or more groups, the Kruskal-Wallis test was used. The relationship between variables was analyzed using Spearman correlation analysis. All analyses were performed using GraphPad Prism (version 5.0d for Mac OS X, GraphPad software, San Diego, CA), and values equal or less than 0.05 were considered significant. If nothing else is indicated, all values are presented as median (25th percentile-75th percentile).

4. Results

The study comprises 160 children with confirmed celiac disease, 55 males and 105 females. Median age at inclusion, that is, when the questionnaire was filled in, was 13 years (range 8-18 years), and the median time since the diagnosis of CD was 10 years (range 1-17 years). The children were diagnosed between the years 1989 and 2006. A high percentage of the included cases (43%) were diagnosed between 1992 and 1996. The children were divided into three age groups: 8-11 years (), 12-15 years (), and 16-18 years (). The final response rate was 97.5% (, 54 males, 102 females) among the children and 95% () among the parents. One child-questionnaire was ruined and three parents were visiting the clinic without their children, hence the loss among the children (). Eight adolescents visited the clinic without their parents, explaining the loss among the parents (). Hence, the results from comparisons between children and parents are presented from 149 child/parents pairs. Age and sex distribution, as well as the response rate, are shown in Table 1.

4.1. Total Score

The median value of the children's total score was 92 points (85.5-96). The median values in the separate specific domains were mental health 85 points (75-95), social health 95 points (85-100), and physical health 100 points (90-100).

4.2. Sex and Age

Sex and age did not correlate with the children's HRQoL score ( and , resp.). The only difference was seen in the age group 8-11 years, in which the boys () scored lower than the girls () in the domain physical health, with scores of 95 (90-100) and 100 (100-100), respectively ().

4.3. Years Since Diagnosis

The years since diagnosis were weakly () but significantly () correlated with the children's self-assessed quality of life. Those who received their diagnosis nine or more years ago valued their HRQoL higher than those who received it more recently (1-8 years), with scores of 92 (58-96) and 90 (36-94), respectively (). This was true also in the domain mental health where the groups scored with the median of 90 (55-95) and 85 (35-90), respectively ().

4.4. Age at Diagnosis

Age at diagnosis was negatively correlated with the HRQoL score (). The children who received the diagnosis before the age of five () scored higher than to those who were five years old or more () at the diagnosis, with scores of 92 (88-96) and 90 (82-94), respectively () (Figure 1).

In the domain mental health, the children diagnosed before or after five years of age scored with the median of 90 (55-95) and 85 (35-95), respectively (), and in the domain social health median 95 (90-100) and 90 (85-100), respectively () (Figure 1).

4.5. Disease Manifestation at Onset

The children who presented with the classical form of CD () valued their present HRQoL as higher than those who presented with atypical form () or those who were asymptomatic () with scores of 92 (88.5-97.5), 90 (84-94), and 88 (80.5-94.5), respectively, with a significant difference between the classical and the atypical group (). The median age in the three groups was 1, 7, and 7.5 years, respectively. The disease state at onset was found to be correlated with the children's total score ().

4.6. Parents/Children

The parents' median total score for their children's HRQoL was 86 (80-92) while the children's median total score was 92 (84-96), and this difference was significant (), although the values were well correlated (, ). The parental estimations were lower also in the specific domains: in mental health the parents' and the children's median score was 80 (75-90) and 85 (75-95) (); in social health 90 (80-95), and 95 (85-100) (); and in the domain physical health 100 (20-100) and 100 (50-100) (), respectively (Figure 2).

Age and sex of the children did not correlate with the parents' valuation of the children's HRQoL, neither did the manifestation of the disease at onset. However, there were significant differences in the estimation of the HRQoL if the child was diagnosed before or after the age of five (median 86, 82-94 and median 84, 78-90, resp.) (). There was also a weak, but significant, correlation between the parents' estimation and the duration of the disease for the child ().

5. Discussion

In this study, we have assessed the subjective health-related quality of life in children and adolescents with treated CD, and the corresponding evaluation made by their parents. We found that the children valued their quality of life as very high, but the parents estimated their children's HRQoL as lower than their children.

The results suggest that the children, as a group, have adapted well to the disease. Indeed, in two earlier studies [ 14, 15], the authors claim that children with CD who keep a strict gluten-free diet experience the same high HRQoL as healthy children. While being aware that we could lower the sensitivity and specificity by not choosing a disease specific measure [ 20], we have used the DISABKIDS chronic generic measure, which is a well-established and validated instrument for assessing HRQoL in children with chronic diseases [ 18]. The instrument may be used for different diagnostic groups, and this makes comparisons possible on how distinct diseases affect children's self-estimated quality of life. In a pilot study done by the DISABKIDS group, other chronic diseases, such as asthma, arthritis, dermatitis, diabetes, cerebral palsy, cystic fibrosis, and epilepsy, were tested [ 18]. The mean total score for these conditions ranged between 63 and 81 points, with the cerebral palsy children scoring lowest and the asthma children highest. There were no reference values for celiac disease; hence, the present study is to best of our knowledge the first to show values for CD using this instrument. The CD children in our study scored higher than the children affected by other chronic diseases both in total score and in the three domains of the questionnaire.

Measurements of HRQoL based on life situations are difficult to perform, since both subjective and objective circumstances must be taken into consideration. It has been reported that children's compliance to a gluten-free diet was correlated with the parent's knowledge and understanding of the disease. This in turn was highly correlated with the social status of the families [ 21]. In the present study, neither the socioeconomic factors of the family, nor the parents' occupation, education, or the living environment have been highlighted. However, in order to elucidate the significance of different factors on the quality of life, we related the HRQoL of the children to age, sex, years since diagnosis, age at diagnosis, and the severity of the disease at onset. The results show that sex had no impact on the HRQoL, neither had age as a single factor.

Children who were diagnosed before the age of five scored better than those who were five years or older at the diagnosis. Furthermore, we noted that children who had had their disease for a long time experienced their current quality of life as higher. These results are consistent with the report from Högberg et al. [ 22], where children who were diagnosed before the age of four accepted their illness and the gluten-free diet better than those who were diagnosed later. The young children have probably not been accustomed to the taste of gluten-containing food, which may result in a better compliance to the gluten-free diet. There are studies showing that it may be difficult to adapt to a chronic disease during adolescence, the period of life when the needs to be like the others probably are the highest [ 3, 23, 24].

An additional factor influencing the children's HRQoL was the manifestation of the disease at onset. The classification into three groups was done retrospectively by an experienced paediatric gastroenterologist, thereby increasing the reliability of the assessment. The children who presented with the classical form of the disease valued their HRQoL as highest. The majority of the children in this study who were diagnosed before the age of four presented with the typical CD symptoms, for example, diarrhea, failure to thrive, loss of weight, and enlarged abdomen. Currently, the median age at diagnosis has increased, and children receive their diagnosis more often at an older age and present with more diffuse symptoms [ 25]. Further studies should be performed on the latter patient group, using the same instrument, in order to reveal the importance of age at diagnosis and disease severity as predictors of HRQoL later in life.

Some children in this study had extremely low scores in HRQoL (Figure 2). We cannot explain if this is due to celiac disease or due to other factors that were not assessed in this study. Yet, such low values should alert the health professionals to evaluate the need for psychological and social support.

According to Eiser and Morse [ 26], parents with chronically ill children are able to make a better valuation of their child's HRQoL as compared to parents with healthy children. In the present study, the parents valued their children's HRQoL as lower than the children themselves did. This was noted both for the total quality of life and for the three domains mental, social, and physical health. Sawyer et al. [ 27] described how health care professionals often listen only to the parent's description of the child's problems, which may lead to a misinterpretation of the child's HRQoL by the staff and a risk for overtreatment of the child. Parents of CD children are often worried about possible complications, development of other autoimmune diseases, fertility, and heredity. They are also concerned about what the children have to endure, and what they have to abstain from, and indeed, the greatest discrepancy between children and parents in this study was seen in the domain social health. The parent's lower valuation of their children's HRQoL may also be due to the parent's sense of responsibility and concern as the basis for the valuation [ 27]. Many parents feel guilt, sadness, bitterness, and difficulties of coping in the everyday life when their child is diagnosed with a chronic disease. Indeed, parents in all the diagnostic groups in the pilot studies in DISABKIDS valued the children's HRQoL lower than their children did [ 18]. Interestingly, when assessing HRQoL in the parents of children with CD, de Lorenzo et al. [ 13] found an impaired self-valuation in comparison to parents of healthy children, especially in the social dimension. This suggests an impact of the diet regimen and possibly other factors on the parents and on close relatives, a suggestion that was also proposed by Sverker et al. [ 7].

The parent's valuation was also affected by the age of the child at the time of diagnosis. The younger the child was at onset, the better was the parent's valuation of its present HRQoL. This may be due to the fact that the youngest children also had the most severe symptoms of the disease and, hence, were the ones that most obviously benefitted from the gluten-free diet. Furthermore, parents of children who had the diagnosis for a long time tended to value their child's quality of life higher, possibly reflecting that the families were getting used to the diet regimens and all the difficulties that could come out of it.

One important limitation of the present study was the lack of a control group of healthy individuals. However, the instrument used in the study was developed to address children with chronic diseases making the use of a healthy control group difficult. Furthermore, while our study group had higher HRQoL than groups with other chronic diseases, other studies reported that children with CD generally had high values in HRQoL measurements and that the values were similar to the control groups [ 13, 14]. On the contrary, when assessing psychological symptoms in treated CD children and controls, Mazzone et al. [ 6] found signs of more depression and anxiety in the CD group, indicating an influence of the strict diet regimen on the child's psychological well-being, something that health care professionals should be aware of.

The reason for using HRQoL instruments in health care is to get a combined picture of the mental, social, and physical health of the child. This could help the health care professionals in getting a clearer view of how the children and their relatives experience chronic diseases. In the present study, it was important that both the celiac child and the parents made an estimation of the child's current HRQoL, in order to improve our knowledge of the living conditions for celiac families.

In conclusion, children who were diagnosed before the age of five and who presented with the classical form of CD scored their health-related quality of life higher. The children who have had the disease for a longer time also scored higher. The celiac children in this study scored higher than other diagnostic groups assessed with the same instrument. Notably, the parents scored significantly lower than the children when they were asked to evaluate their child's HRQoL. The disagreement between the self- and the proxy valuations highlights the importance of letting the children themselves be heard about their perceived quality of life.

Abbreviations

Acknowledgments

The authors express their gratitude to the children and their parents for participating in this study, and to the staff at the paediatric clinics in Linköping, Norrköping, Motala, and Västervik for administering the questionnaires. This work was financially supported by the Swedish Research Council (VR: Medicine), The Health Research Council in the South-East of Sweden (FORSS), and the Swedish Celiac Society.

# data[].attributes.attachment_link.title
Health-Related Quality of Life in Children and Adolescents with Celiac Disease: From the Perspectives of Children and Parents

# data[].attributes.attachment_link.description
Aim . To examine how celiac children and adolescents on gluten-free diet valued their health-related quality of life, and if age and severity of the disease at onset affected the children's self-valuation later in life. We also assessed the parents' valuation of their child's quality of life. Methods .

# data[].attributes.body
https://journals.sagepub.com/doi/abs/10.1111/1467-9280.00366

Sophie, Aqsa, Tia and Emily

# data[].attributes.attachment_link.readable_text
Research on exposure to television and movie violence suggests that playing violent video games will increase aggressive behavior. A meta-analytic review of the video-game research literature reveals that violent video games increase aggressive behavior in children and young adults. Experimental and nonexperimental studies with males and females in laboratory and field settings support this conclusion. Analyses also reveal that exposure to violent video games increases physiological arousal and aggression-related thoughts and feelings. Playing violent video games also decreases prosocial behavior.

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Huesmann, L.R. (Ed.). (1994). Aggressive behavior: Current perspectives. New York: Plenum Press.
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# data[].attributes.attachment_link.title
Effects of Violent Video Games on Aggressive Behavior, Aggressive Cognition, Aggressive Affect, Physiological Arousal, and Prosocial Behavior: A Meta-Analytic Review of the Scientific Literature

# data[].attributes.attachment_link.description
Research on exposure to television and movie violence suggests that playing violent video games will increase aggressive behavior. A meta-analytic review of the video-game research literature reveals that violent video games increase aggressive behavior in children and young adults. Experimental and nonexperimental studies with males and females in laboratory and field settings support this conclusion.

# data[].attributes.body
Coronavirus (COVID-19) and the use of face coverings in education settings (publishing.service.gov.uk)Emma, Daisy and Tori

# data[].attributes.body
https://journals.sagepub.com/doi/abs/10.1111/1467-9280.00366

- Sophie, Aqsa, Tia and Emily

# data[].attributes.attachment_link.readable_text
Research on exposure to television and movie violence suggests that playing violent video games will increase aggressive behavior. A meta-analytic review of the video-game research literature reveals that violent video games increase aggressive behavior in children and young adults. Experimental and nonexperimental studies with males and females in laboratory and field settings support this conclusion. Analyses also reveal that exposure to violent video games increases physiological arousal and aggression-related thoughts and feelings. Playing violent video games also decreases prosocial behavior.

Anderson, C.A., Bushman, B.J. (in press). The General Aggression Model: An integrated social-cognitive model of human aggression. Annual Review of Psychology.
Google Scholar

Anderson, C.A., Dill, K.E. (2000). Video games and aggressive thoughts, feelings, and behavior in the laboratory and in life. Journal of Personality and Social Psychology, 78, 772-790.
Google Scholar

Bandura, A. (1971). Social learning theory of aggression. In Knutson, J.G. (Ed.), Control of aggression: Implications from basic research (pp. 201-250). Chicago: Aldine-Atherton.
Google Scholar

Buchman, D.D., Funk, J.B. (1996). Video and computer games in the '90s: Children's time commitment and game preference. Children Today, 24, 12-16.
Google Scholar

Bushman, B.J., Huesmann, L.R. (2001). Effects of televised violence on aggression. In Singer, D.G. Singer, J.L. (Eds.), Handbook of children and the media (pp. 223-254). Thousand Oaks, CA: Sage.
Google Scholar

Cohen, J. (1988). Statistical power analysis for the behavioral sciences (2nd ed.). Hillsdale, NJ: Erlbaum.
Google Scholar

Hedges, L.V., Olkin, I. (1985). Statistical methods for meta-analysis. New York: Academic Press.
Google Scholar

Huesmann, L.R. (Ed.). (1994). Aggressive behavior: Current perspectives. New York: Plenum Press.
Google Scholar

Neter, J., Wasserman, W., Kutner, M.H. (1990). Applied linear statistical models (3rd ed.). Homewood, IL: Irwin.
Google Scholar

Weller, S.C. (1993). A meta-analysis of condom effectiveness in reducing sexually transmitted HIV. Social Science and Medicine, 36, 1635-1644.
Google Scholar

Zillmann, D. (1983). Cognition-excitation interdependencies in aggressive behavior. Aggressive Behavior, 14, 51-64.
Google Scholar

# data[].attributes.attachment_link.title
Effects of Violent Video Games on Aggressive Behavior, Aggressive Cognition, Aggressive Affect, Physiological Arousal, and Prosocial Behavior: A Meta-Analytic Review of the Scientific Literature

# data[].attributes.attachment_link.description
Research on exposure to television and movie violence suggests that playing violent video games will increase aggressive behavior. A meta-analytic review of the video-game research literature reveals that violent video games increase aggressive behavior in children and young adults. Experimental and nonexperimental studies with males and females in laboratory and field settings support this conclusion.

# data[].attributes.body
https://www.cambridge.org/core/journals/disaster-medicine-and-public-health-preparedness/article/psychological-effects-and-associated-factors-of-covid19-in-a-mexican-sample/7F6A1DB36F91BA6957BF1D0743F683B4

# data[].attributes.attachment_link.readable_text
Coronavirus disease 2019 (COVID-19) originated in the city of Wuhan, China, on December 31, 2019. Since its discovery, a rapid community, regional, and international spread has occurred with exponential growth in cases and deaths. The COVID-19 outbreak was confirmed to have reached Mexico on February 28, and on March 30, the Mexico government declared a national health emergency.Reference de Gobernación2 In the face of a health crisis, not seen in several years, response efforts by the government in coordination with the Secretaría de Salud (Ministry of Health) of Mexico have been swift, implementing a series of preventions, actions, and control infections in the country, including extension of school vacation period, home office, restriction of massive events, suspension of "nonessential activities" in all economic sectors, and the recommendation of home confinement for the general population. Some negative implications that COVID-19 has had in Mexico include the generation of panic buying and shoplifting, which in turn has led to the eventual shortage of antibacterial hand gel and face masks, a fall in the price of fuel, and the temporary or definitive closure of companies.Reference Villa y Caña and Morales6 In fact, in the past month, 346,878 formal jobs were lost in Mexico between March 13 and April 6.Reference Díaz-Bautista7

COVID-19 not only threatens people's physical health, but also could affect people's mental health, as many theories indicate. For example, according to Behavioral Immune System theory,Reference Terrizzi, Shook and McDaniel8 people show emotions, such as aversion and anxiety, for self-protection.Reference Mortensen, Becker and Ackerman9,Reference Schaller and Murray10 Moreover, stress theoryReference Norris, Friedman and Watson11 and perceived risk theory mention that public health emergencies trigger negative emotions, which may reduce the immune function of people and destroy the balance of their normal physiological mechanisms.Reference Kiecolt-Glaser, McGuire and Robles13 In support, previous studies have shown the immediate psychological sequelae of a pandemic, as occurred with severe acute respiratory syndrome (SARS) and H1N1, include stress, poor sleep, depressed mood, weepiness, nightmares, and poor concentration.Reference Chua, Cheung and McAlonan14 Furthermore, it has also been shown that people experience fear of falling sick or dying themselves, feelings of helplessness, irrational nervousness, loneliness, and stigma.Reference Tsang, Scudds and Chan15,Reference Wang, Xu and Zhao16

Also, it has been identified that certain groups are more vulnerable to high psychological distress during a pandemic. Taylor et al. reported that, during an outbreak of equine influenza, younger people, those with no formal educational qualifications, and those with financial dependence on an industry facing a crisis are significantly predisposed to high psychological distress. Finally, the authors also identified that those with 1 child had a 1.2 times higher risk of high psychological distress than those with no children.Reference Taylor, Agho and Stevens17 For their part, during pandemic influenza, Jacobs et al. found that individuals with poor self-rated health reported greater risk perception and concern for self and others than individuals with good self-rated health.Reference Jacobs, Taylor and Agho18 Finally, di Giuseppe et al. reported that people with lower socioeconomic status and lower education showed significantly higher risk perception during avian influenza.Reference Di Giuseppe, Abbate and Albano19

Therefore, it is essential to understand the potential psychological effects caused by COVID-19 in a timely manner. Based on our understanding, there is no information on the psychological distress and mental health of Mexican populations concerning COVID-19. This is especially pertinent with the uncertainty surrounding an outbreak of such unparalleled magnitude in our country. Therefore, this study aims to examine the levels of psychological distress (anxiety, depression, and stress) and identify risk factors contributing to worse outcome during the COVID-19 outbreak in a Mexican sample. We hypothesized that most of the respondents will show severe psychological distress and moderate depressive, anxiety, and stress levels caused by COVID-19. In addition, age, gender, and financial status will be factors contributing to worse outcomes.

METHODS

RESULTS

A total of 1105 persons from 32 states in Mexico were included in the study (more details see Appendix 2, online only) from a convenience sample of 1109 respondents (response rate = 99.63). Sociodemographic characteristics of the final sample of respondents are presented in Table 1. The majority of respondents were female (62.1%), aged 18 to 28 y (68.7%) (SD = 10.46), single (71.1%), with a household size of >3 people (51.6%), without children (67.4%), and well educated (71.2% ≥ college degree).

DISCUSSION

This study examined the psychological distress of COVID-19 in a Mexican sample, just 1 wk after a national health emergency was declared in Mexico. To our knowledge, this study is the first to evaluate psychological distress in a Mexican sample. Our findings showed that 50.3% of respondents rated the psychological distress of the outbreak as moderate to severe; 15.7% of respondents reported moderate to severe depressive symptoms; 22.6% of respondents reported moderate to severe anxiety symptoms; and 19.8% reported moderate to severe stress levels. The prevalence of moderate or severe psychological distress as measured by IES-R was higher than the prevalence of depression, anxiety, and stress as measured by the DASS-21. The differences in the results obtained between IES-R and DASS-21 may be due to the fact that the IES-R assesses psychological distress after a specific event. Therefore, respondents might refer the COVID-19 outbreak as the event, while the DASS-21 did not specify any such event, as previously reported.Reference Wang, Pan and Wan20

According to similar epidemics and pandemics, in such cases, serious concerns, such as fear of death can arise, and feelings of loneliness and anger can develop among people who are quarantined.Reference Brooks, Webster and Smith26 In addition, people who are quarantined lose face-to-face connections and traditional social interventions, and this is a stressful phenomenon.Reference Zandifar and Badrfam27 Therefore, at these points, it was not surprising to find that the Mexican sample showed severe psychological distress during the COVID-19 outbreak, similarly with the findings originating from China,Reference Wang, Pan and Wan20,Reference Dong and Bouey28 Canada,Reference Asmundson and Taylor29 Iran,Reference Zandifar and Badrfam27 Japan,Reference Shigemura, Ursano and Morganstein30 and Singapore.Reference Ho, Chee and Ho31

In support, it is recognized that widespread outbreaks of infectious diseases, such as SARS,Reference Wu, Fang and Guan32 H1N1,Reference Matsuishi, Kawazoe and Imai33 and actually, COVID-19, are associated with psychological distress and symptoms of mental illness.Reference Bao, Sun and Meng34 Both psychologists, psychiatrists, and the health care system at large should be aware of these manifestations to subsequently implement early psychological interventions according the needs of specific populations.

Our findings suggest that females suffered greater psychological distress of the outbreak as well as higher levels of stress, anxiety, and depression. This finding corresponds to previous studies which found that women were at higher risk of depression,Reference Baxter, Scott and Ferrari35,Reference Whiteford, Degenhardt and Rehm36 anxiety,Reference Jalnapurkar, Allen and Pigot37 and stress.Reference Sandanger, Nygård and Sørensen38 It is likely that genetic, biological, chemical, hormonal, environmental, psychological, and social factors all intersect to contribute to mental disorders in women. In addition, we found that with older age, participants showed greater stress and had a greater psychological distress of COVID-19 outbreak. Young, middle-aged, and older adults may have diﬀerent levels of exposure to school-related, work-related, and health-related stressors because of their life stages and associated life events.Reference Chen, Peng and Xu40 In addition, the Mexico government has shut down schools at all levels indefinitely. Currently, teachers are using online platforms to deliver lectures or other teaching activities. However, the uncertainty and potential negative distress on academic progression could have an adverse effect on the mental health of young people.

We found that divorced status had a greater likelihood of depression during the epidemic; in support, prior findings showing that the end of marriage through divorce is associated with a significant increase in the probability of a future depressive episode.Reference Sbarra, Emery and Beam41 Participants who live with 1 other person exhibited greater anxiety and greater psychological distress of the COVID-19 outbreak. This finding corresponds to previously extensive epidemiological studies which found that family size predicts anxiety.Reference Grinde and Tambs42

On the other hand, it is necessary that the health authorities identify the immediate psychological needs of the general population presenting with physical symptoms during the epidemic. Our results revealed that the Mexican sample, which presented specific symptoms of COVID-19, experienced greater psychological distress on the outbreak and higher levels of stress, anxiety, and depression. Health professionals should take the opportunity to provide resources for psychological support and interventions for those who present with the above symptoms, especially during clinical consultations. Moreover, such interventions should also be guaranteed for infected individuals and their caregivers.Reference Wang, Pan and Wan20 Taking a family history is essential, and health professionals should enquire about the level of concern for other family members of contracting COVID-19, as these concerns are associated with altered mental status. In support, our results showed respondents had been in direct or indirect contact exhibited higher levels of anxiety, stress, and depression.

The goal of communication before and during a pandemic is to provide and exchange relevant information with the public, partners, and stakeholders to allow them to make well-informed decisions and take appropriate actions to protect health and reduce the distress of rumors. In our study, lack of confidence in the COVID-19 test security and lower satisfaction with the health information received were associated with higher psychological distress of the outbreak and higher levels of stress, anxiety, and depression. Therefore, it is crucial to provide clear health information, with comprehensible messages and based on evidence to avoid adverse psychological reactions.Reference Wray, Becker and Henderson44

A major adverse consequence of the COVID-19 pandemic is likely to be increased social isolation and loneliness, which are strongly associated with anxiety, depression, self-harm, and suicide attempts across the lifespan.Reference Holmes, O'connor and Perry45 In our study, the majority of the participants that were homebound for >9 h/d during the epidemic suffered greater psychological distress from the outbreak as well as higher levels of depression. Under these conditions, the content of psychological interventions needs to be modified to suit the needs of the general population during the epidemic. Psychologists should produce and disseminate information materials on the psychological consequences of the quarantine and toll-free numbers should be activated to support all those who are confronted with psychological distress.Reference Orrù, Ciacchini and Gemignani46 For example, cognitive behavior therapy could be delivered online or by means of telephone to counteract depression in the home environment. For this reason, fine tuning effective psychological interventions is a future need, given that, after the public health emergency, a psychological distress emergency seems on the horizon.

Finally, our findings showed that specific precautionary measures as hand hygiene and wearing masks were associated with lower levels of psychological distress, depression, anxiety, and stress. Our finding is similar to a previous study, which suggests that the precautionary measures adopted to prevent the spread of COVID-19 could have had protective psychological effects during the early stage of the epidemic.Reference Wang, Pan and Wan20

This study has several limitations. First, due the time-sensitivity of the COVID-19 outbreak, we used the snowball sampling strategy; this strategy was not based on a random selection of the sample, and the study population did not reflect the actual pattern of the general population. Second, the sampling was carried out by students, leading to selection bias. Therefore, our conclusion was less generalizable to the entire population, particularly less-educated people. Last, the number of respondents with contact history and who had sought medical consultations was very small. As a result, our findings could not be generalized to confirmed or suspected cases of COVID-19.

Notwithstanding the above limitations, this study provides invaluable information on the psychological effects in the Mexican sample, 1 wk after the outbreak of COVID-19 was declared a national health emergency in Mexico. In addition, our results could be used as a historical reference and provide a baseline for evaluating prevention, control, and treatment efforts throughout the remainder of the COVID-19 epidemic.

CONCLUSIONS

Together, the data show that the COVID-19 outbreak results in considerable psychological distress among the Mexican sample examined. Public health officials, infectious diseases physicians, psychiatrists, psychologists, and the health care system at large need to be made aware of this issue.

# data[].attributes.attachment_link.title
Psychological Effects and Associated Factors of COVID-19 in a Mexican Sample | Disaster Medicine and Public Health Preparedness | Cambridge Core

# data[].attributes.attachment_link.description
Coronavirus disease 2019 (COVID-19) originated in the city of Wuhan, China, on December 31, 2019. Since its discovery, a rapid community, regional, and international spread has occurred with exponential growth in cases and deaths.

# data[].attributes.attachment_link.readable_text
G. A. Rees , C. J. Richards , J. Gregory ,

J. Gregory

School of Biological Sciences, The University of Plymouth, Drake Circus, Plymouth, UK
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C. J. Richards

School of Biological Sciences, The University of Plymouth, Drake Circus, Plymouth, UK
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G. A. Rees

School of Biological Sciences, The University of Plymouth, Drake Circus, Plymouth, UK
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First published:

Dr G. Rees, School of Biological Sciences, University of Plymouth, Drake Circus, Plymouth, PL4 8AA, UK.Tel.: 01752 238317Fax: 01752 232970E-mail: gail.rees@plymouth.ac.uk

Abstract

Background New school meal standards are currently being phased in by the government in an attempt to improve the nutritional composition of school food. However, no standards are applied to packed lunches. The present study aimed to compare the food and nutrient intakes of primary school children eating a school meal with those taking a packed lunch.

Methods A sample of 120 children, aged 6-11 years, was observed once at a lunch time and all items consumed were recorded. Nutrient analysis was performed, and differences in nutrient intake between those children consuming packed lunches and school meals were determined.

Results Mean energy and protein intakes were similar. The amount of energy provided by starchy carbohydrate was also similar but, compared with school meals, packed lunches provided twice as much energy from sugar ( P < 0.001). School meals on average provided more energy from fat ( P < 0.001), but intakes of saturated fat were lower in the school meals group ( P = 0.021). Packed lunches provided more sodium ( P < 0.001), calcium ( P < 0.001) and iron ( P  = 0.016) than the school meals. Very few packed lunches contained vegetables, and fruit intake was particularly low for those having a school meal.

Conclusions Children taking a packed lunch to school were consuming approximately double the amount of sugar and 50% more sodium and saturated fat in their midday meal compared with those having a school lunch. However packed lunches were providing children with more calcium, iron and fruit.

Conflict of interests, sources of funding and authorship

The authors declare that they have no conflict of interest.

No funding declared.

All authors were involved in the conception and design of the study. CJR and JG collected the data and performed the nutritional analysis. GAR performed the statistical analysis and wrote the paper. All authors critically reviewed the manuscript and approved the final version submitted for publication.

Introduction

With the rising prevalence of obesity in children causing concern in the UK, government and media attention has recently focused on school food, especially the nutritional composition of school meals. Food-based standards for school meals have been in place since 2001, but these have not been effective at improving nutrient intake ( Nelson et al., 2007). A national survey conducted in primary schools ( Nelson et al., 2006) showed that schools were failing to meet the food-based standards. Of 146 schools, only 23% met all the compulsory standards at the start of service over 5 days.

The government therefore established a review of school meals and set up the School Meals Review Panel (SMRP) to consider nutrient-based standards. In 2005, a new public body 'The School Food Trust' ( http://www.schoolfoodtrust.org.uk) was established by the Department for Education and Skills (DfES) to take forward the recommendations of the SMRP ( SMRP, 2005).

The new standards for school meals were announced in May 2006 and have been gradually phased in. In September 2006, interim food-based standards were introduced (revised September 2007; School Food Trust, 2007a); 1 year later, food-based standards for food other than lunches served in schools were introduced; and the final food and nutrient-based standards will be introduced in September 2008 ( Table 1). DfES is providing £220 million of funding over 3 years (2005-2008) to schools and local authorities in order to introduce the new standards, with an additional £240 million to cover the period 2008-2011 ( School Food Trust, 2007a).

Energy

30% of the estimated average requirement (± 5%)

Protein

Minimum of 30% of reference nutrient intake (RNI)

Total carbohydrate

Minimum of 50% of food energy

Nonmilk extrinsic sugars

Maximum of 11% of food energy

Fat

Maximum of 35% of food energy

Saturated fat

Maximum of 11% of food energy

Fibre (NSP)

Minimum of 30% of the calculated reference value

Sodium

Maximum of 30% of the SACN recommendation

Vitamin A

Minimum of 35% of the RNI

Vitamin C

Minimum of 35% of the RNI

Folate

Minimum of 35% of the RNI

Calcium

Minimum of 35% of the RNI

Iron

Minimum of 35% of the RNI

Zinc

Minimum of 35% of the RNI

SACN, Scientific Advisory Committee on Nutrition.

The concept of nutrient-based guidelines for school meals is not new. The Caroline Walker Trust first published guidelines in 1992, which were updated in 2005 ( Crawley, 2005) and used by the SMRP in establishing the government standards.

Analysis of primary school children's nutritional intake at lunchtimes before the introduction of the interim standards shows both school meals and packed lunches to be far from meeting the targets ( Rogers et al., 2007). Intake of total and saturated fat, sugar and sodium were too high and micronutrients too low, although school meals were found to be slightly more healthy than packed lunches.

A recent survey published in summary by the School Food Trust (2007b) of children aged 8-10 years old in six primary schools in Sheffield showed lower intakes of total fat, saturated fat and sodium, and higher intakes of some micronutrients compared with previous surveys. This could be the beginning of food provided by schools undergoing a beneficial change to meet the new food and nutrient standards set by the SMRP.

Many children prefer to take a packed lunch to school and so their lunchtime meal will not be covered by the new standards. The take-up of school meals in primary schools in England has fallen by 1% between 2005/6 (42%) and 2006/7 (41%) but there is wide local variation ( School Food Trust, 2007c). For example, in the South East region, a reduction of 4% was observed between these dates, and now only 28% of children are having a school meal. Inner London experienced a reduction of 2.4% but had the highest current up-take at 57%. In the South West region, there was a substantial increase of 8.2%, with 36% of children having a school meal. Primary school caterers have experienced the change in menus differently; although 9.5% of primary school caterers agreed that the provision of 'healthy' options in the last year had resulted in more pupils bringing in packed lunches, 10.6% cited 'healthy options' as a reason for the increase in the uptake of school meals.

With large numbers of children bringing food in from home, it is important that packed lunches also follow healthy guidelines. Some schools do have restrictions on items such as fizzy drinks and sweets but this does not necessarily mean the lunch will be healthy.

The present study aimed to assess the food and nutrient intake of a sample of primary school children at lunchtime, comparing those consuming meals provided by schools with children consuming packed lunches. Nutrient intakes are also compared with government standards for primary school meals that will be introduced in September 2008. Schools were surveyed in November and December 2006 (i.e. after the introduction of the interim food-based standards).

Materials and methods

Four primary schools in Cornwall were asked to participate in the study and all agreed. The percentage of children receiving free school meals at the schools was between 1.8% and 17%. All parents were provided with an information leaflet and consent form. Ethical approval was granted by the ethics committee of the Faculty of Science, University of Plymouth. Children were chosen at random from class lists of those children for whom informed consent had been granted. Approximately equal numbers of girls/boys, packed lunch/school lunch were chosen. The children were in the age range 6-11 years and all were of white ethnic origin.

Participants were observed once at a meal time and the food items consumed were recorded. Wastage was also observed and the weight estimated visually. Portion sizes for school meals were estimated using household measures with help from the catering staff. For packed lunches, some assumptions were made regarding portion sizes. For example, for fruit, the weight of a medium sized fruit was used; bread was either brown or white, medium slice thickness from a large loaf. Portion sizes were estimated using the portion size guide on the nutrient analysis programme, CompEat (Nutrition Systems, Banbury, Oxon, UK). Additional information was obtained from packaging and some recipes were obtained from catering staff. It was not possible to weigh food because it was considered too disruptive for the schools' lunchtime routine and, as there was only a limited time available for the study, far fewer children would have been surveyed. Statistical analysis was performed using SPSS, version 14.0 (SPSS Inc., Chicago, IL, USA). The differences in means between groups were determined by independent samples t-tests.

Results

There were 120 pupils that took part (school meals, n = 62; packed lunches, n = 58; females, n = 61; males, n = 59). The mean energy intake was similar between pupils eating school meals ( Table 2) (1856 kJ; 440 kcal, range 44-895 kcal) and packed lunches (2058 kJ; 480 kcal, range 53-813 kcal). This is just below the government standards for a child aged 7-10 years old of 530 kcal (30% of estimated average requirement; Table 1) ( Department of Health, 1991). Although the amount of energy provided by starchy carbohydrate was similar, compared with school meals, packed lunches provided twice as much energy from sugar ( Fig. 1). Conversely, on average, the school meals provided more energy from fat.

School meals (n = 62)

Packed lunch (n = 58)

P

Mean

(SD)

Mean

(SD)

From Table 2, it can be seen that, although children having school meals consumed more total fat, their intake of saturated fat was lower than the children having a packed lunch. Sodium, iron and calcium intakes were all significantly higher in those children consuming packed lunches. There was no statistically significant difference in vitamin C intakes between the two groups. Sodium intake in the school meals group was above the government maximum of 499 mg in the midday meal for this age group ( Fig. 2). Calcium and iron intakes from the school meals were below the standards.

Although most (81%) pupils consuming school lunch ate at least one portion of vegetables with their meal, only 13% consumed a portion of fruit ( Table 3). Conversely, in the packed lunch group, 58% of pupils consumed a portion of fruit but only 8% (five pupils) ate a portion of vegetables. Eighty-one percent of pupils bringing a packed lunch ate ham, cheese or prepackaged ham/cheese with crackers or breadsticks ( Fig. 3). Eleven percent had no source of protein (e.g. jam or chocolate spread sandwiches) with only 8% having poultry or fish.

Food item

School meals (% of pupils)

Packed lunches (% of pupils)

Discussion

Sodium

The high intake of sodium provided via the packed lunches is not surprising considering that nearly all packed lunches consisted of bread or crackers, the majority of pupils had ham or cheese as a filling, and 56% had a packet of crisps or similar salted snack on the day of the survey. The intake of sodium in our packed lunch group (834 mg) is very similar to that found by Evans et al. (2007) (868 mg) in a recent survey of packed lunches commissioned by the Food Standards Agency, but much more than that found by the School Food Trust (2007b) (577 mg). In our study, 76% of children taking packed lunches were consuming over 600 mg of sodium in their meal and 15% were consuming over 1000 mg. Although the mean sodium intake for the school meals group was below that of the packed lunch group, 52% consumed over 600 mg and 8% consumed over 1000 mg. The amount of sodium in the school meals was very variable: one day the children surveyed ate roast chicken and vegetables (low sodium) and different children on another day ate sausage and bean pie (high sodium). The main limitation of the study is that we were unable to survey for a whole week for a more representative indication of intake.

This high sodium intake is of particular concern because a recent analysis by He et al. (2008) of the salt intake and blood pressure data from the National Diet and Nutrition Survey for young people ( Gregory et al., 2000) found a significant association in children and adolescents between salt intake and systolic blood pressure after adjustment for age, sex, body mass index and potassium intake. An increase in 1 g day −1 was related to 0.4 mmHg in systolic blood pressure. The government target for children 7-10 years old is to consume less than 5 g salt per day; the packed lunch group in our study were consuming on average 2.1 g in their midday meals alone compared with 1.4 g in the school meals.

Sugar and saturated fat

Sugar and saturated fat intakes were also significantly higher in those consuming packed lunches compared with school meals. Confectionary, cakes and biscuits were the main sources of saturated fat and sugars. Although many schools have banned 'sweets', some children were still bringing chocolate confectionary and full coated chocolate biscuits, and 10% were bringing more than one of these items. Our findings on sugar intake (11% of energy via school meals versus 22% for packed lunch) are similar to those found by Rogers et al. (2007) who found that sugar provided 14% of energy for children having school meals and 21% of energy for those having a packed lunch. Rogers' study, part of the Avon Longitudinal Study of Parents and Children, involved 3-day unweighed food records of over six hundred 7-year-old children. Worryingly, they found that children having packed lunches had higher daily intakes of sugar and saturated fat and lower daily intakes of potassium and zinc than those having a school meal. Thus, meals consumed at home do not appear to compensate for the high sugar and fat content of the packed lunches.

Fruit, vegetables and vitamin C

Most children having a school lunch consumed at least one vegetable and those not consuming a portion of vegetables had left them uneaten (19%). Only five children with packed lunches ate some vegetables. This is similar to the findings of the School Food Trust (2007b), which found that 72% of children taking school meals consumed vegetables compared with only 6% of children taking a packed lunch.

Unfortunately, most children (87%) were not consuming fruit with their school meal (although 10% did have pure fruit juice). During our survey, fresh fruit salad, fruit crumble and other fresh fruit were available, but these were chosen by a minority of children. With options such as yogurts, whips, biscuits and sponges still on offer, fruit was not being chosen. Fifty-eight percent of pupils with a packed lunch consumed fruit. Most often, if it was provided, it was eaten along with other dessert items, such as yogurts and biscuits. Children having a school meal choose only one dessert and, unsurprisingly, fruit is not the first choice for most. Our findings are different to those of the School Food Trust (2007b) who found that 31% of children having packed lunches consumed fruit compared with 23% of children having a school meal.

Vitamin C intakes were well above Government standards, with those consuming packed lunches having slightly more, although this was not a statistically significant difference. This was not only due to the higher fruit intake (we surveyed just before Christmas and satsumas were popular) but also 10% were consuming fruit-based drinks containing vitamin C, which were of a larger portion size than the fruit juice provided by schools.

Although it is difficult to relate childhood diet to adult disease risk due to many possible confounders and the difficulty of estimating childhood diet in retrospective studies, epidemiological studies have associated increased childhood fruit intake with a reduced risk of cancer incidence ( Maynard et al., 2003) and increased vegetable intake with reduced risk of stroke ( Ness et al., 2005). Thus, it would seem important to address the poor fruit and vegetable intake in young children.

Calcium and iron

Calcium intakes were significantly higher in the packed lunches compared with the school meals. With 26% of the packed lunches containing cheese and many also having a yogurt or fromage frais, this is not surprising. However, children consuming school meals were not meeting the government standard of 35% of reference nutrient intake (RNI) (193 mg for a child aged 7-10 years). This was due in part to children not eating all the food provided and, although yogurt and cheese and biscuits were a dessert option, they were rarely chosen.

Likewise, iron intakes were slightly but significantly higher in those consuming a packed lunch, mostly coming from bread and meat sandwich fillings. Food consumed from the school meals did not meet the new standards for iron (35% of RNI; i.e. 3.0 mg for a child aged 7-10 years). The school meals offered lower iron choices, such as chicken and fish in place of red meat, which is only required to be offered twice a week. Potatoes, which are low in iron, were the main form of complex carbohydrate.

Other studies have found similar results. In a small scale study of dietary recalls with Brownies and Cubs ( n = 26), James & Wickett (2007) found that iron and calcium intakes were reported to be lower in the school meals group than the packed lunch group.

Protein

Mean protein intakes were 18 g in both groups and above the government guideline of 30% of RNI (which is 7.5 g for a child aged 7-10 years). Although the mean for the groups were more than adequate, 11% had no meat, fish, vegetarian alternative or cheese in their packed lunch. The alternative sandwich fillings, such as jam, marmalade and chocolate spread, were contributing to high sugar intakes.

Government standards require school meals to offer fish once per week, which is why a large number of the children in our sample had eaten fish. Only one child ate tuna fish in their packed lunch.

Limitations of the study

It is perhaps unfair to compare our results to the government standards because the standards are meant be applied to 5 days of consecutive meals, which we did not do. We only surveyed children on 1 day and, although we surveyed on different days and weeks of the menu cycle, we were unable to survey a whole week at a time. By only surveying each child once, we were unable to obtain a more reliable estimation of habitual intake. In addition, we analysed food that was eaten, which, for some children, was considerably less than what was served.

There are also likely to be errors in estimation of portion size because the foods eaten and wasted were not weighed, but these were minimized by consultation with the catering staff and close inspection of the packed lunches. It is possible that bias was introduced by the school cooks who may have served larger portions of foods that they thought were healthy and smaller servings of foods that they thought were unhealthy. However, children were able to leave unwanted food and the wastage was estimated by the researchers.

Conclusions

The present study has demonstrated that, on average, children taking a packed lunch to school are consuming approximately double the amount of sugar and 50% more sodium and saturated fat in their midday meal compared with those having a school lunch. This is useful information for two reasons. First, it demonstrates the nutritional advantages of school meals over packed lunches which could be used to help promote school meals to parents, and, second, it shows that, for those still wanting to bring a packed lunch, more needs to be done to reduce the sugar, sodium and saturated fat content.

Improvements are needed in fruit intake in both groups but especially for children having school meals. This can be addressed in school meals by reducing the number of times other desserts are offered to increase the times that a fruit-based dessert is chosen. Limiting the choice for unhealthy foods has been called for by others ( Nelson et al., 2007). This strategy would appear to have had some success for sodium and saturated fat in our schools by reducing the number of times processed meat and fried foods are offered.

Many schools and organizations such as the Food Standards Agency and the School Food Trust provide advice on healthy packed lunches but educating and engaging parents can be a difficult task. Perhaps one way forward, as advocated by The School Food Trust, is the adoption of a packed lunch policy as part of a whole school healthy eating policy ( http://www.schoolfoodtrust.org.uk/packedlunches). Further research could evaluate such policies and other interventions aimed at improving the content of children's packed lunches. Future surveys of school meals will be able to document continued improvements in school meals and determine whether nutrient standards for micronutrients are met.

Acknowledgments

We would like to thank the children for taking part, the teaching and catering staff for their assistance and parents for granting consent.

Abstract

Background New school meal standards are currently being phased in by the government in an attempt to improve the nutritional composition of school food. However, no standards are applied to packed lunches. The present study aimed to compare the food and nutrient intakes of primary school children eating a school meal with those taking a packed lunch.

Methods A sample of 120 children, aged 6-11 years, was observed once at a lunch time and all items consumed were recorded. Nutrient analysis was performed, and differences in nutrient intake between those children consuming packed lunches and school meals were determined.

Results Mean energy and protein intakes were similar. The amount of energy provided by starchy carbohydrate was also similar but, compared with school meals, packed lunches provided twice as much energy from sugar ( P < 0.001). School meals on average provided more energy from fat ( P < 0.001), but intakes of saturated fat were lower in the school meals group ( P = 0.021). Packed lunches provided more sodium ( P < 0.001), calcium ( P < 0.001) and iron ( P  = 0.016) than the school meals. Very few packed lunches contained vegetables, and fruit intake was particularly low for those having a school meal.

Conclusions Children taking a packed lunch to school were consuming approximately double the amount of sugar and 50% more sodium and saturated fat in their midday meal compared with those having a school lunch. However packed lunches were providing children with more calcium, iron and fruit.

Conflict of interests, sources of funding and authorship

The authors declare that they have no conflict of interest.

No funding declared.

All authors were involved in the conception and design of the study. CJR and JG collected the data and performed the nutritional analysis. GAR performed the statistical analysis and wrote the paper. All authors critically reviewed the manuscript and approved the final version submitted for publication.

Introduction

With the rising prevalence of obesity in children causing concern in the UK, government and media attention has recently focused on school food, especially the nutritional composition of school meals. Food-based standards for school meals have been in place since 2001, but these have not been effective at improving nutrient intake ( Nelson et al., 2007). A national survey conducted in primary schools ( Nelson et al., 2006) showed that schools were failing to meet the food-based standards. Of 146 schools, only 23% met all the compulsory standards at the start of service over 5 days.

The government therefore established a review of school meals and set up the School Meals Review Panel (SMRP) to consider nutrient-based standards. In 2005, a new public body 'The School Food Trust' ( http://www.schoolfoodtrust.org.uk) was established by the Department for Education and Skills (DfES) to take forward the recommendations of the SMRP ( SMRP, 2005).

The new standards for school meals were announced in May 2006 and have been gradually phased in. In September 2006, interim food-based standards were introduced (revised September 2007; School Food Trust, 2007a); 1 year later, food-based standards for food other than lunches served in schools were introduced; and the final food and nutrient-based standards will be introduced in September 2008 ( Table 1). DfES is providing £220 million of funding over 3 years (2005-2008) to schools and local authorities in order to introduce the new standards, with an additional £240 million to cover the period 2008-2011 ( School Food Trust, 2007a).

Energy

30% of the estimated average requirement (± 5%)

Protein

Minimum of 30% of reference nutrient intake (RNI)

Total carbohydrate

Minimum of 50% of food energy

Nonmilk extrinsic sugars

Maximum of 11% of food energy

Fat

Maximum of 35% of food energy

Saturated fat

Maximum of 11% of food energy

Fibre (NSP)

Minimum of 30% of the calculated reference value

Sodium

Maximum of 30% of the SACN recommendation

Vitamin A

Minimum of 35% of the RNI

Vitamin C

Minimum of 35% of the RNI

Folate

Minimum of 35% of the RNI

Calcium

Minimum of 35% of the RNI

Iron

Minimum of 35% of the RNI

Zinc

Minimum of 35% of the RNI

SACN, Scientific Advisory Committee on Nutrition.

The concept of nutrient-based guidelines for school meals is not new. The Caroline Walker Trust first published guidelines in 1992, which were updated in 2005 ( Crawley, 2005) and used by the SMRP in establishing the government standards.

Analysis of primary school children's nutritional intake at lunchtimes before the introduction of the interim standards shows both school meals and packed lunches to be far from meeting the targets ( Rogers et al., 2007). Intake of total and saturated fat, sugar and sodium were too high and micronutrients too low, although school meals were found to be slightly more healthy than packed lunches.

A recent survey published in summary by the School Food Trust (2007b) of children aged 8-10 years old in six primary schools in Sheffield showed lower intakes of total fat, saturated fat and sodium, and higher intakes of some micronutrients compared with previous surveys. This could be the beginning of food provided by schools undergoing a beneficial change to meet the new food and nutrient standards set by the SMRP.

Many children prefer to take a packed lunch to school and so their lunchtime meal will not be covered by the new standards. The take-up of school meals in primary schools in England has fallen by 1% between 2005/6 (42%) and 2006/7 (41%) but there is wide local variation ( School Food Trust, 2007c). For example, in the South East region, a reduction of 4% was observed between these dates, and now only 28% of children are having a school meal. Inner London experienced a reduction of 2.4% but had the highest current up-take at 57%. In the South West region, there was a substantial increase of 8.2%, with 36% of children having a school meal. Primary school caterers have experienced the change in menus differently; although 9.5% of primary school caterers agreed that the provision of 'healthy' options in the last year had resulted in more pupils bringing in packed lunches, 10.6% cited 'healthy options' as a reason for the increase in the uptake of school meals.

With large numbers of children bringing food in from home, it is important that packed lunches also follow healthy guidelines. Some schools do have restrictions on items such as fizzy drinks and sweets but this does not necessarily mean the lunch will be healthy.

The present study aimed to assess the food and nutrient intake of a sample of primary school children at lunchtime, comparing those consuming meals provided by schools with children consuming packed lunches. Nutrient intakes are also compared with government standards for primary school meals that will be introduced in September 2008. Schools were surveyed in November and December 2006 (i.e. after the introduction of the interim food-based standards).

Materials and methods

Four primary schools in Cornwall were asked to participate in the study and all agreed. The percentage of children receiving free school meals at the schools was between 1.8% and 17%. All parents were provided with an information leaflet and consent form. Ethical approval was granted by the ethics committee of the Faculty of Science, University of Plymouth. Children were chosen at random from class lists of those children for whom informed consent had been granted. Approximately equal numbers of girls/boys, packed lunch/school lunch were chosen. The children were in the age range 6-11 years and all were of white ethnic origin.

Participants were observed once at a meal time and the food items consumed were recorded. Wastage was also observed and the weight estimated visually. Portion sizes for school meals were estimated using household measures with help from the catering staff. For packed lunches, some assumptions were made regarding portion sizes. For example, for fruit, the weight of a medium sized fruit was used; bread was either brown or white, medium slice thickness from a large loaf. Portion sizes were estimated using the portion size guide on the nutrient analysis programme, CompEat (Nutrition Systems, Banbury, Oxon, UK). Additional information was obtained from packaging and some recipes were obtained from catering staff. It was not possible to weigh food because it was considered too disruptive for the schools' lunchtime routine and, as there was only a limited time available for the study, far fewer children would have been surveyed. Statistical analysis was performed using SPSS, version 14.0 (SPSS Inc., Chicago, IL, USA). The differences in means between groups were determined by independent samples t-tests.

Results

There were 120 pupils that took part (school meals, n = 62; packed lunches, n = 58; females, n = 61; males, n = 59). The mean energy intake was similar between pupils eating school meals ( Table 2) (1856 kJ; 440 kcal, range 44-895 kcal) and packed lunches (2058 kJ; 480 kcal, range 53-813 kcal). This is just below the government standards for a child aged 7-10 years old of 530 kcal (30% of estimated average requirement; Table 1) ( Department of Health, 1991). Although the amount of energy provided by starchy carbohydrate was similar, compared with school meals, packed lunches provided twice as much energy from sugar ( Fig. 1). Conversely, on average, the school meals provided more energy from fat.

School meals (n = 62)

Packed lunch (n = 58)

P

Mean

(SD)

Mean

(SD)

From Table 2, it can be seen that, although children having school meals consumed more total fat, their intake of saturated fat was lower than the children having a packed lunch. Sodium, iron and calcium intakes were all significantly higher in those children consuming packed lunches. There was no statistically significant difference in vitamin C intakes between the two groups. Sodium intake in the school meals group was above the government maximum of 499 mg in the midday meal for this age group ( Fig. 2). Calcium and iron intakes from the school meals were below the standards.

Although most (81%) pupils consuming school lunch ate at least one portion of vegetables with their meal, only 13% consumed a portion of fruit ( Table 3). Conversely, in the packed lunch group, 58% of pupils consumed a portion of fruit but only 8% (five pupils) ate a portion of vegetables. Eighty-one percent of pupils bringing a packed lunch ate ham, cheese or prepackaged ham/cheese with crackers or breadsticks ( Fig. 3). Eleven percent had no source of protein (e.g. jam or chocolate spread sandwiches) with only 8% having poultry or fish.

Food item

School meals (% of pupils)

Packed lunches (% of pupils)

Discussion

Sodium

The high intake of sodium provided via the packed lunches is not surprising considering that nearly all packed lunches consisted of bread or crackers, the majority of pupils had ham or cheese as a filling, and 56% had a packet of crisps or similar salted snack on the day of the survey. The intake of sodium in our packed lunch group (834 mg) is very similar to that found by Evans et al. (2007) (868 mg) in a recent survey of packed lunches commissioned by the Food Standards Agency, but much more than that found by the School Food Trust (2007b) (577 mg). In our study, 76% of children taking packed lunches were consuming over 600 mg of sodium in their meal and 15% were consuming over 1000 mg. Although the mean sodium intake for the school meals group was below that of the packed lunch group, 52% consumed over 600 mg and 8% consumed over 1000 mg. The amount of sodium in the school meals was very variable: one day the children surveyed ate roast chicken and vegetables (low sodium) and different children on another day ate sausage and bean pie (high sodium). The main limitation of the study is that we were unable to survey for a whole week for a more representative indication of intake.

This high sodium intake is of particular concern because a recent analysis by He et al. (2008) of the salt intake and blood pressure data from the National Diet and Nutrition Survey for young people ( Gregory et al., 2000) found a significant association in children and adolescents between salt intake and systolic blood pressure after adjustment for age, sex, body mass index and potassium intake. An increase in 1 g day −1 was related to 0.4 mmHg in systolic blood pressure. The government target for children 7-10 years old is to consume less than 5 g salt per day; the packed lunch group in our study were consuming on average 2.1 g in their midday meals alone compared with 1.4 g in the school meals.

Sugar and saturated fat

Sugar and saturated fat intakes were also significantly higher in those consuming packed lunches compared with school meals. Confectionary, cakes and biscuits were the main sources of saturated fat and sugars. Although many schools have banned 'sweets', some children were still bringing chocolate confectionary and full coated chocolate biscuits, and 10% were bringing more than one of these items. Our findings on sugar intake (11% of energy via school meals versus 22% for packed lunch) are similar to those found by Rogers et al. (2007) who found that sugar provided 14% of energy for children having school meals and 21% of energy for those having a packed lunch. Rogers' study, part of the Avon Longitudinal Study of Parents and Children, involved 3-day unweighed food records of over six hundred 7-year-old children. Worryingly, they found that children having packed lunches had higher daily intakes of sugar and saturated fat and lower daily intakes of potassium and zinc than those having a school meal. Thus, meals consumed at home do not appear to compensate for the high sugar and fat content of the packed lunches.

Fruit, vegetables and vitamin C

Most children having a school lunch consumed at least one vegetable and those not consuming a portion of vegetables had left them uneaten (19%). Only five children with packed lunches ate some vegetables. This is similar to the findings of the School Food Trust (2007b), which found that 72% of children taking school meals consumed vegetables compared with only 6% of children taking a packed lunch.

Unfortunately, most children (87%) were not consuming fruit with their school meal (although 10% did have pure fruit juice). During our survey, fresh fruit salad, fruit crumble and other fresh fruit were available, but these were chosen by a minority of children. With options such as yogurts, whips, biscuits and sponges still on offer, fruit was not being chosen. Fifty-eight percent of pupils with a packed lunch consumed fruit. Most often, if it was provided, it was eaten along with other dessert items, such as yogurts and biscuits. Children having a school meal choose only one dessert and, unsurprisingly, fruit is not the first choice for most. Our findings are different to those of the School Food Trust (2007b) who found that 31% of children having packed lunches consumed fruit compared with 23% of children having a school meal.

Vitamin C intakes were well above Government standards, with those consuming packed lunches having slightly more, although this was not a statistically significant difference. This was not only due to the higher fruit intake (we surveyed just before Christmas and satsumas were popular) but also 10% were consuming fruit-based drinks containing vitamin C, which were of a larger portion size than the fruit juice provided by schools.

Although it is difficult to relate childhood diet to adult disease risk due to many possible confounders and the difficulty of estimating childhood diet in retrospective studies, epidemiological studies have associated increased childhood fruit intake with a reduced risk of cancer incidence ( Maynard et al., 2003) and increased vegetable intake with reduced risk of stroke ( Ness et al., 2005). Thus, it would seem important to address the poor fruit and vegetable intake in young children.

Calcium and iron

Calcium intakes were significantly higher in the packed lunches compared with the school meals. With 26% of the packed lunches containing cheese and many also having a yogurt or fromage frais, this is not surprising. However, children consuming school meals were not meeting the government standard of 35% of reference nutrient intake (RNI) (193 mg for a child aged 7-10 years). This was due in part to children not eating all the food provided and, although yogurt and cheese and biscuits were a dessert option, they were rarely chosen.

Likewise, iron intakes were slightly but significantly higher in those consuming a packed lunch, mostly coming from bread and meat sandwich fillings. Food consumed from the school meals did not meet the new standards for iron (35% of RNI; i.e. 3.0 mg for a child aged 7-10 years). The school meals offered lower iron choices, such as chicken and fish in place of red meat, which is only required to be offered twice a week. Potatoes, which are low in iron, were the main form of complex carbohydrate.

Other studies have found similar results. In a small scale study of dietary recalls with Brownies and Cubs ( n = 26), James & Wickett (2007) found that iron and calcium intakes were reported to be lower in the school meals group than the packed lunch group.

Protein

Mean protein intakes were 18 g in both groups and above the government guideline of 30% of RNI (which is 7.5 g for a child aged 7-10 years). Although the mean for the groups were more than adequate, 11% had no meat, fish, vegetarian alternative or cheese in their packed lunch. The alternative sandwich fillings, such as jam, marmalade and chocolate spread, were contributing to high sugar intakes.

Government standards require school meals to offer fish once per week, which is why a large number of the children in our sample had eaten fish. Only one child ate tuna fish in their packed lunch.

Limitations of the study

It is perhaps unfair to compare our results to the government standards because the standards are meant be applied to 5 days of consecutive meals, which we did not do. We only surveyed children on 1 day and, although we surveyed on different days and weeks of the menu cycle, we were unable to survey a whole week at a time. By only surveying each child once, we were unable to obtain a more reliable estimation of habitual intake. In addition, we analysed food that was eaten, which, for some children, was considerably less than what was served.

There are also likely to be errors in estimation of portion size because the foods eaten and wasted were not weighed, but these were minimized by consultation with the catering staff and close inspection of the packed lunches. It is possible that bias was introduced by the school cooks who may have served larger portions of foods that they thought were healthy and smaller servings of foods that they thought were unhealthy. However, children were able to leave unwanted food and the wastage was estimated by the researchers.

Conclusions

The present study has demonstrated that, on average, children taking a packed lunch to school are consuming approximately double the amount of sugar and 50% more sodium and saturated fat in their midday meal compared with those having a school lunch. This is useful information for two reasons. First, it demonstrates the nutritional advantages of school meals over packed lunches which could be used to help promote school meals to parents, and, second, it shows that, for those still wanting to bring a packed lunch, more needs to be done to reduce the sugar, sodium and saturated fat content.

Improvements are needed in fruit intake in both groups but especially for children having school meals. This can be addressed in school meals by reducing the number of times other desserts are offered to increase the times that a fruit-based dessert is chosen. Limiting the choice for unhealthy foods has been called for by others ( Nelson et al., 2007). This strategy would appear to have had some success for sodium and saturated fat in our schools by reducing the number of times processed meat and fried foods are offered.

Many schools and organizations such as the Food Standards Agency and the School Food Trust provide advice on healthy packed lunches but educating and engaging parents can be a difficult task. Perhaps one way forward, as advocated by The School Food Trust, is the adoption of a packed lunch policy as part of a whole school healthy eating policy ( http://www.schoolfoodtrust.org.uk/packedlunches). Further research could evaluate such policies and other interventions aimed at improving the content of children's packed lunches. Future surveys of school meals will be able to document continued improvements in school meals and determine whether nutrient standards for micronutrients are met.

Acknowledgments

We would like to thank the children for taking part, the teaching and catering staff for their assistance and parents for granting consent.

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Food and nutrient intakes of primary school children: a comparison of school meals and packed lunches

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G. A. Rees , C. J. Richards , J. Gregory , J. Gregory School of Biological Sciences, The University of Plymouth, Drake Circus, Plymouth, UK Search for more papers by this author C. J. Richards School of Biological Sciences, The University of Plymouth, Drake Circus, Plymouth, UK Search for more papers by this author G.

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https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4552069/

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Abstract

Keywords: Learning styles, mixed approach for learning, perceptions, student's awareness

INTRODUCTION

Learning styles (LSs) have been defined as the composite cognitive, affective, and physiological characteristics that are relatively stable indicators of how a learner perceives, interacts with and responds to the learning environment.[ 1] Bruner[ 2, 3] have described how humans assimilate knowledge about the environment through four sensory modalities: Visual (observing pictures, symbols or diagrams), auditory (listening, discussing), visual/iconic (reading and writing), and kinesthetic (using tactile sensory abilities such as smell and touch). Many tools have been developed over time to understand how individuals learn such as the Vermunt's inventory, Kolbe learning style indicator, Meyer Brigg Indicator, Flemming's Visual, Aural, Read/Write, and Kinesthetic (VARK) questionnaire, etc.[ 4, 5, 6] VARK is an acronym for Visual, Aural, Read/Write, and Kinesthetic.[ 7] Some examples of the VARK learning style preferences (LSPs) are: Visual (looking at and making pictures, animations, graphs, tables, etc.); aural (listening to and participating in speeches, discussions, and question answer sessions); read/write (reading and writing text associated with the textbook, class notes, laboratory reports, etc.) and kinesthetic (engaging in physical experiences, manipulating objects, etc., e.g. laboratories).

Learning strategies are specific combinations or patterns of learning activities used during the learning process. The quality of learning outcomes achieved is dependent to a considerable extent on the learning activities used by learners. These learning strategies can be broadly divided into self-regulated strategy in which the students perform most regulation activities themselves, externally regulated strategy in which the students let their learning process to be regulated by teachers/books or lack of regulation when students are unable to regulate their learning process by themselves and also experience insufficient support from external regulation as provided by teachers and learning environment.[ 8, 9]

Recent research has made it fairly clear that different students have different LSs.[ 10, 11, 12] LSPs are significantly different in males and females.[ 13] Read-write and kinesthetic learners who adopt a deep approach learning strategy perform better academically than do the auditory, visual learners who employ superficial study strategies.[ 14] Much work has been done on studying the individual learning preferences and how instructional methods can be tailored to cater to the different styles.[ 10, 13, 14, 15] However, individualization of instructional methods has not been shown to contribute significantly to learn outcomes.[ 3, 8, 16, 17] Studies have also shown that the most effective learners are able to adapt to the style which the learning situation requires.[ 18] The teachers can help students to develop strategies for adapting to differing situations, especially when LSs do not fit to a task.[ 19] Awareness of LSs can create a better learning environment by enabling students to use appropriate strategies.[ 20]

The best learning "style" for benefitting from instruction is to avoid depending upon any single style, or any style-like consistency in approach.[ 21, 22] It has been advocated that learners take a very flexible approach to instruction, so to optimize what they get out of each formal instructional situation that is useful in the long term, not just useful for coping with the instructional situation in the short-term. Developing the flexibility to respond productively to all sorts of instructional situations would be a laudable goal for medical students.[ 21, 22] How best to encourage this flexibility is yet to be determined.

Therefore, the aim of this study was to determine the impact of awareness of LSs and motivating students by externally regulated strategies to use mixed methods of learning.

Fifty 1 st year medical undergraduate students participated in this study. The study was approved by research and ethics committee of the institute and written informed consent was taken from all participants before enrolling them for the study. Permission for using VARK questionnaire for the educational project was taken from Dr. Neil D. Flemming, who holds the copyright for it (VARK version 7.1; 2011) and related copyright materials were available on the website. Validity and reliability of the VARK questionnaire have been recently established.[ 23]

In the beginning, during session one, VARK questionnaire was administered for determining LSs of participants and student questionnaire was used to determine their awareness of various LSs. In session two, purpose of the study was explained to the students and written informed consent was taken. Sessions 1-4 and 6 were classroom sessions of 45 min to 1 h duration conducted by the investigator (AB). In session three, a lecture on LSs and learning strategies in accordance with VARK preferences for intake, revision, and output was taken. In session four, students were informed about their individual VARK preferences and grouped into eight groups with seven/eight students per group. The investigator consciously made the group such that there was a mixture of students with different LSs in a group. This ensured that there was direct interaction between read-write/kinesthetic type of learners (who use a deeper approach to learning) and the visual/auditory learners (who use a superficial approach for learning). Session five consisted of group sessions with the students. Only one group of students and the investigator were present in each discussion. Each session took about half an hour in which individual learning strategies of students were discussed. A conscious effort was made by the investigator not to refer to their VARK learning preference at this time, so that the students did not get the message of restricting to their own LSP. Each student described in detail the learning strategies used by them. The investigator (AB) then helped the students in identifying the learning strategies not being utilized or underutilized by them. The students were encouraged to try mixed methods of learning for enhancing performance in the examinations. The examination system for these students was a composite process which includes theory, practical, and viva-voce examination in which the first three levels that is, knows, knows how, and shows of Millar's pyramid and first five levels of Blooms taxonomy were assessed.

Session six was again with the entire class in which deep learning strategies identified in each group were discussed, and students were further encouraged to adapt a mixed method approach for enhancing their learning. Feedback from all students was taken using student questionnaire at 3 months and from some students by interviews at 6 months.

Student questionnaire

The questionnaire had three sections. Section 1 was for collecting demographic data. Section 2 was for pre- and post-type assessment. Questions in this section were close-ended with a 4-point Likert scale regarding the awareness of LSs. Section 3 of the questionnaire was administered only at the end of the study. It had open-ended questions which were graded on a 5-point Likert scale. The last question in this section was regarding the strength/challenge faced during the intervention. Questions in this section were mainly for process evaluation and students' perceptions to a mixed method approach of learning.

The evidence for validity was gathered for the questionnaire based on current usage of the term where all validity is construct validity[ 24] and as described elsewhere.[ 25] The questions were framed and aligned for the purpose of the study. The questionnaire was reviewed by two experts to see if the questions as framed were clear, would elicit the desired responses, and captured all issues of concern. Pilot testing was done with students of another MBBS batch as subjects. Based on the suggestions, modifications were made in the student questionnaire. Reliability coefficient Cronbach's alpha for section 3 of the student questionnaire was 0.923.

Student interview

A guided interview for an in-depth understanding of the students' experiences while participating in the project was conducted. This was one of the components for overall program evaluation and evaluating program effectiveness to improvise future interventions. Six students volunteered for the interview. They were given time and date for the interview. However, the students were hesitant of being video/audio taped, so the investigator asked them for a narrative, describing the effect of participating in the project, positive points of the intervention, what activities to be scaled up and what to be discontinued, what were the barriers for the students, and how did they overcome them.

Quantitative data were analyzed using SPSS statistical software (SPSS Inc. 2013, version 22.0 for Windows,Armonk, NY, USA). Qualitative data analysis was done using a grounded theory approach with constant comparative analysis. To start with the narrative, data were first organized in a tabular format. Some themes were identified beforehand and then in each response the particular theme if identified was given a code comprising 2-3 alphabets. However, while reading and coding the data certain emergent themes were also identified and were added to the initial list. Thus, at the end we had a list of themes and the comments in support of those themes. Similar themes were then combined to form a category. The previously read data were then reviewed to check for the appropriateness of the themes developed. Two authors independently analyzed the data. The inter-rater reliability of identified themes and comments assigned to them was 100% after discussion as determined by the Miles and Hubermann's formula.[ 23]

Of the 50 medical undergraduate students who participated in the study, 34 were female and 16 male. Mean age of the participants was 19.24 ± 0. 63 years. Mean VARK questionnaire scores before and after 3 months are shown in . Comparison of the preintervention VARK scores with the postintervention VARK scores using Wilcoxon signed ranks test revealed significant difference only in the mean V scores ( P = 0.023).

Analysis of the ranks of various LS scores and their pre- to post-difference has been detailed in . For all the LSs, there was a change in the pre- to post-scores. For example, comparison of V postscore versus V prescore reveals that there were 13 negative ranks, 26 positive ranks, and 8 ties. This means that out of 47 students, V postscore was less than V prescore in 13, V postscore was more than V prescore in 26, and 8 students did not show any change in the visual scores before and after the intervention. Thus, there was a change in the visual learning scores of 39 students. Statistical analysis of the number of students showing changes in LS scores with those showing no changes revealed a highly significant difference for all the four LS categories ( P < 0.001).

Figures and show pre- and post-intervention response of students to questions in section 2 of student questionnaire. These responses on a 4-point Likert scale showed a highly significant increase ( P < 0.001) in the mean scores for all the questionnaire items in this section for assessing student awareness of LSs. At the beginning of the study, there was a lack of awareness about the concept of LSs amongst the students but after the intervention there was a significant increase in the number of students reporting that they were aware of LSs. More than three-fourth of the participants reported that they were familiar with the VARK LSPs (88%) and also familiar with the strategies available for enhancing learning (82%). Last question in this section was: According to you which type of learner you are (V/A/R/K)? In response to this question, we expected students to tick mark any one of the acronym given in the question. Few students did tick mark one of the acronyms, but it did not match with their VARK analysis result. Thus, initially no student was able to identify their own LS in accordance with the VARK preference but by the end of study 46% students could correctly identify their own LSP.

shows the responses of students to questions in section 3 of the student questionnaire on a 5-point Likert scale ranging from strongly disagrees to strongly agree.

These results emphasized important points about the externally regulated strategy for enhancing learning. First, the group discussions were held in a nonthreatening environment in which all participants were encouraged to freely exchange their way of learning. They felt part of a learning community and the facilitator was successful in motivating them to try adapting to new LSs. For example, more than three-fourth of the participants agreed/strongly agreed that there was a proper demonstration of the way of discussing LSs in a group. In group discussions, they felt part of a learning community and discussions in the group helped them to develop a sense of collaboration with others in the group, discussing about LSs was an effective method of enhancing their learning and discussions were valuable in helping them to appreciate different perspectives.

The results also showed that there was adequate faculty encouragement and support to the groups and effective feedback provided by the faculty. For example, more than three-fourth of the students agreed/strongly agreed that faculty encouraged them from time to time for group discussions, helped to remain engaged in group discussions and even encouraged students to explore new LSs, felt motivated to explore other LSs, and feedback provided by faculty was helpful in developing new LSs. More than three-fourth students reported that combining new LSs helped them in improving their performance in examinations.

However, it is important to note that only 58% were actually able to identify the best combination of LSs for them. Almost a similar percentage (56%) was able to incorporate LSs of others in their group into their own LS and felt comfortable disagreeing with others in the group.

Forty-three students commented on the open-ended question in section 3 regarding challenges faced during the intervention. The major themes derived from the content analysis of this qualitative data were that applying and incorporating new LS was difficult (19/43), there was difficulty in meeting for group discussions (13/43), and it was initially difficult but later they adapted to new LSs (5/43). These themes along with the sub-themes and comments are listed in .

One suggestion to overcome the time constraint was "This survey should be done at school level or at the time of enrollment in medical college." Overall students found the intervention useful and helpful. One student commented: "Knowledge of our LS helps in improving the skill. Also, group discussions helped to learn and incorporate and improve other learning methods."

In the narratives, all six students were able to list the different LSs, identify their own LS, and describe various activities they undertook as participants. Themes regarding the strength of the intervention, barriers encountered, and recommendations along with comments of the students regarding the mixed method approach of learning are described in Tables and . In brief, the strength of the intervention was group discussions which helped in learning. The students also developed an awareness of new LSs and more importantly the skills to incorporate it into their own style. They could also apply these learning strategies in other subjects as well. The students also became more organized.

The barriers encountered were lack of time which hindered group discussions and group members not comfortable with each other in sharing views. Despite these barriers, the students also recommended that in future all activities to be continued for a subsequent group of students, with emphasis on including more interactive sessions.

DISCUSSION

In the onion concept of LSs, an analogy has been drawn between the various concepts of LSs and the layers in an onion.[ 26] Thus, the three layers that is, innermost, middle, and outer represents students' cognitive personality style, information-processing style, and instructional preference, respectively. The instruments for assessing the LSs fit into one of the three layers. The outermost layer of the LSs that is, instructional preference is the most superficial of all and also is most vulnerable to change. This justifies the use of VARK questionnaire for the present study since it is based on the sensory modality used for acquiring information and thus fits into the outermost layer that is, instructional preference.

It has recently been reported that read-write and kinesthetic learners who adopt a deep approach learning strategy perform better academically than do the auditory, visual learners who employ superficial study strategies. Previous studies have suggested that visual and auditory learners can be encouraged to adopt kinesthetic and read-write styles to enhance their performance in the examinations.[ 14] Thus, although there may be a predominant LS yet students can be taught to use alternative styles.

However, in available literature the process of motivating students to adapt to different LSs has not been described clearly. In the present study, more emphasis was on the process of motivating the students toward incorporating other LSs. Our first effort, therefore, was to make the students aware of various LSs and strategies they could use to enhance their learning.

After this, external regulation as a motivating factor for adopting various learning strategies was used and results of the study confirmed that the entire program for enhancing students learning was meticulously planned and well executed thereby validating the entire process. Group discussions between faculty and students were effectively conducted. The students could freely exchange their methods of learning. Student awareness of various learning strategies helped in better acceptability of external regulation for adopting various learning strategies and made it more effective.

The subsequent impact of awareness and effective external regulation was evident from student comments. A large number of students (78%) commented that use of these LSs helped them in improving their performance in the examinations even if they were not able to identify the best combination of LSs (58%) for themselves. This meant that although students could not actually figure out what was best for them yet they had already started utilizing a variety of methods for enhancing their learning. This observation was further quantitatively strengthened by pre- and post-intervention comparison of VARK scores indicating that there was a change in VARK scores of a significant number of students after the intervention. On qualitative analysis, various themes derived from the content analysis of the student interviews added further support.

Group discussions were the most important part of this external regulation strategy for enhancing learning.

Although LSs of the students were assessed using VARK questionnaire and the students were told about their preferred LSs, yet less than half the class could later on correctly recall their own VARK LS. This emphasizes the point that although initially groups were made in accordance with the LSPs of the students so as to have a heterogeneous group yet this point was not reemphasized further. This was done to facilitate students to try to incorporate other styles and not stick on to their own.

Previous research has shown that matching the teaching style to LSs of learners has some benefit.[ 27, 28] There is also evidence that providing creative teaching/LS mismatch which required students to experience the less dominant qualities of their LSs stimulated learning.[ 29, 30, 31, 32, 33] Educational research suggests that optimal learning results from a certain degree of tension and disequilibrium and the learners need to be "stretched" somewhat to learn.[ 31, 34, 35]

In summary, this study outlines a well-planned roadmap of appropriate use of externally regulated learning strategy, wherein on the background of prior knowledge of various LSs and strategies, students were encouraged to incorporate a combination of learning strategies which best suits them.

Since this study was carried out at the time when students were nearing the completion of their 1 st year in medical college and were very close to taking the final examination, paucity of time needed for self-directed efforts at incorporating newer LS strategies was an important limitation. This could be overcome by undertaking these efforts at the time of enrollment of students in medical college so that students have sufficient time at hand to try out the novel techniques.

Another limitation of the study was that we did not specifically measure the level of Blooms taxonomy/Miller's pyramid, this intervention tried to address.

Further research in sufficiently sensitized students toward the use of the mixed method approach for learning, can be planned to find out which domain of learning and which level of Blooms taxonomy/Miller's pyramid has been enhanced.

CONCLUSION

Awareness of individual LSs among 1 st year MBBS students and the use of an externally regulated strategy for enhancing learning helped students adapt to other LSs. This enhanced the use of better learning practices and, therefore, better learning outcomes. Thus, knowledge of VARK LSP of the student should not be considered as a restriction to use that particular style only. Rather, teachers should make a conscious effort to let the students explore other LSs as well.

Acknowledgments

I acknowledge all the students who participated in the study, my head of department who allowed me all the time I needed for conducting this study and all learned FAIMER Faculty whose constructive criticism was helpful in giving this study the present shape.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

REFERENCES

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Students awareness of learning styles and their perceptions to a mixed method approach for learning

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Keywords: Learning styles, mixed approach for learning, perceptions, student's awareness Learning styles (LSs) have been defined as the composite cognitive, affective, and physiological characteristics that are relatively stable indicators of how a learner perceives, interacts with and responds to the learning environment.[ 1] Bruner[ 2, 3] have described how humans assimilate knowledge about the environment through four sensory modalities: Visual (observing pictures, symbols or diagrams), auditory (listening, discussing), visual/iconic (reading and writing), and kinesthetic (using tactile sensory abilities such as smell and touch).

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Maths anxiety (MA) is a negative emotional response to current or prospective situation involving mathematics. The effects of MA are educationally debilitating; MA sufferers have decreased maths self-confidence, enjoy maths less and may even avoid maths altogether (Ashcraft et al., 1998, Hembree, 1990, Maloney and Beilock, 2012). Nevertheless, the majority of studies have investigated MA in university and secondary school samples; MA research employing primary and early secondary school populations remains surprisingly sparse (Jackson & Leffingwell, 1999). Questions remain regarding MA gender differences amongst child and adolescent populations and it is unclear whether the MA/maths performance link seen in older students also presents in the younger age-range. A further question centres on the specificity of MA and whether MA is only related to maths or is a manifestation of general anxiety.

In response to these research gaps, here we had three objectives. Firstly, we examined gender differences in MA during primary and early secondary school. Secondly, we mapped developmental changes relating to MA and its link with maths performance in both primary and secondary school. Finally, we investigated whether MA is a maths specific anxiety-type and is independent of general anxiety.

Studies employing adult populations have consistently revealed women to have higher MA than men (e.g. Chang and Cho, 2013, Ferguson et al., 2015, Miller and Bichsel, 2004, Woodard, 2004). Yet, far less is known about the development of MA gender differences in childhood and adolescence.

More researchers are beginning to investigate the incidence and effects of MA in primary samples (e.g. Galla and Wood, 2012, Vukovic et al., 2013, Wu et al., 2012). However, such studies rarely report gender-related findings. Of the few which have, the majority found no gender MA differences (e.g. Gierl and Bisanz, 1995, Harari et al., 2013, Newstead, 1998, Punaro and Reeve, 2012, Ramirez et al., 2013, Young et al., 2012). Nevertheless, the possibility that MA gender differences surface in primary school should not be ruled out. Some studies have reported primary-age girls' to have higher levels of MA than boys (e.g. Griggs et al., 2013, Yüksel-Şahin, 2008) and Krinzinger, Wood, and Willmes (2012) revealed primary boys to have more positive attitudes towards maths than girls. Further, Satake and Amato (1995) revealed that 5th and 6th grade girls reported higher levels of 'maths test anxiety' compared to male peers. Thus, it remains unclear as to whether girls experience higher MA than boys in primary education.

Data at the secondary level are more consistent with those revealed in adult populations. Although some studies have revealed no MA gender differences (e.g. Birgin et al., 2010, Dede, 2008, Kyttälä and Björn, 2014), more have revealed higher MA in girls than boys (e.g. Devine et al., 2012, Frenzel et al., 2007, Jain and Dowson, 2009, Kvedere, 2012, Luo et al., 2009, Primi et al., 2014).

Collectively, although null findings have been reported in both primary and secondary samples, the literature suggests girls experience more MA than boys at both educational levels. However, the evidence for a MA gender difference is considerably more extensive and conclusive amongst secondary samples. Although this may simply be due to a lack of research at the primary level, it may also indicate that the MA gender difference is more established and visible in secondary samples, and thus more likely to be reported by researchers. However, this is speculative and more research is required to ascertain whether MA gender differences are already present at the primary level or develop later. Hence, here we examined the presence and nature of MA gender differences in primary and early secondary school students.

Mathematics performance gender differences are also of interest. Meta-analytic studies have demonstrated a male advantage in mathematics amongst secondary-age students (Hedges and Nowell, 1995, Hyde et al., 1990). Nevertheless, this does vary across country (Else-Quest, Hyde, & Linn, 2010) and recent data suggest this gender gap is disappearing (Hyde et al., 2008, Hyde and Mertz, 2009, Lindberg et al., 2010). Further, Devine and colleagues showed no gender difference in arithmetic performance, despite girls reporting higher MA than boys (Devine et al., 2012). Thus, here we also compared girls' and boys' arithmetic performance to elucidate whether or not there a gender related mathematics attainment gap.

Findings relating to the development of the MA/maths performance link are even less clear-cut than those focusing simply on MA incidence. In secondary school, MA has been found to be negatively correlated with mathematics performance, including term/exam grades and mathematics tests (Hembree, 1990, Ma, 1999, Resnick et al., 1982, Richardson and Suinn, 1972, Wigfield and Meece, 1988). However, evidence suggests that the MA/maths performance link typically seen in older students is not present in primary school. For instance, Thomas and Dowker (2000) found no association between MA and calculation ability in six- to nine-year-olds, prompting Dowker (2005) to suggest that MA only affects maths performance after fourth grade. Supporting this, Krinzinger, Kaufmann, and Willmes (2009) found no significant correlations between MA and maths ability in early primary school children.

Nevertheless, other researchers have revealed opposing evidence. For instance, Punaro and Reeve (2012) found a significant relation between nine-year-old children's maths worry ratings and their maths problem-solving judgments. Further, they revealed that a high maths-worry subgroup showed poorer maths performance than other subgroups (Punaro & Reeve, 2012). Similarly, Wu et al. (2012) discovered that 2nd and 3rd grade maths achievement was negatively associated with MA scores. Evidently, the findings lack consistency, with some finding an MA/maths performance relationship even in young children, and others suggesting that it develops later. Thus, here we tested both primary and early secondary school students to explore whether this relationship differs by education level.

By definition, MA is exclusively related to maths (Hembree, 1990). However, an important issue concerning MA's specificity relates to whether MA is only linked to maths performance or whether it also has associations with other academic domains and skills. The vast majority of research on academic anxiety has focused on mathematics, yet research indicates that reading/literacy anxiety may also exist. For instance, children and adolescents with poor literacy have been shown to exhibit more language anxiety than their literate peers (Carroll, Maughan, Goodman, & Meltzer, 2005) and researchers have noted an association between reading difficulties and anxiety symptomology (Carroll & Iles, 2006). Furthermore, Punaro and Reeve (2012) revealed that nine-year-old children reported high levels of worry in a literacy judgement task corroborating the possibility that literacy can elicit anxiety. Consequently, here we measured maths and reading performance to explore whether MA is exclusively related to maths or whether it is also related to performance in literacy.

Nevertheless, Punaro and Reeve (2012) also discovered that, whilst the high maths-worry subgroup only reported a maths task to be worrisome and not a language task, the high language-worry subgroup reported both maths and language tasks to be worrisome. It may be that these children were worried about mathematics and about language simply because they were generally anxious children, with a disposition towards many forms of anxiety. General anxiety (GA) differs conceptually and in definition from MA in that it does not relate to a specific situation or activity, but rather refers to an individual's general disposition to worry about events, behaviours and personal abilities. However, evidence suggests that GA and MA may not be entirely independent; GA is moderately correlated with MA (Hembree, 1990) and, in a study exploring the genetic variance of MA, genetic and non-shared environmental factors associated with GA were found to influence MA, implicating GA in MA aetiology (Wang et al., 2014).

There is the further possibility that methodological issues are clouding the issue. Researchers have distinguished between trait and state anxiety (Bieg et al., 2014, Goetz et al., 2013). Trait anxiety refers to habitual emotions, whereas state anxiety relates to transitory, contextual worries elicited by real-life experiences. Self-report measures of state and trait anxiety can lead to different results (Porter et al., 2000) and findings reveal higher intensities of trait as compared to state emotions (Goetz et al., 2013). Yet, researchers typically employ self-report questionnaires measuring trait, rather than state, MA.

Whereas state MA reflects an individual's momentary anxiety levels in a given maths-based situation, trait MA reflects an individual's typical feelings towards maths, therefore making it more akin to general anxiety. Furthermore, unlike state MA, trait MA levels have been found to be influenced by dispositional and temperament-based factors such as subjective beliefs (Robinson & Clore, 2002) and competence beliefs (Goetz et al., 2013). Consequently, it is conceivable that typical self-report (i.e. trait) MA measures are influenced by GA levels. With this is mind, a pertinent (yet often overlooked) question relates to whether, and how, general and maths anxiety are associated. Are typical self-report MA measures simply highlighting generally anxious individuals rather than those specifically worried about maths? By utilising both a measure of GA and a typical self-report measure of trait MA we aimed to further explore relations between the two anxiety-types and whether controlling for GA would affect the relationship between students' MA and their maths performance.

In response to the abovementioned research gaps, here we had three objectives. Firstly, by testing both primary and secondary students, we further explored MA gender differences and investigated whether gender-related patterns are visible in secondary school, primary school or at both educational levels. Secondly, we mapped developmental changes relating to MA and its link with maths performance in both primary and secondary school. Finally, we examined the specificity of MA by exploring relations between MA and reading performance, as well as those between MA and GA.

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Maths anxiety in primary and secondary school students: Gender differences, developmental changes and anxiety specificity

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Maths anxiety (MA) is a debilitating negative emotional reaction towards mathematics. However, MA research in primary and early secondary school is su...

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https://www.journals.uchicago.edu/doi/abs/10.1086/602621

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Post-Positivist Research: Two Examples of Methodological Pluralism | The Library Quarterly: Vol 63, No 4

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A post-positivist research approach advocates methodological pluralism. It is based on the assumption that the method to be applied in a particular study should be selected based on the research question being addressed. The research described here takes a post-positivist approach, applying interpre…

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https://www.proquest.com/docview/1770514323?pq-origsite=gscholar&fromopenview=true

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Positivist

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Abstract
There is a substantial international literature around the impact of different types of grouping by attainment on the academic and personal outcomes of students. This literature, however, is sparse in student voices, especially in relation to mixed-attainment practices. Research has indicated that students of different attainment levels might have different experiences and views of grouping structures. This paper represents a significant contribution to this literature. Drawing on the data collected as part of a large study on student grouping and teaching in England, we analyse the attitudes of students of different attainment levels to mixed-attainment practice, focusing on their explanations for their preferences or aversion to mixed-attainment classes. The data-set is drawn from group discussions and individual interviews with 89 students age 11/12 (Year 7) from eight secondary schools practicing mixed-attainment grouping in mathematics and English. Our analysis identifies some broad patterns in student attitudes, including a strong preference for mixed attainment among those at lower prior attainment. The analysis of the explanations students give for their opinions on mixed-attainment practice demonstrates how the learner identities of different groups of students are constituted in various ways by the discourses around 'ability', and constrained by the dominant ideology of 'ability' hierarchy.

Background

The practice of grouping students by 'ability' is commonplace in school systems around the world and takes various forms (Chmielewski ). The practice of subject-by-subject grouping, known as 'setting' in the UK, is theoretically a more flexible form of grouping than 'streaming' or 'tracking' systems that involve assigning students to fixed classes based on their presumed ability, achievement level, or career aspirations. Mixed attainment or heterogeneous grouping (also known as 'detracking' in the US and other international contexts) refers either to random allocation of students or a conscious effort to achieve a balance of students of different prior attainment in the class.

Mixed-attainment practice is not unknown in English secondary schools and is, in fact, the prevalent mode of grouping students in art, music and humanities (Kutnick et al. ). However, it is rare to find mixed attainment extended to core subjects, especially mathematics - in the Programme for International Student Assessment (PISA) 2012 less than 5 percent of UK students were in maths classes with 'no ability grouping' (OECD , 79). Additionally, Ofsted's figures show that, on average, 62 percent of secondary science and 58 percent of English classes were 'setted, streamed or banded by ability' in the 2009/2010 academic year (cited in Dracup ).

The findings of the research on the effects of grouping by attainment on the academic and personal outcomes of students have suggested positive benefits for students assigned to high groups (Kulik and Kulik ; Kerckhoff ; Ireson and Hallam ). The progress of students in lower groups, however, was found to be delayed by one or two months each year, and their confidence and engagement were undermined (Higgins et al. ). Questioning the practice of separation by attainment further, a recent second-order meta-analysis synthesising research in the USA on the effects of ability grouping on secondary students' attainment identified no significant benefits from between-class grouping (i.e. 'setting') for either high, middle or low attainers (Steenbergen-Hu, Makel, and Olszewski-Kubilius ). By contrast, a number of studies (Slavin ; Venkatakrishnan and Wiliam ; Burris et al. ) revealed positive effects of mixed-attainment grouping on the achievement of the lower attaining subgroups. Furthermore, mixed attainment was found to foster greater self-esteem and positive attitudes to school (Ireson and Hallam ).

Though the research on student grouping by attainment is abundant with quantitative analyses of the outcomes, it is sparse in student voices (for exceptions see Boaler, Wiliam, and Brown ; Gillborn and Youdell ; Ireson and Hallam ). The literature on what constitutes good mixed-attainment practice is limited in any case (Francis et al. ), but even more so in relation to secondary students' experiences. This paper addresses the gap in research on how different learners perceive mixed-attainment grouping. Drawing on the qualitative aspects of the ongoing study, involving Year 7 students in schools with mixed-attainment practice at Key Stage 3 (KS3), we provide a nuanced analysis of students' responses to mixed attainment by their level of prior attainment.

What do we know about students' perceptions of mixed-attainment grouping?

A large-scale survey conducted by Hallam and Ireson () suggests that students' preferences for mixed or 'setted' classes differ according to a range of factors. The extent of attainment grouping adopted at school and students' current and previous experience of setting were identified among predictors of preferences for mixed-attainment grouping or setting. Notably, a higher percentage of students from schools practicing near complete mixed attainment expressed a preference for mixed-attainment classes compared to respondents within the settled and partially settled schools. There were also higher levels of satisfaction with their class placement among students taught in mixed-attainment groups (Hallam and Ireson ).

The survey findings also suggest that lower attainers and disadvantaged students are most likely to favour mixed-attainment classes (Hallam and Ireson ). Indeed, a greater proportion of students in bottom sets for all curriculum subjects expressed preference for mixed classes compared to those in middle and top sets. There was also a greater preference for mixed-attainment classes amongst students taking free school meals. The most commonly named advantages of mixed-attainment classes related to cooperation, friendships, social mixing, and equality of learning opportunities. A smaller number of students gave reasons for disliking mixed attainment due to behavioural problems in class, and feeling left out or behind (Hallam and Ireson ). However, these comments were not systematically examined by students' level of attainment, set or other social characteristics.

The few studies that have attempted to disaggregate and compare the views of different groups of students within mixed-attainment classes indicate that students of different attainment levels, as well as of different racial and socio-economic backgrounds, could have different experiences. For example, some insights into learners' prior attainment and their attitudes to mixed attainment are offered by Kutscher and Linchevski (), who found that low and middle attainers consistently preferred learning mathematics in mixed-attainment groups, while results were more mixed for higher attainers. There is further evidence that less confident learners dislike the competitive and stressful environment of top sets (Boaler ), while studies with 'gifted and talented' students have found a stronger preference for homogeneously grouped classes (Shields ; Adams-Byers, Whitsell, and Moon ).

Boaler's () research in a diverse American high school found that learning mathematics in mixed-attainment groups promoted relational equity among students, responsibility towards lower attaining peers, and improved achievement. The success of detracking in this case was underpinned by the effective classroom implementation of this reform by the teachers. Other research on students' perspectives on detracking revealed doubts about educators' ability to teach challenging material in a mixed-attainment classroom, to have equally high expectations of all students, and to abandon favouritism on the basis of 'ability', as well as class-related and racial stereotypes [Yonezawa and Jones ; see Corbishley et al. (), Gillborn and Youdell () for UK context]. Even teachers devoted to the detracking reform could face difficulties in raising the achievement of low attainers in the academically competitive classroom, dominated by the values of credentialing, with limited time for academic scaffolding of struggling learners (Bixby ; Rubin ).

Sociological research has demonstrated that students' learner identities are also interconnected with raced, classed and gendered identity practices and institutional discourses (Francis ; Archer ; Youdell ). Furthermore, particular 'constellations' of identities could 'suffer' in the context of mixed attainment. For example, Rubin () describes how the context of small group work in an American detracked classroom brought to the fore the already pervasive racial and socioeconomic tensions and reinforced minority students' prior understandings about their social and academic possibilities [see also Modica ()]. In Yonezawa, Wells, and Serna's () study on detracking, the school effort to create heterogeneous classes through the mechanism of student 'choice' failed due to even higher attaining Black and Latino students choosing 'respect' over high-track courses where they felt unwelcomed. Hence, despite teachers' best intentions to ensure diversity, it is possible that students might themselves prefer 'a compatibility rooted in sameness' (Rubin , 558).

The association between learner identities and constructions of 'ability' were particularly salient within our study, and most commonly evoked and problematised by students when asked about mixed-attainment practice. This prominence reflects the very nature of the differentiation and categorisation practices inside schools,

... underpinned by the notions, for instance but not exclusively, of ability (intelligence); rationality and self-reflection; good conduct; hard work and commitment; and childhood and adolescent development. (Youdell , 179)

Scherer's () analysis shows that some children are keen to 'challenge' judgemental institutional labels. Other literature has suggested that such opportunities are constrained by the naturalisation of hierarchies of 'ability' within and beyond schools, with working-class students being most affected by school messages about their 'ability' identity (Abraham ; Hamilton ). Even in the mixed-attainment context disadvantaged students were found to rationalise unequal treatment by differences in 'ability' and 'behaviour' among students (Gillborn and Youdell , 209). And, despite liking mixed attainment mathematics, 'average' students were found to implicitly prioritise the potential needs of the high attainers, expressing concerns about whether 'excellence' [ sic] students were stretched enough in mixed-attainment classes (Walls , 192). Hence, we suggest that the assemblage of measurement, categorisation and differentiation practices in school, and associated discourses around 'ability' that shape learner identities, provide a useful framework for examining students' attitudes to mixed-attainment grouping.

Methodology

The 'Best Practice in Grouping Students' is an ongoing large-scale project. It adopts a randomised control trial (RCT) design to investigate which approach to grouping students in English secondary schools - setting or mixed attainment - is most effective in improving the educational outcomes of students, especially those in low sets and from lower socio-economic backgrounds (Francis et al. ). The trial 'Best Practice in Setting' investigates setting in English and/or mathematics across 126 secondary schools located in England. A feasibility study 'Best Practice in Mixed Attainment' investigates mixed-attainment grouping and teaching practices across 13 schools. The project also undertakes mixed-method research to explore young people's experiences of different student grouping practices in English and mathematics.

This paper is based on analysis of the qualitative data from the pilot and main phases of 'Best Practice in Mixed Attainment'. The data-set comprises data from 20 group discussions and nine individual interviews with a total of 89 students aged 11/12 (Year 7) drawn from eight state-funded schools practicing mixed-attainment grouping in core subjects. Three of these schools were part of the pilot phase of the study. The remaining five schools were purposefully sampled from the 13 schools participating in the ongoing trial with the view to representing a variety of pupil demographics (e.g. rural, suburban, and urban; multi-ethnic and predominantly white, deprived and affluent areas, etc.). We also sought to sample schools from both the intervention and control groups of the trial, as well as some new to mixed-attainment teaching and others with an established practice. Of the schools selected, two were located in the South East, one in the Eastern region, one in Yorkshire, two in the Midlands, two in London (Table 1).

In the pilot phase of the study, students were interviewed individually and in focus groups. However, we found, in line with the common observation of child and youth researchers (Punch ), that group environments provided security, reduced power imbalance and offered a more relaxed atmosphere where Year 7 students did not have to supply lengthy verbal accounts but, reacting to each other's perspectives, could more fully articulate their own implicit views. Therefore, the decision was made to interview students in groups in the main phase of the study. This format also suited a social constructionist study framework in that participants were explicitly encouraged to interact and talk, thereby constructing a collective meaning (Wilkinson ).

Already during the preliminary analysis of the pilot data, it transpired that students of higher and lower attainment levels held divergent views of mixed-attainment grouping. Thus, in the main phase of the project we asked teachers to put together group discussions of students with similar prior attainment. We expected that the interaction among students with comparable experiences would exemplify the views and beliefs representative of certain groups of students in mixed-attainment settings. We also hoped that interviewing students with peers at similar attainment levels would create a 'safe' space for pupils to articulate their feelings about their experience of mixed-attainment classes, which could potentially be at odds with experiences of those at other attainment levels (Boaler, Wiliam, and Brown ).

Our definitions of students' attainment levels (see Table 2) were based on their Key Stage 2 (KS2) test results attained on completion of primary school: low attaining - below level 4 in the KS2 tests; middle attaining - at level 4 in the KS2 tests; high attaining - at level 5 or above in the KS2 tests. Including the pilot phase, a total of 89 students (31 boys and 49 girls) took part in 20 group discussions and nine individual interviews (1 boy and 8 girls). The gender imbalance in the sample for this qualitative work is because two of the pilot schools were single-sex all-girl schools.

Students came from a range of socioeconomic and ethnic backgrounds. Social class categorisations were assigned by the authors on the basis of parental occupations. The higher status occupation between two parents was used to classify students into the following broad categories: higher SES (36%, n = 32), middle SES (38%, n = 34), low SES (20%, n = 18) and unknown (6%, n = 5). Students self-categorised their ethnicity in the following way: White British - English, Scottish, Welsh and Northern Irish (57%, n = 51), South Asian - Bangladeshi, Indian, Pakistani (18%, n = 16), White Other (7%, n = 6), Arab (7%, n = 6), Black (3%, n = 3) and any other mixed backgrounds (8%, n = 7).

Individual interviews lasted between 20 and 30 min, and group discussions lasted between 40 and 60 min. All interviews were audio-recorded, transcribed and then anonymised prior to analysis. The semi-structured schedules covered experiences of school and English and mathematics, perceptions of reasons for mixed-attainment grouping and impact on students, feeling about being/learning in mixed classes, perceptions of mixed-attainment teaching, experiences in primary school, as well as views on setting. Data were organised and thematically coded in NVivo to facilitate analysis. This paper draws on the analysis of students' responses to the key interview questions about their experiences and views of mixed-attainment classes. First, where respondents expressed their sentiments, the lead author classified each student's contribution as 'positive', 'negative' or 'mixed' and mapped it against his/her prior attainment level to identify broad patterns. The coding of several debatable cases was checked by two other authors. The subsets of data were then further examined to explore main reasons for young people's preferences for or dissatisfaction with mixed-attainment grouping, and analysed in light of the literature cited earlier.

Overview of students' attitudes to mixed attainment

The content analysis of contributions by 85 students suggests that more students were consistently 'positive' than 'negative' about mixed-attainment grouping, but there was also a substantial minority of those who highlighted both 'positive' and 'negative' aspects of being in mixed-attainment classes (see Table 3).

Table 4 breaks down responses by student attainment. It demonstrates that learners of lower prior attainment are proportionately more likely than other students in our sample to express positive views about mixed-attainment grouping, with three-quarters (16 out of 21) speaking favourably about mixed classes. Half of higher attainers (18 out of 35), spoke positively about their experiences of mixed-attainment classes, and further nine students in this group discussed both positive and negative sides of mixed attainment. Middle attainers appear to be more divided than the other two groups in their responses to mixed attainment.

Although the respondent sub-group numbers are small, rendering this identified trend impressionistic, elements of these findings echo those in previous research on grouping preferences among students. Hallam and Ireson's () survey found that students in bottom sets, and those who did not achieve high scores at Key Stage 3 tests, were likely to prefer mixed attainment to setting. Our own analyses of the present project's baseline questionnaire data demonstrate that Year 7 students with lower KS2 test results for reading and maths expressed the most negative views towards setting, as did students in bottom sets (Archer et al. ).

The figures displayed in Table 4 do not entirely support a previously reported strong opposition to heterogeneous grouping among higher attainers (Adams-Byers, Whitsell, and Moon ; Hallam and Ireson ). And our findings suggesting that less than half of middle attainers favoured mixed-attainment grouping also challenge Kutscher and Linchevski's () finding that middle attainers in their classroom research preferred to learn mathematics in mixed groups with stronger students who supported their progress - albeit here our findings are in keeping with Hallam and Ireson's () survey results, which found that middle set students' views of mixed attainment grouping are significantly less positive than those of students in bottom sets.

To unpack these findings, we turn to consider the reasons that each group of students offered for preferring or disliking mixed-attainment classes. Importantly, we examine not only differences between groups but also variations within the attainment groups, and how these are infused by classroom practices and wider discourses.

High-attaining students - between equity and individualism

'You don't feel like you're isolated': mixed attainment as a fair system

A significant proportion of the higher attainers who expressed positive views about mixed-attainment grouping were found to draw on equity discourses that emphasised the ability of this grouping system to support fairness and equality of opportunity. In keeping with earlier research (Ireson and Hallam ), the majority of the students who expressed support for mixed attainment believed that it promoted the attainment and inclusion of lower attainers through access to the curriculum content, and perhaps to the pedagogy, that in the setting system would be 'deemed beyond the 'bottom' stream' (Abraham , 15).

[L]ess able at maths, they get taught the same thing as people who are more able and so they're not like left behind. (Lara, School K, White British, higher SES)

[I]f there's like a class of lower achieving students [...] they wouldn't have that much like ability to share with the other students, whereas if you're a higher student, you can easily share ideas with them. (Gary, School M, White British, higher SES)

Many respondents expressly valued the social inclusivity of heterogeneous grouping. The girls we interviewed at School F were effusive about the emotional advantages (i.e. confidence due to established bonds of friendship) of learning in their form. At another school, Chris found the diversity of mixed classes interesting: 'I do quite like the mixed groups because you get to see what other people are thinking' (School E, White British, higher SES). In relation to reasons behind mixed-attainment grouping Jeremy believed that 'we're humans, we're not brilliant at everything', and in 'the real world, there are going to be people who don't like you and people who are different to you, so you've got to get used to that' (School K, White British, higher SES). Hayat, who seemed uncomfortable with the idea of hierarchies and did not want to be regarded as 'the girl who does all this', said that mixed attainment allowed her to feel included:

I think it makes it better because you don't feel like you're isolated and you're away from other people. (School L, mixed ethnic background, higher SES)

In some ways, being in mixed-attainment classes shaped these students' support of the education system where, to quote Abraham (), the 'needs' of at least some higher attainers are related to 'helping others' as opposed to just 'striving ahead' (861). Offering help to others was also framed as a benefit to their own learning, not just to the learning of low attainers - the view that coheres with research on the positive effects of cooperative learning on highest attainers and those offering explanations (Slavin ). For example, Muna thought that 'if you're helping another person maybe you learn something new' (School F, South Asian, higher SES). Likewise, Evelyn argued, 'if the higher level students are helping the lower level, they might learn some more by helping them as well' (School N, White British, higher SES).

Perhaps echoing Boaler's () finding that some higher attainers dislike the 'fast and furious paradigm' of the top sets, Susan welcomed extra practice and revision in mixed-attainment lessons: 'I think it's nice because you can always start off with an easier bit of work and then build up' (School A, White British, middle SES). Higher attainers from other schools also described how the inclusive mixed-attainment pedagogy could fill potential gaps in their knowledge and deepen their understanding:

[T]hen while they're teaching sort of the lower level, the higher levels can maybe listen to things that they've missed out on when they've been away or something. (Evelyn, School N, White British, higher SES)

[S]ay you're quite good and you forget about the easy stuff, you learn from the ones that aren't as good because they just keep going through the easy stuff. (Simon, School K, White British, low SES)

The perceptions by students presented in this section touch upon wider social issues behind the egalitarian principles of mixed attainment. Yet, despite recognising that mixed attainment supported equity, many high-attaining students, as discussed below, were also academically competitive and adopted a meritocratic view of education - that equality of opportunity implies maximising the potential of individual students in accordance with their merit (i.e. 'abilities').

'I feel a bit held back': competitive individualism in mixed-attainment classes

Those high attainers who expressed negative views of the mixed-attainment grouping tended to describe their lessons as being 'easy', 'boring', 'a bit dull', 'slow' and 'not challenging enough', thus, as Lochan put it, 'bad for the top class students' (School O, British Asian, low SES). The quote below, by a high-attaining student, captures such sentiments:

Then the bright kids, it's quite hard for them because when we have the easy stuff, it bores them quite easily because they can just do it and then they're sitting there because they've done it and there's not much for them to do because they find it so easy. (Camilla, School E, White British, higher SES)

On the one hand, these concerns relate to a recognised challenge of meeting the varied 'needs' of students within mixed-attainment classes (Hart ). Some previous work described a lack of appropriate change in the teaching approaches and content of the lessons in schools which adopted all attainment teaching (cf. Ball ), where, as Rubin () found, higher attainers could be 'bored' with 'stuff that I kind of already knew' (687), and even lower attainers felt their 'classes were easy, so I didn't have a challenge' (665). However, given that we do not have evidence of such uninspiring pedagogy in our schools, the views and learner identities of the higher attainers may have been influenced earlier by attainment structures and cultures in primary schools. Yonezawa, Wells, and Serna () maintain that 'students who are labelled gifted in elementary school develop a habitus of entitlement' (52). The setting structures in secondary schools, as Reay, Crozier, and James () argue in their study of white middle-classes choosing urban comprehensives, 'simultaneously build upon and maintain' the sense of superiority and entitlement for middle-class high-attaining students and their parents:

A key motivator for being in the top set was to ensure academic success, but this was also linked for both the parents and young people to the desire to be separated off by the putative 'disruptive elements in the school' - the undesirable Other. (Reay, Crozier, and James , 133)

Several higher attainers in our study used the language of 'behaviour', rather than 'ability', to justify their desire to be kept apart from 'distracting students' who 'mess around' and, supposedly, 'just don't really enjoy the subject' (Felicity, School K, White British, higher SES). The majority of the students however described mixed-attainment grouping as limiting their individual academic progress, thus reproducing the 'common sense' view supported by most politicians, teachers and parents that students are best engaged in learning on their level of 'ability' (see Francis et al. for discussion). For example,

It is quite annoying because we've already learnt that stuff and we're just going over it, which is good but like we want to learn more, we don't want to just carry on going over the same thing. (Brooke, School M, White British, higher SES)

And then, like, the people, like, are trying to learn the stuff but then slowing down when we could be doing something else different. (Neil, School O, White British, middle SES)

High attainers have been previously described as operating according to the pragmatic code of 'making the grade' (Becker, Geer, and Hughes , quoted in Bixby, , 119). The following quotes exemplify their instrumental focus on certification, alongside the recognition that mixed attainment is good for low attainers:

I think it benefits the lower-ish people because they feel encouraged to do better but the higher people, they might not feel pushed enough to get better grades. (Alice, School A, South Asian, higher SES)

It means you can't cover the stuff you're supposed to cover in the lesson so it means you're less able when it comes to tests and stuff because there have been so many people messing around you haven't been able to cover the stuff you should be. (Camilla, School E, White British, higher SES)

These views expressed by the students highlight the need to recognise the challenge of implementing such a 'radical' change in a context infused by individualistic interests, investments and desires, and resistance from those who perceive benefit from the separation by 'ability' within the comprehensive system (see, e.g. Oakes et al. ). Indeed, Loveless () found that suburban schools serving students from higher socioeconomic backgrounds were least likely to respond to the US policy recommendations on detracking. It is possible, however, that effectively differentiated teaching in heterogeneous classes (see e.g. Taylor et al. ) could contribute to resolving the tensions between the higher attainers' individualistic orientations and their support for the learning and social benefits, and egalitarian principles of mixed-attainment grouping related to reduction of inequality.

Low-attaining students - between 'empowered' and 'positioned' learner identities

Valuing inclusion and collaboration: 'you can help some people and some other people can help you in return'

As Table 4 above illustrated, the large majority of low prior attainers valued mixed-attainment practice. Many articulated a strong awareness of a range of opportunities available to them due to the conditions in mixed-attainment classrooms. For example, Mabel (School M, White British, middle SES) appreciated access to a less stratified curriculum - a chance she would not have had in the bottom set to learn about 'what the good people are doing' and thus being able to realise 'what you are good at'. Likewise, being exposed to 'what [others] are doing' helped Rania (School F, South Asian, middle SES) 'see things that I am able to do'. Debbie (School O, White British, low SES) noted that, where attainment grouping segregates students socially as well as by attainment, mixed-attainment grouping facilitated the ability to 'talk [things] through and make friends and then that could, like, help with your work'. Although Debbie's classmate Colm initially had doubts about whether he belonged in mixed classes, being 'really nervous' about sitting 'next to the smart people', he later changed his perception of his learning capacity and came to believe that being taught in a mixed-attainment class would open up his opportunities beyond the school:

But now I know if you're sitting next to smart people, you can get a better job, then you can -

Get a better grade on your GCSEs.

Yeah. Then you can get a lot of money to have a nice family and have a nice house.

(School O, White British, low SES) By contrast, in Ireson and Hallam's () study of setting practice, the better long-term prospects such as 'good jobs' and 'lots of money' were associated by most students with top sets, while students in lower sets were described as 'left for unemployment' (98).

Students' awareness of mixed-attainment practice's facilitation of opportunities to learn and get help from peers have been previously identified (Hallam and Ireson ). Teachers were also found to believe that 'mixed ability classes provide the less able students with positive models of achievement' (Ireson and Hallam , 126). In the maths classroom where students worked in homogeneous groups, low attainers reportedly accomplished very little on their own without the input of more competent peers or teachers (Kutscher and Linchevski ). Collaborative work in mixed-attainment maths classes, on the other hand, allowed students that were regarded as weaker 'to shine in some areas' (Boaler, Wiliam, and Brown , 645). Most of our interviews reflected these issues:

I think it's better because since there's different abilities, you can help some people and some other people can help you in return. So then you get extra help for like if you're in one of the lowers with loads of people who aren't very good at maths and there's only like one teacher then you can't get other students to help you. (Adele, School N, White British, middle SES)

It is notable, given that low attainers are often constructed as benefitting from receiving help in mixed-attainment classes, that Adele highlights the ability to help others as a mutual benefit for all students, including low prior attainers. We found that while many higher attainers in this study and in other research (Boaler ; Adams-Byers, Whitsell, and Moon ) expressed preferences for individual learning at faster pace, the learner identities of the lower prior attainers in mixed-attainment classes were constituted by their preference for collaboration and shared responsibility for the learning of others. Asked about why they preferred mixed-attainment classes, a number of students revealed the importance they attached to learning together as a community for mutual benefit:

Because, like, as Furud said, it's 32 brains and from one brain everybody can learn and say if somebody got something wrong, other brains can help them and then they work on their own. (Hichem, School L, Arab, low SES)

Because you have the people to help you around you, but then you also have the people you can help, so it's easier. (Joey, School M, White British, middle SES)

The fact that everybody around me is helpful and they can give you advice on the things you don't understand, and I can help other people gain more knowledge. (Rania, School F, South Asian, middle SES)

The above comments speak to Hart et al.'s () findings on the impact of teaching based on the principles of trust, co-agency and community on young people's learner identities within classrooms free from ability labelling. They argue that such classrooms produce 'empowered learners' who take active responsibility for supporting one another's progress. On a related note, less stratification in school improves the self-esteem and general self-concept of all students, and particularly those of low prior attainment (Ireson and Hallam ).

Wanting to be with peers of similar attainment: 'I think we should have all the same levels'

Nevertheless, a small number of low prior attainment respondents expressed dislike of mixed-attainment practice. The following reason given by one of our study participants could appear to confirm the existing belief among the proponents of setting that low attainers would be intimidated and disheartened by challenging work and the faster pace of the mixed-attainment lessons (for discussion see Mazenod et al. ; Hallam and Ireson ; Rosenbaum ).

I'd prefer it if we were all the same level classes because then there's some people that have the same levels as me, not just all higher and it will be easier, I think. (Lauren, School K, White British, low SES)

Such views could also be read in light of the self-fulfilling prophecy literature which argue that young people's 'levelled' aspirations and expectations, and their learner identities are affected by their inferior position in the 'ability' hierarchy of the school (Yonezawa, Wells, and Serna ; Hart et al. ; Boaler ). As the overwhelming majority of our participants had had some experience of 'ability' grouping in primary school, it could be that they adopted what the system had been communicating to them about their identities as learners (see Walls ; Marks ; Scherer ), resulting in some of the students doubting their capacity to succeed in a more demanding mixed-attainment environment. Moreover, as indicated by Serena, quoted in the title of this section, students strongly identify with 'levels' attained at standardised tests at the end of primary school, supporting prior research findings on the 'regulatory' function of such assessment on students, whereby they come to view themselves and their peers 'entirely in terms of the levels to which [their] performance in the SATs is ascribed' (Reay and Wiliam , 346). Indeed, the negatively disposed lower attainers believed that the school had enough information about students to set them in Year 7 at the start of the secondary phase:

Well, you've done your SATs, so I think like they shouldn't really overly just put us in classes

So you mean you think that they should put you in sets already, they should be able to do that?

Yes.

(School N, Other White, higher and middle SES)

Although there is evidence in these interviews of the internalised thinking that 'ability' is an innate and measurable quality, it is noteworthy that low-attaining students with ambivalent views of heterogeneous grouping centred their criticism on certain mixed-attainment teaching practices that impinged on their learning. Specifically, the following quotes suggest the lack of attention to differentiation for students' individual needs that is considered 'pivotal to a fair system where all children are able to succeed' (Hart ; cited in Taylor et al. , 26).

Sometimes it's really hard because the teachers think that we all understand it because there is higher people who do understand it and then they just move along. (Haley, School N, White British, middle SES)

Because it's not really fair on the people who think like they can't do it, but then the teacher's like paying more attention to the people that have done it and just like, 'Oh yes, you've done really well.' When you like put your hand up and say, 'I don't really understand any of this,' and they're just like, 'You'll get the hang of it'. (Kayla, School N, Other White, higher SES)

These students seem to agree with some of the negative remarks by the higher attaining peers related to the practical implications of mixed-attainment teaching. Yet, they also highlight the need to ensure special provision for struggling learners in heterogeneous classes to maximise their chances for academic success (Burris et al. ).

Middle-attaining students - comparison, competition and status

'If I don't get something I will ask somebody who does'

In contrast with the high attainers, who saw the benefits of mixed attainment primarily for low-attaining students, those middle attainers who held positive views of mixed-attainment grouping focused on benefits for their own learning. Asked about what she thought of mixed-attainment grouping at her school, Shazana reflected,

I think it's a really good idea because we can teach each other, rather than being at the same level and knowing the same things and not knowing the same things, so if I don't get something I will ask somebody who does. (Shazana, School F, South Asian, higher SES)

Like most students at low prior attainment, the middle attainers thought that working with other students enabled their progress. It was good to learn in a mixed class because 'you need other's help', said Maryam (School L, Arab, low SES). Other students noted that getting help or hearing from other students made them 'learn more from their answers' (Claire, School A, White British, middle SES), 'see what they agree with' and 'always [learn] something new' (Mehdi, School L, White British, higher SES).

We also found that this group of middle-attaining students appreciated 'equal work' (Vanita, School F, South Asian, higher SES) in mixed-attainment classes. Their opposition to separation by attainment, described by one student as 'favouritism towards the intelligent' (Josh, School O, White British, middle SES), might be explained by the worries middle attainers previously revealed in relation to their 'precarious' position in the 'ability' hierarchy of the schools - that 'they might indeed be assigned to the lower tracks in the following year' and, as a result, 'feel inferior' (Kutscher and Linchevski , 7). Furthermore, several students made critical allusion to the limits imposed by attainment grouping on young people's learning and future opportunities:

I just think that it's better for the school to like put different people together because it's not just about intelligent and lower because the lower people might have high dreams. (Cara, School O, White British, middle SES)

I don't think it's fair to like split people because of their ability because then some people won't learn the things that they need to learn to get to university and go pass their GCSEs and A Levels. (Kian, School K, Black, low SES)

The issue of 'status' (e.g. feeling clever and respected - Hallam and Ireson []) is implicit in the concerns of the students cited above. Anxieties around (loosing) their 'status' within the 'ability' hierarchy shaped the negative views of mixed attainment among the other group of middle-attaining students.

'I'm not the smartest person in the lesson': feeling threatened and exposed by high attainers

This section discusses the experiences of the substantial number of middle attainers, which broadly relate to the diminished academic and self-concept in mixed-attainment settings due to the high-attaining reference group effects (Marsh ). The following allusion to the quick work pace of 'clever people' is significant for understanding the concerns of this group of students about their position in the academic 'race':

It's like some stuff I know pretty well. It's just the other kids that don't know it. But sometimes I don't know the stuff, and then there's tons of clever people like racing ahead of me. (Lee, School E, White and Asian, higher SES)

Engaging in comparison with higher attainers and assessing their 'ability' as inferior, the dissatisfied middle-attaining students felt 'frustrated', 'discouraged' and 'embarrassed' due to 'struggling' with the work they perceived as being 'hard' and, therefore, above their 'ability' level:

Because certain people could be struggling and sometimes in certain lessons, I'm not the smartest person in the lesson, so they are giving out hard work and I don't understand it and they can't expect you to do it if it's mixed. (Mary, School A, White British, middle SES)

I feel like I am, kind of, struggling on the work and everyone else gets it and stuff like that so I, kind of, feel a bit more discouraged if everyone else gets it and I don't and I also feel quite frustrated if that happens. (Edie, School N, White British, higher SES)

One key factor that seemed to contribute to the distress of middle attainers was the use of peer tutoring where high attainers were placed in the role of the helper by teachers who are often pressured to provide challenge for 'the most able' (Ofsted ). This left some middle attainers feeling 'babied' and even 'humiliated':

[P]eople that have finished, they go round helping everyone else. I kind of find it a bit humiliating because I'm just sitting there and everyone knows that I haven't finished and everyone else has. (Hilda, School E, White British, middle SES)

These experiences of the students suggest that the well-intentioned strategies adopted by teachers to cater for the needs of both high and lower attainers can lower self-confidence, highlight differences, and even promote labelling and antagonism towards higher attainers. For instance, higher attaining students were described as 'show-offs' by middle attainers at School K. As Roberts () argues, a less problematic solution to utilising the strengths of students of different attainment is to find ways to place 'the more capable peer' in role as 'a co-collaborator in the learning process', rather than 'a teacher of those less capable' (44).

Distancing from low attainers: 'we're at different stages and it's a bit hard to cooperate'

Finally, a small number of middle attainers bemoaned the presence of low-attaining students in their mixed-attainment classes. These students openly distanced themselves from low-attaining peers whom they described as being 'at different stages', 'hard to cooperate' with, 'asking loads of questions', 'stopping the whole class from doing their work' and the like. Suzanna voiced a typical view:

I don't like working with people who are mixed abilities because say people who aren't as high a level as us, they could be just asking loads of questions, 'I don't understand', and stopping the whole class from doing their work when you just want to get it done and go home. (Suzanna, School A, White and Black African, low SES)

These views are similar to the discourses of competitive individualism by higher attainers. However, a notably larger portion of higher attainers were more cooperative than these middle attainers and open to the idea of providing assistance to students of low prior attainment. This further highlights the point that the necessity of students to navigate and assert their place in the learnt 'ability' hierarchy of the school might take priority over values of fairness and social responsibility.

Conclusion

This research has made a significant contribution to the international literature on mixed attainment by seeking and analysing secondary students' views and experiences of mixed-attainment practice. Overall, the findings suggest that students' attitudes to mixed attainment are related to their prior attainment levels. As predicted by earlier literature, we found that mixed-attainment grouping was especially appreciated by students at low prior attainment level due to its inclusive and collaborative environment. However, our analysis somewhat challenges prior findings on the proportions of higher attainers that do not support mixed attainment, and suggests a more nuanced picture in which many high and middle attainers also appreciate aspects of mixed-attainment grouping. While in 'setted' schools top set students tend to prefer setting (Hallam and Ireson ), this research highlighted many high-attaining students' commitment to communitarianism and social justice that they felt underpinned mixed-attainment practice. The middle attainers who spoke positively about mixed attainment also felt the practice indicated that their school was committed to equity.

As noted in the introduction, schools practising mixed attainment in core subjects are unusual in England. As we have discussed elsewhere, there is a range of socio-political reasons (Francis et al. ), as well as practical and pedagogical explanations (Taylor et al. ), for why mixed-attainment grouping is rejected. American research has also found notable pressures towards tracking in schools that educate relatively advantaged and heterogeneous student populations (Loveless ; Domina et al. ). Those schools who 'buck the trend' and provide mixed-attainment learning environments in England are able to do so because of a wider focus on improving learning and teaching or equity, with implications for young people's learner identities (Hodgen et al. forthcoming).

The sociological analysis of the explanations students provided for their disaffection with mixed attainment across our 8 schools suggests that the responses of different groups of learners are configured by the wider discourses around 'ability' and constrained by the dominant ideology of 'ability' hierarchy. Specifically, this relates to the reluctance of a small number of low-attaining students to endorse mixed attainment due, hypothetically, to their previous experiences with 'ability' grouping practices in primary school that shaped their learner identities. While these low prior attainers appear to doubt their ability to succeed in heterogeneous classes, some high attainers feel entitled to preferential treatment, and the middle attainers appear to be preoccupied with their own status and asserting their position in the academic hierarchies.

The negative views of students discussed in the paper also bring to the fore the importance of distinguishing between 'mixed-ability classes and mixed-ability teaching ' (Abraham , 856; emphasis in the original). By way of implications for mixed-attainment practice, the findings suggest that it is crucial for teachers to ensure differentiation by outcome with rich tasks and quality feedback - otherwise learners of all attainment levels will be left dissatisfied (see Taylor et al. ). Additionally, while paired learning and peer tutoring seem to be appreciated by many students, these strategies also present strong risks that teachers need to be attuned to, to avoid scenarios where same people always give or receive help. These concerns are consistent with the ideas from classroom research that it is vital to support structural detracking with pedagogy explicitly designed to enable all students to succeed in spite of social and educational inequalities (Rubin ). Indeed, the quality of teaching students encounter has been found to make the most difference to the success of any grouping structure, including mixed attainment (Burris et al. ). This led Gamoran () to call for combining research on 'ability' grouping with research on teaching to continue to examine the two evidently successful approaches to detracking: raising standards for low attainers and providing differentiated learning in mixed-attainment classrooms. Our forthcoming analysis will combine the present findings with the scrutiny of the teaching students encounter in English and mathematics in order to continue to shed light on the topic of mixed attainment in secondary schools.

Notes on contributors

Antonina Tereshchenko is a research associate on the 'Best Practice in Grouping Students' project at UCL Institute of Education.

Becky Francis is the director of the 'Best Practice in Grouping Students' project and the director of UCL Institute of Education.

Louise Archer is the Karl Mannheim Chair of Sociology of Education at UCL Institute of Education. She is a co-investigator on the 'Best Practice in Grouping Students' project and the director of the Aspires2 and Enterprising Science projects.

Jeremy Hodgen is the chair of Mathematics Education at UCL Institute of Education. He is a co-investigator on the 'Best Practice in Grouping Students' project.

Anna Mazenod is a research associate on the 'Best Practice in Grouping Students' project at UCL Institute of Education.

Becky Taylor is researcher practitioner and project manager of the 'Best Practice in Grouping Students' at UCL Institute of Education.

David Pepper was a research associate on the 'Best Practice in Grouping Students' project and is now a Lecturer in International Education in the School of Education, Communication and Society at King's College London.

Mary-Claire Travers is an associate team member of the 'Best Practice in Grouping Students' project who contributes to the research data collection.

Funding

This work was supported by a grant from the Education Endowment Foundation.

Disclosure statement

No potential conflict of interest was reported by the authors.

Acknowledgements

The authors would like to acknowledge the contribution of the wider Best Practice in Grouping Students team, including Professor Paul Connolly and Dr Seaneen Sloan, Centre for Evidence and Social Innovation, Queen's University Belfast.

1. The Office for Standards in Education, Children's Services and Skills (Ofsted) is the chief inspection and regulation department responsible for inspecting educational institutions in the UK.

2. This term refers to the first two years of secondary education (Years 7 and 8) in state schools in England, Wales and Northern Ireland.

3. Because few schools in England use mixed-attainment grouping in core subjects, the scale of the trial is necessarily small. Our separate publication reports on our struggle to recruit schools for the mixed-attainment study, and explains why mixed attainment is seen as problematic (Taylor et al. ). Additionally, our review of the literature found little evidence on what constitutes good mixed-attainment practice - thus the need to pilot the intervention on a small-scale basis (Francis et al. ).

4. With the view to develop the intervention, prior to commencement of the RCT study period, the project team worked during 2014-2015 academic year with three pilot secondary schools practicing mixed attainment (see Taylor et al. for full details).

5. Although both groups practiced mixed attainment in English and mathematics in KS3, the control group was doing 'business as usual', while the intervention group was receiving a pedagogic intervention designed by the research team that drew on existing research evidence around 'best practice in mixed-attainment grouping' (see Taylor et al. for details).

6. The baseline survey data comprises questionnaire responses from 12,997 Year 7 students in 96 secondary schools across England. The survey was offered to all schools in the study, and 96 out of 139 participated and provided data, a response rate of 69%.

References

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2014. "The Politics of Setting." https://giftedphoenix.wordpress.com/2014/11/12/the-politics-of-setting/.

Garmoran, Adam . 2009. "Tracking and Inequality: New Directions for Research and Practice." In The Routledge International Handbook of the Sociology of Education, edited by Michael W. Apple, Stephen J. Ball, and Luis Armando Gandin, 213-228 Abingdon: Routledge.

Gillborn, David , and Deborah Youdell. 2000. Rationing Education: Policy, Practice, Reform, and Equity. Buckingham: Open University Press.

Kulik, Chen-Lin C. , and James A. Kulik. 1982. "Effects of Ability Grouping on Secondary School Students: A Meta-Analysis of Evaluation Findings." American Educational Research Journal 19 (3): 415-428.

Kutscher, Bilha , and Liora Linchevski. 2000. "Moving between Mixed-Ability and Same-Ability Settings: Impact on Learners." 24th Conference of the International. Group for the Psychology of Mathematics Education, Hiroshima, Japan, July 23-27.

OECD. 2013. PISA 2012 Results: What Makes Schools Successful? Resources, Policies and Practices (Volume IV). PISA: OECD Publishing.

OFSTED. 2015. "The Most Able Students: An Update on Progress since June 2013." Manchester. www.gov.uk/government/organisations/ofsted.

Punch, Samantha . 2002. "Research with Children: The Same or Different from Research with Adults?" Childhood 9 (3): 321-341.

, Gill Crozier, and David James. 2011. White Middle-Class Identities and Urban Schooling. Basingstoke: Palgrave Macmillan.10.1057/9780230302501

2008. "Detracking in Context: How Local Constructions of Ability Complicate Equity-Geared Reform." Teachers College Record 110 (3): 647-700.

Taylor, Becky , Mary-Claire Travers, Becky Francis, Jeremy Hodgen, and Claudia Sumner. 2015. Best Practice in Mixed-Attainment Grouping. London: Education Endowment Foundation/King's College London.

Walls, Fiona . 2009. Mathematical Subjects: Children Talk about Their Mathematics Lives. Dordrecht: Springer.10.1007/978-1-4419-0597-0

Wilkinson, S. 1999. "How Useful Are Focus Groups in Feminist Research?" In Developing Focus Group Research: Politics, Theory and Practice, edited by S. Barbour Rosaline and J. Kitzinger. London: Sage.

# data[].attributes.attachment_link.title
Learners' attitudes to mixed-attainment grouping: examining the views of students of high, middle and low attainment

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Abstract There is a substantial international literature around the impact of different types of grouping by attainment on the academic and personal outcomes of students. This literature, however, is sparse in student voices, especially in relation to mixed-attainment practices. Research has indicated that students of different attainment levels might have different experiences and views of grouping structures.

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https://journals.sagepub.com/doi/abs/10.1177/000169939904200205

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Interpretivist

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ABSTRACT
Research on reading achievement and reading motivation has rarely addressed the question if and how they affect each other over time. In our study, we investigate the reciprocal effects between reading achievement and both intrinsic and extrinsic reading motivation during elementary school. We measured reading achievement and intrinsic and extrinsic reading motivation in 966 students at 3 points of measurement during 3rd and 4th grade. Consistent with previous research, cross-lagged panel analyses revealed positive reciprocal effects between reading achievement and intrinsic reading motivation. Effects of reading achievement on intrinsic reading motivation were found during Grades 3 and 4, whereas effects of intrinsic motivation were limited to Grade 3. No reciprocal effects between reading achievement and extrinsic reading motivation were found. We discuss the implications of our results for daily teaching practices and effective reading instruction.

Acknowledgments

No potential conflict of interest was reported by the authors.

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Reciprocal Effects between Reading Achievement and Intrinsic and Extrinsic Reading Motivation

# data[].attributes.attachment_link.description
ABSTRACT Research on reading achievement and reading motivation has rarely addressed the question if and how they affect each other over time. In our study, we investigate the reciprocal effects between reading achievement and both intrinsic and extrinsic reading motivation during elementary school.

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http://jhr.uwpress.org/content/48/1/236.short

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Christopher Cornwell is a professor of economics at the University of Georgia. David B. Mustard is an associate professor of economics at the University of Georgia. Jessica Van Parys is an economics PhD student at Columbia University. Previous versions of this paper were presented at the University of Georgia and the Federal Reserve Bank of New York and the 2010 SOLE/EALE, 2011 AEFP and the 2011 ESEM annual conferences

Abstract

Using data from the 1998-99 ECLS-K cohort, we show that the grades awarded by teachers are not aligned with test scores. Girls in every racial category outperform boys on reading tests, while boys score at least as well on math and science tests as girls. However, boys in all racial categories across all subject areas are not represented in grade distributions where their test scores would predict. Boys who perform equally as well as girls on reading, math, and science tests are graded less favorably by their teachers, but this less favorable treatment essentially vanishes when noncognitive skills are taken into account. For some specifications there is evidence of a grade "bonus" for boys with test scores and behavior like their girl counterparts.

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Noncognitive Skills and the Gender Disparities in Test Scores and Teacher Assessments: Evidence from Primary School

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Christopher Cornwell is a professor of economics at the University of Georgia. David B. Mustard is an associate professor of economics at the University of Georgia. Jessica Van Parys is an economics PhD student at Columbia University.

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https://ojs.cumbria.ac.uk/index.php/step/article/view/375

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Motivation is seen as one of the most important aspects that educational practitioners can target to effect engagement and thereby improve student outcomes (Meece et al., 2006). This case study research, which took place in an above-average sized secondary school, aimed to investigate the perceived effect of learning mentor support on the motivation of those students in Year 11 receiving pupil premium funding. Questionnaires for twelve students and seven teachers explored the impact of motivation on student outcomes; the role goal setting plays on student motivation; the benefit of mentoring relationships and how a learning mentor can support disadvantaged students and their motivation. A semi-structured interview with the Deputy Headteacher responsible for monitoring pupil premium within the school provided further insight into learning mentor effectiveness in improving motivation and the resultant effect on outcomes such as attendance, behaviour, and attainment. Documentary analysis of student progress data at two reporting points provided triangulation.

Key findings indicated that learning mentors were effective in promoting student motivation and thereby positively affecting outcomes of attainment, confidence, homework and focus in lessons. Findings also suggested that participants viewed mentoring positively; it produced beneficial relationships. However, the findings for outcomes of attendance and organisation contrasted with key literature; it did not appear that learning mentors had a positive effect on these particular outcomes in this case study.

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Learning mentor support: an investigation into its perceived effect on the motivation of pupil premium students in year 11.

# data[].attributes.attachment_link.description
Motivation is seen as one of the most important aspects that educational practitioners can target to effect engagement and thereby improve student outcomes (Meece et al., 2006). This case study research, which took place in an above-average sized secondary school, aimed to investigate the perceived effect of learning mentor support on the motivation of those students in Year 11 receiving pupil premium funding.

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Current Evidence on Healthy Eating | Annual Review of Public Health (annualreviews.org)- We believe this because it uses lots of data.

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https://jech.bmj.com/content/62/8/734.short

It uses qualitative research throughout the study like interviews and open ended questions for example ‘tell me what kind of healthy foods you eat’.

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Journal of Epidemiology & Community Health

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Abstract

Objectives: To empirically test the impact of dietary intake at several time points in childhood on children's school attainment and to investigate whether any differences in school attainment between children who ate packed lunches or school meals was due to who these children were, their pre-school dietary patterns, or to what they ate at school.

Design: Using longitudinal data available in the Avon Longitudinal Study of Parents and Children (ALSPAC), multivariate linear regression was used to assess the relative importance of diet at different ages for school attainment.

Main outcome measures: Three indicators of school attainment were used: at ages 4-5 entry assessments to school, at ages 6-7 Key Stage 1 national tests and at ages 10-11 Key Stage 2 national tests. These outcome variables were measured in levels as well as in changes from the previous educational stage.

Results: The key finding at age 3 was that "junk food" dietary pattern had a negative association with the level of school attainment. A weak association remained after controlling for the impact of other dietary patterns at age 3, dietary patterns at ages 4 and 7 and other confounding factors. The authors did not find evidence that eating packed lunches or eating school meals affected children's attainment, once the impact of junk food dietary pattern at age 3 was accounted for in the model.

Conclusions: Early eating patterns have implications for attainment that appear to persist over time, regardless of subsequent changes in diet.

The content and quality of food eaten is related to developmental, cognitive and behavioural outcomes that are important in childhood for health and well-being, but also for specific experiences, such as school life. 1⁻4

This issue has had a high profile in the UK partly as a result of the Jamie's School Dinners television programme originally broadcast in 2005. The programme raised awareness about the poor nutritional content of school meals and children's preference for foods that are high in energy, fat, sugar and salt. Celebrity chef Jamie Oliver worked with staff and students in UK schools to improve the nutritional content of school meals and began a national campaign to highlight the importance of nutrition for children's well-being and to improve the nutritional quality of food offered in schools. 5 The UK government increased funding for school meals and instituted an agency to advise schools on nutritional standards. 6 Staff in schools that managed to improve the nutritional content of their meals reported improvements in students' behaviour in the classroom that they felt was related to the change in diet. 7

Via their effects on cognition, behaviour and physical health, the foods children eat have the potential to impact upon engagement in school and consequent attainment. Previous research on breakfast has focused on the short-term effects of nutrition on cognition and behaviour for children. 8⁻10 There is also evidence that early diet affects children's ability to think and perform in the long term. 11⁻13 This suggests that appropriate early childhood diets can be important for subsequent school outcomes. However, we are unaware of any studies linking early nutrition specifically to later school attainment.

This paper addresses two research questions. First, what is the relative importance of early diet versus later diet in predicting school attainment? Second, spurred by the recent debate about the role of schools in determining what children eat and research showing that, on average, the nutritional content of school meals is superior to that of packed lunches, we ask: does school attainment differ between children who eat packed lunches and children who eat school meals, conditioned on their pre-school dietary patterns? 14

METHODS

Data and sample

The Avon Longitudinal Study of Parents and Children (ALSPAC) is an ongoing population-based study designed to investigate the effects of environmental, genetic and other influences on the health and development of children. 15 Eligible participants were pregnant women resident in the former Avon health authority in South West England who were expected to deliver between 1 April 1991 and 31 December 1992. A cohort of 14 541 pregnant women were recruited resulting in 13 988 children (alive at 12 months old). Self-completion questionnaires were administered to the mothers during pregnancy and at various ages of the child. Ethical approval for the study was obtained from the ALSPAC Law and Ethics Committee and the Local Research Ethics Committees.

Outcome variable: school attainment

In the UK, each member country (England, Wales, Scotland and Northern Ireland) sets standards for what children should be taught at particular ages or Key Stage (KS). Children are then assessed for their attainment of the set curricula at each age or stage. KS scores obtained from the relevant education authorities in the National Pupil Database (NPD) were matched to the ALSPAC data. We used the Key Stage 2 (KS2) results for English, maths and science, administered when children are 10-11 years old, to assess school attainment.

In ALSPAC, some data on KS scores are missing because the NPD does not cover children in private schools (4.3% of pupils); matching was based on the child's name, date of birth and current postcode, so perfect matching was not always achieved; children initially included in ALSPAC who subsequently moved outside of England were not covered by the NPD. We do not know the proportion of pupils missing because of the last two explanations.

We used KS1 assessments of reading, writing, and maths, administered when the children were 6-7 years old, and on entry assessment in maths, reading, language, and writing, administered by schools and set by local education authorities when the children were 4-5 years old to measure attainment prior to KS2. This allowed for investigation of the impact of dietary patterns on attainment at different ages and on the change in school attainment. Entry assessments were not national or compulsory during the period of data collection so information was available for only two-thirds of the children.

Dietary data

Mothers, or main female carers, completed food frequency questionnaires (FFQs) about their child's consumption of foods and beverages when the child was 38 months (about 3 years old), 54 months (about 4 years old) and 81 months (about 7 years old). Of the 13 988 children in ALSPAC, dietary information at all three ages was only available for 7703 children (55%).

At 81 months, mothers reported whether their child ate meals served at school or packed lunches provided from home and the frequency with which they did each, recorded as either rarely, once in 2 weeks, once a week, two to four times a week or 5 days a week. Of these children, 29 per cent ate school dinners 5 days a week and nearly half (46%) ate packed lunches 5 days a week.

Of the 7703 children for whom dietary information was collected, 74 per cent had information on both KS2 and KS1 scores. The final study sample consisted of 5741 children with complete information on food frequencies and both school attainment scores results (41%).

Socioeconomic, demographic and lifestyle confounders

As both diet and achievement are influenced by a number of socioeconomic, demographic and lifestyle factors, such factors were controlled for in the analysis to attempt to remove confounding bias. These variables related to measurements taken prior to, or at the time of, the food intake, that is at ages 3-4 and before our measurements of school attainment. For all these variables, we included a missing category to avoid further loss of data.

Relevant sociodemographic information about the child included whether the child was a singleton or multiple birth, their gender and ethnicity, birth weight and the number of siblings at birth. Information on the mother included whether she felt she had difficulties affording food, her employment status, whether she had a partner, her highest educational qualifications at the time of birth, her socioeconomic group (SEG) (defined as professional for SEG I, managerial and technical for SEG II, skilled manual and non-manual for SEG III, partly skilled for SEG IV and unskilled for SEG V), whether she smoked during her pregnancy, whether she was a vegetarian when the child was born and her age at delivery.

Other variables included mother's parenting, breastfeeding, the household weekly income, housing tenure, whether the child watched children's television programmes and the HOME score, an indicator of the cognitive stimulation and emotional warmth in the home environment. 16

Table 1 lists the frequencies of the confounding variables used in this analysis, comparing those in our sample with the whole cohort. Overall, differences between the means are fairly small. The study sample contains more white male children, more children who watched television, more mothers from the middle socioeconomic group SEG (III), fewer mothers from the lowest SEG (IV or V), more mothers with secondary educational qualifications, fewer mothers with educational qualifications below secondary level and fewer mothers who smoked during pregnancy.

Statistical methods

Factor analysis (FA) was used to identify dietary patterns from the FFQ on 43 foods at 38 months, and on 57 foods at 54 and 81 months. FA reduces data by forming linear combinations of the original observed variables, thus grouping correlated variables and identifying underlying patterns in the data. In these data, three components or dietary patterns were identified for each time point. They were described as "junk food" characterised by high-fat processed foods (sausages, burgers and poultry products), snack foods high in fat and/or sugar (such as crisps, sweets, chocolate, ice lollies and ice creams) fizzy drinks and the number of takeaway meals eaten per month; "health-conscious" characterised as vegetarian foods, nuts, salad, rice, pasta, fruit, cheese, fish, cereal, water and fruit juice; and "traditional", typically meat and cooked vegetables. 17 18 Table A1 in the appendix (available online) provides further information on the dietary intake among children with diets high and low in "junk food" at 54 months.

A score was created for each child by multiplying the factor loadings by the corresponding standardised value for each food and summing across the food types for each of the three dietary patterns. The score has a mean of 0 and a higher score indicates closer association to that dietary pattern. 19 An indicator variable was also generated to differentiate between children who ate school dinners 5 days a week, those having packed lunches 5 days a week and those having a combination of packed lunches and school meals.

FA was also performed on the individual KS2 assessments to obtain an overall score with loadings of 0.79 for English, 0.86 for maths and 0.89 for science. Overall scores were also obtained for KS1 and entry assessments. Factor loadings for KS1 were 0.88 for reading, 0.87 for writing and 0.74 for maths, and for entry assessments 0.79 for reading, 0.70 for writing, and 0.70 for maths. The resulting scores had a mean of 0 and standard deviation of 1, thus a higher score indicates a higher result on overall tests.

Multivariate linear regression was used to assess the relative importance of diet at different ages for school attainment, allowing for the cluster of multiple births. The dependent variables, attainment score at different ages, were regressed against the dietary pattern scores, controlling for observable confounding factors. In this way, we assessed the relative importance of dietary patterns at different ages in predicting school attainment at different ages. The first model estimated the impact of dietary patterns at ages 3 and 4 on entry assessments (age 4-5) controlling for socioeconomic and demographic variables. The second model estimated, separately, the impact of dietary patterns at ages 3, 4 and 7 on KS1 and KS2 results, controlling for all confounding variables. The final two models estimated the impact of dietary patterns on KS1 controlling for entry assessments, and on KS2 controlling for KS1 attainment, both including all confounding variables. Models 1 and 2 estimate the impact of dietary patterns on the level of attainment, whereas the final model estimates this impact on the change in attainment.

Finally, we investigated the differences in KS2 attainment between children who ate packed lunches and those who ate school meals, controlling for KS1 test scores, food intake prior to school entry (age 3) and other relevant socioeconomic and demographic factors. In this estimation, we focused on the importance of the estimated parameter of packed lunches relative to school meals.

RESULTS

Data analyses

Table 2 shows descriptive statistics for the main variables used in the analysis according to whether children were in the top or the bottom 20th percentiles of KS2 results. Children with the highest KS2 scores also had higher average KS1 scores and entry assessment results. Higher "junk" dietary pattern scores at 3, 4 and 7 years were associated with lower average KS2 results. In contrast, a positive association was shown for the "health-conscious" dietary pattern and KS2 results. The "traditional" dietary pattern was not associated with KS2 results. Finally, there was a negative association between eating school meals and attainment whereby a lower proportion of high attaining children eat school meals. The opposite association was shown for packed lunches.

Dietary patterns at different ages in childhood and school attainment

Figure 1 shows the results from a regression analysis of dietary patterns at different ages on three measures of school attainment, controlling for confounding factors. The main result is that the "junk food" dietary pattern was more strongly associated with school attainment at age 3 than at later ages. Increased "junk food" scores were negatively associated with attainment even after adjusting for all confounding variables. Moreover, although the impact of other dietary patterns on attainment fluctuated around zero (once the age 3 measure was included), the impact of "junk food" score at 3 was always negative and of substantive magnitude.

Change in attainment conditional on previous attainment

We modelled change in attainment from entry assessments to KS1 and from KS1 to KS2. Increasing "junk food" score at 38 months was negatively associated with an increase in school attainment for both time periods. Moreover, the measures of early (pre-school) dietary patterns were more predictive of school success than later measures of diet ( table 3).

Second, the estimated coefficient of the "junk food" dietary pattern at age 3 on KS2 attainment was smaller than that on KS1 attainment, after controlling for prior attainment. One standard deviation increase in the score of "junk food" dietary component at 38 months was associated with a decrease of 0.027 (2.7% of a standard deviation) in the KS2 and of 0.065 (6.5%) in the KS1 score. Further, one standard deviation increase in the score of the "health-conscious" dietary component at 38 months was associated with an increase of 3.9 per cent of a standard deviation in the KS2, larger than that on KS1, and no association in the KS1 score. However, when compared with the impact of prior attainment on current attainment, which fluctuates between 53 per cent and 69 per cent of standard deviation, these are relatively small changes ( table 3).

In subgroup analysis, we found a negative socioeconomic gradient for the relationship between "junk food" dietary pattern and school attainment, but only between those in the highest SEG and the rest of the population. The estimated effect for the highest socioeconomic group was the lowest (−0.021); the effect for the middle socioeconomic group was −0.046 and finally the effect for the lowest socioeconomic group was −0.043. However, we found no evidence that SEG moderated the relationship between dietary patterns and attainment.

School meals or packed lunches and KS2 results

We found no difference in the average increase of KS2 scores between children who ate packed lunches 5 days a week and children who ate school meals 5 days a week or children who ate school meals 5 days a week and children who had some combination of packed lunches and school meals during the school week (table 4). This result was robust to the inclusion of prior attainment and consumption of "junk food" at age 3, differentiating for a free school meal indicator (column 1) and to the inclusion of other confounding variables (column 2).

DISCUSSION

For the children in this sample, an increased score on the "junk food" pattern at age 3 was associated with lower results in KS2 tests. An opposite association was found for the "health-conscious" dietary pattern score and school attainment. Further, when confounding factors were taken into account, the impact of increased pre-school "junk food" dietary pattern remained a risk factor for poor school attainment. This result is consistent with other findings suggesting that nutritional deficiencies prior to school entry have the potential to negatively impact upon cognitive outcomes in school-aged children. 19 Though contested, intake of foods high in sugar may also be associated with behavioural problems, such as hyperactivity, that can interfere with attention in the classroom and thus attainment, another potential explanation for these findings. 8 20

Although there was a negative association between early "junk food" consumption and later attainment scores, the estimated effect was small, suggesting that nutrition may have a diminishing role in attainment as children grow older, when the effect is more likely to be mediated by prior attainment. This may indicate a developmental period or stage where children are more susceptible to the long-term cognitive impact of poor nutrition. There is potential for a stronger effect as this sample is slightly biased towards more educated, middle class, and health-conscious mothers, though there was no evidence that socioeconomic status of the family mediated this relationship.

There was no relationship between school meals or packed lunch consumption and later attainment once the "junk food" dietary pattern prior to school entry and other confounding factors were introduced in the analysis. This suggests that although the emphasis on school meals is valuable and important, it must be part of a wider concern with nutrition more generally, in homes, in packed lunches and in school meals.

Full data were available on only 41 per cent of the original cohort and there were fewer ethnic minorities and disadvantaged families in this group than in the original cohort. Therefore, it was important to take account of these variables in the statistical models used. With a longitudinal research design, it is possible to account for some of the confounding bias in the relationship between dietary patterns and school attainment. For instance, mothers' health beliefs, educational attitudes and parenting behaviours may impact upon the provision of healthy food at home and provision of an educational environment, thus confounding the relationship. 21 In as much as we have information about the mother, via the HOME score and other measures, we can condition out some of the confounding bias. Still, results from this paper do not prove causality.

We used FA to reduce KS results on maths, science and English into a single variable related to school attainment. We also relied on the dietary patterns identified using FA. 17 18 This method for obtaining dietary patterns has been criticised for its subjectivity in identifying the underlying patterns. 22 It has also been argued that FA is population specific, and, as such, the results reported here may not be replicated in other studies. Despite this, previous research with different populations has linked diet and aspects of school performance. 11

This study has extended this area of research by linking children's diet before entry into formal education with outcomes for later school attainment. This highlights a challenge for policy-makers in establishing the location of responsibility for school outcomes related to aspects of health. The recent debate in the UK on school dinners has placed the onus on government agencies responsible for education to respond to the health needs of children to improve their educational outcomes. But if educational outcomes in part depend on nutritional intake before the start of school, with whom does responsibility lie? At what stage are interventions most effective? Is money best spent on school dinners or on the provision of health information to new mothers? This further supports movements towards collaborative efforts between agencies, but highlights the challenge of designing policy when the outcomes of one agency rely upon the inputs of another. 23 Improving the nutritional intake of children in the UK calls for a concerted effort between schools, families, government departments and other agencies to improve diets inside and out of school.

Acknowledgments

We are extremely grateful to all the families who took part in this study, the midwives for their help in recruiting them, and the whole ALSPAC team, which includes interviewers, computer and laboratory technicians, clerical workers, research scientists, volunteers, managers, receptionists and nurses. The UK Medical Research Council, the Wellcome Trust and the University of Bristol provide core support for the Avon Longitudinal Study of Parents and Children and the Smith Institute for funding the research project.

Author contributions: Leon Feinstein, Ricardo Sabates and Annik Sorhaindo carried out the analysis of the data and wrote the first draft of the paper. David Herrick compiled the school assessment data, Pauline Emmett and Imogen Rogers designed and led the dietary data collection within ALSPAC, Kate Northstone produced the dietary patterns scores from the original ALSPAC questionnaires. All authors were responsible for critical revisions and final approval of the manuscript.

# data[].attributes.attachment_link.title
Dietary patterns related to attainment in school: the importance of early eating patterns

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Objectives: To empirically test the impact of dietary intake at several time points in childhood on children's school attainment and to investigate whether any differences in school attainment between children who ate packed lunches or school meals was due to who these children were, their pre-school dietary patterns, or to what they ate at school.

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Teachers' Perspectives on the Challenges of Teaching Physical Education in Urban Schools: The Student Emotional Filter: Research Quarterly for Exercise and Sport: Vol 77, No 4 (tandfonline.com)

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The purpose of this study was to analyze how the challenges of urban schools influence physical education teachers' emotional understanding and connections with their students and the implications on their teaching. Sixty-one elementary physical educators from an urban school district in the midwestern U.S. were interviewed multiple times (N = 136) over 3 years using interpretive methodology. Teachers reported five unique challenges that significantly shaped their thinking about students and their careers, along with strategies they used to overcome or manage those challenges. The challenges were: (a) insufficient instructional resources, (b) implementing culturally relevant pedagogy, (c) dealing with community violence, (d) integrating more games in curricula, and (e) teaching in a culture of basketball. Implications centered on the guilt-inducing nature of urban teaching, developing an informed and realistic vision of urban physical education, and the role of teacher preparation and professional development.

Additional information

Notes on contributors

# data[].attributes.attachment_link.title
Teachers' Perspectives on the Challenges of Teaching Physical Education in Urban Schools

# data[].attributes.attachment_link.description
The purpose of this study was to analyze how the challenges of urban schools influence physical education teachers' emotional understanding and connections with their students and the implications on their teaching. Sixty-one elementary physical educators from an urban school district in the midwestern U.S.

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https://www.tandfonline.com/doi/abs/10.1080/13613320050074005

# data[].attributes.attachment_link.title
Minding the Gap: Ethnic, gender and social class differences in attainment at 16, 1988‐95

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(2000). Minding the Gap: Ethnic, gender and social class differences in attainment at 16, 1988‐95. Race Ethnicity and Education: Vol. 3, No. 2, pp. 117-143.

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https://www.tandfonline.com/doi/full/10.1080/0954025042000301429

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The last century, in particular the latter half, saw radical shifts in the roles and expectations of women in society. This article investigates the views of 14‐ to 16‐year‐olds in the year 2000 on work and family roles, exploring both their general views on gender roles and their own personal aspirations for the future. In general the young people believed that it was equally important for males and females to get good qualifications at school, to have worthwhile careers and that childcare should be a joint responsibility. They also believed that males and females could do any job they wanted to these days. Their views were tempered, however, by the inequalities that they saw around them in the workplace and in their own families. While young people's attitudes may have changed, they are still choosing fairly gender‐typical subjects at school and aspiring to different types of occupation. The article concludes that while great strides have been made in changing attitudes towards gender equality, there is still a long way to go before equal opportunities are really achieved.

Notes

A system used by Government to classify occupations: I Professional, II Managerial and technical, IIINM Skilled non‐manual, IIIM Skilled manual, IV Partly skilled, V Unskilled.

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Gender and attitudes to work and family roles: the views of young people at the millennium

# data[].attributes.attachment_link.description
The last century, in particular the latter half, saw radical shifts in the roles and expectations of women in society. This article investigates the views of 14‐ to 16‐year‐olds in the year 2000 on work and family roles, exploring both their general views on gender roles and their own personal aspirations for the future.

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Interpretivist- Jackson, Milly, Erin, Gemma &Tori

# data[].attributes.subject
Interpretivist- Jackson, Milly, Erin, Gemma &Tori

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https://www.tandfonline.com/doi/full/10.1080/03004279.2021.1963803

# data[].attributes.attachment_link.title
‘We just have to sail this sea all together until we find a shore’: parents’ accounts of home-educating primary-school children in England during COVID-19

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(2021). ‘We just have to sail this sea all together until we find a shore’: parents’ accounts of home-educating primary-school children in England during COVID-19. Education 3-13. Ahead of Print.

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https://ulris3.ul.ie/live/!W_VA_PUBLICATION.POPUP?LAYOUT=N&OBJECT_ID=2696015

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This empirical doctoral research study, which commenced in October 2012, examined wellbeing and resilience of guidance counsellors in the Irish post-primary sector using an interpretivist approach.

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Positivist- Jackson, Milly, Erin Gemma & Tori

# data[].attributes.subject
Positivist- Jackson, Milly, Erin Gemma & Tori

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https://www.unicef-irc.org/publications/pdf/COVID-19_Trends_Promising_Practices_and_Gaps_in_Remote_Learning_for_Pre-Primary_Education_brief.pdf

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https://www.bl.uk/britishlibrary/~/media/bl/global/social-welfare/pdfs/non-secure/e/v/a/evaluation-of-pupil-premium-research-report.pdf

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https://scholar.google.com/scholar?hl=en&as_sdt=0%2C5&q=impact+of+covid+19+on+primary+education&btnG=#d=gs_qabs&u=%23p%3DqnJpzvT7Q04J

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Suzanne Bunniss, NHS Education for Scotland, 2 Central Quay, 89 Hydepark Street, Glasgow G60 5JP, UK. Tel: 00 44 7766 056816; Fax: 00 44 141 223 1480; E-mail:  Suzanne.bunniss@nes.scot.nhs.uk

Abstract

Medical Education 2010: 44: 358-366

Context The growing popularity of less familiar methodologies in medical education research, and the use of related data collection methods, has made it timely to revisit some basic assumptions regarding knowledge and evidence.

Methods This paper outlines four major research paradigms and examines the methodological questions that underpin the development of knowledge through medical education research.

Discussion This paper explores the rationale behind different research designs, and shows how the underlying research philosophy of a study can directly influence what is captured and reported. It also explores the interpretivist perspective in some depth to show how less familiar paradigm perspectives can provide useful insights to the complex questions generated by modern healthcare practice.

Conclusions This paper concludes that the quality of research is defined by the integrity and transparency of the research philosophy and methods, rather than the superiority of any one paradigm. By demonstrating that different methodological approaches deliberately include and exclude different types of data, this paper highlights how competing knowledge philosophies have practical implications for the findings of a study.

Introduction

In recent years, there has been much debate about how to ensure that medical education research is not perceived as the poor relation of medical research. Various writers have argued that if medical education is to fulfil its research potential and enjoy academic legitimacy, the discipline must develop a clearer sense of purpose,5 and stronger theoretical frameworks and be able to engage in epistemological discussions about the nature of the knowledge medical education research seeks to create.4 Similarly to the development of other research disciplines, these hallmarks of academic activity are crucial to the professionalisation process the discipline is currently undergoing.8

As part of this debate, an increasing number of editorials, commentaries and letters on the subject have been published within medical education journals.3, 9-11 Some of these have argued that medical education research is (and should be) constructed as a social science7 and therefore must engage critically with the questions of research philosophy that are central to that tradition.4 Medical education is a complex, diverse field and effective practice is often defined by contextual factors; similarly, it relies on powerful networks of personal relationships. Unsurprisingly then, a number of writers have expressed an explicit or implicit challenge to the dominant positivist paradigm within medical education research and the prevailing use of experimental methods. The work of Albert8, 14, 15 problematises this debate as a struggle between competing groups to define legitimacy in the research perspectives and practices in operation in the field of medical education research itself.

As yet, this discussion has not widely influenced the studies published in dedicated medical education journals. Explicit references to theoretical frameworks are becoming more common;16 however, most peer-reviewed medical education studies (both quantitative and qualitative) still make no mention of the research paradigm or epistemological assumptions underpinning the work. The term 'methodology' is most often used to refer to an applied approach to a particular issue(e.g. ⁾ and is rarely used within medical education journals to describe research methodology and the related epistemological and ontological perspectives. It is important to note here that this is not necessarily true of the entire field of medical education; educational research published in social science journals and notably in nursing journals is more likely to be underpinned by non-positivist research assumptions and to make those assumptions explicit to the reader. For example, one recent exception is McNamee et al.'s19 inductive phenomenological approach, which describes the research paradigm to contextualise the findings and inform the reader of the underlying assumptions of the work. Most commonly, however, empirical studies in medical education journals continue to focus overwhelmingly on the techniques used for data collection and analysis.20

This is problematic for a number of reasons. Lingard4 argues that: '...while we emphasise the tools when we teach qualitative research, the tools themselves are not the essence of the qualitative paradigm.' Instead, she outlines the importance of the research 'orientation':

'What kind of knowledge are the researchers setting out to make? What are their views on knowledge, their epistemology? Are they conducting the study from an ethnographic, a critical theory, or a case study approach? These dimensions matter much more than the methodological tools, because they shape the way the research question is asked.'4

Academic research stems from a philosophical tradition of systematic knowledge development, the underlying premise of which is that any knowledge claim is only defensible within a wider set of assumptions about the nature of reality.21 Bordage6   observes that the conceptual framework within a study 'will dictate, whether you are conscious of it or not, what you choose to do and how you interpret your outcomes and results'. This is similarly true for the research paradigm, which is itself a grand theory.22 As medical education research hopes to extend into wider scope and influence, it will be important to articulate these research assumptions to the wider academic community so that it can critically consider the nature of the knowledge claims within the discipline.

To this end, this paper aims to position itself as a bridge between the meta-commentary in medical education regarding research paradigms and how these issues are present in everyday research studies within the field. The following sections outline four major research paradigms and present an example of how the underlying ontological and epistemological assumptions of a study ultimately influence the nature of the knowledge claims that are constructed. When introducing the 2005 series on qualitative research methods in medical education, Britten23   observed: '...there is an overwhelming choice of textbooks on qualitative research, aimed at a wide variety of audiences. What are missing are succinct and accessible explanations of the major methods in qualitative research, and their potential application to the kinds of research questions that practitioners would like to investigate.' We propose that the same is now true of research paradigms and this paper aims to address that need.

The authors' research perspective

Before continuing, it is important to note that the overall position of this paper is a constructionist one, which can be broadly characterised as interpretivism. This perspective has two central elements:

1
it uses a subjective epistemology which anticipates multiple, diverse interpretations of reality rather than seeking to reveal an overarching 'truth',24-26 and

2
it is associated with an interpretive effort to gather a range of in-depth accounts with the aim of building a detailed picture of how a particular phenomenon is understood by those who have personal experience of it.

We assert that there is no one superior research approach within the research paradigms outlined here; all are valid and informative when used sensitively in context to answer an appropriate research question. However, this paper describes the underlying research philosophy of interpretivism in particular depth because this approach is often the least familiar to those who have trained as educators and researchers in the positivist medical tradition. As a result, we observe that interpretivist research approaches can be a genuine source of conflict in research discussions because the underlying philosophy of interpretivism is less widely understood and accepted. The data gathering example presented later in this paper is drawn from a study underpinned by interpretivism and again describes this perspective as a useful research position. In these ways, the paper promotes interpretivism (a constructionist position) and discusses the strengths of this perspective as a way to increase understanding between researchers who hold and use different beliefs in their research thinking. This paper is directed at medics, medical educators and medical education researchers whose research perspectives and experiences have been predominantly shaped by the philosophy of research knowledge associated with medical science in the positivist tradition. We aim to clarify some areas of debate and misunderstanding that often occur when researchers from this realist tradition meet colleagues with a constructivist perspective.

Research paradigms in medical education

'Paradigms are sets of beliefs and practices, shared by communities of researchers, which regulate inquiry within disciplines. The various paradigms are characterised by ontological, epistemological and methodological differences in their approaches to conceptualising and conducting research, and in their contribution towards disciplinary knowledge construction.'27

Table 1 outlines four major paradigms currently in use within medical education research and describes the assumptions about ontology (the nature of reality), epistemology (the nature of knowledge), methodology (the nature of research) and the related research methods for each of these perspectives.21, 25-30 The term 'paradigm' is used within this paper to refer to what Morgan describes as an epistemological stance.31 (See Morgan31 for a full critique of this position.)

Positivism

Post-positivism

Interpretivism

Critical theory

Ontology: What is the nature of reality?

Reality is static and fixed The world is ordered according to an overarching objective truth

Reality is subjective and changingThere is no one ultimate truth

Reality may be objective but truth is continually contested by competing groups

Epistemology: What is the nature of knowledge?

Objective, generalisable theory can be developed to accurately describe the worldKnowledge can be neutral or value-free

Objective knowledge of the world is not necessarily fully accessibleSeeks to establish 'probable' truth

Knowledge is subjectiveThere are multiple, diverse interpretations of realityThere is no one ultimate or 'correct' way of knowing

Knowledge is co-constructed between individuals and groupsKnowledge is mediated by power relations and therefore continuously under revision

Methodology: What is the nature of the approach to research?

The aim is to discover what exists through prediction and controlTheory is established deductivelyUses scientific method to develop abstract laws to describe and predict patternsLooks for causality and fundamental laws

Seeks to develop knowledge through the falsification of hypothesesEmphasis on well-defined concepts and variables, controlled conditions, precise instrumentation and empirical testing

Focus on understandingUses inductive reasoningMeaning is constructed in the researcher-participant interaction in the natural environmentGathers diverse interpretations (e.g. grounded theory, ethnography)

Focus on emancipationResearch is used to envision how things could change for the betterSeeks representation of diverse and under-represented viewsCharacterised by continual redefinition of problems and cooperative interaction (e.g. action research)

Methods: What techniques can be used to gather this information?

Tends to use quantitative methods, often including statistical testing of hypotheses (e.g. randomised controlled trials, questionnaires)

Quantitative and qualitative methods: systematically gathered and analysed data from representative samples (e.g. surveys, interviews, focus groups)

Tends to use qualitative methods to capture various interpretations of a phenomenon (e.g. naturalistic observation, interviews, use of narrative)

May use both quantitative and qualitative methods, usually in a participatory wayOften uses iterative research design (e.g. case studies, focus groups, participant observation)

The existing literature demonstrates that each of research paradigms generates valuable informing information. However, medical education research, and indeed medical research, has historically been dominated by positivistic philosophies of knowledge, whereas interpretive and critical methodologies have enjoyed less popularity. Now, more than ever, there is an increasing diversity in research approaches; yet, from the literature published within medical education journals, discussion with colleagues and international conferences, we observe that positivism is still the dominant framework for many medical educators, researchers and practitioners. It is important to note here that this is not necessarily true of the entire field of medical education; educational research published in social science journals and notably in nursing journals is more likely to be underpinned by non-positivist research assumptions and to make those assumptions explicit to the reader.

Although positivist paradigms are invaluable frameworks within which to answer certain questions, the literature increasingly recognises that the related experimental design research methods (e.g. randomised controlled trials) 'are inadequate tools for studying complex, unstable, non-linear social change'.34 By contrast, research underpinned by other paradigms, such as interpretivism or critical research, provides very good ways to study complex, unstable, non-linear change. For medical education research, which explores diverse, contextually dependent issues, these alternative paradigm perspectives are useful because they reflect the ambiguous quality of the research questions themselves and allow for a degree of uncertainty within the study design. Therefore, research approaches with epistemological and ontological assumptions that reflect change and complexity are well suited to inform medical education research.

An observational example: methodological assumptions at work

To demonstrate what these ideas mean in practice, it is useful to explore an example. Figure 1 provides a written account of a conversation with a practice administrator that took place during an observational visit to a research site. This visit was part of a qualitative study into collective learning in primary care teams35 and the account was written up by the researcher based on detailed field notes. This research asked: 'How do collective learning and change happen in primary care teams?' The study adopted observational research methods, used qualitatively, and supporting interviews with key participants. These methods were used ethnographically36 and extended data gathering visits took place over a 1-year period. (See Bunniss and Kelly34 for a more detailed description of the stages of data collection and analysis.) In this study, SB was an overt observer and the data gathering methods were 'naturalistic';27, 37, 38 that is, data were gathered with participants in their natural working environment as they went about their everyday work. All participants were aware of the purpose of the research and provided prior consent in keeping with normal research ethics procedures.

Research of this nature is often referred to as generative (rather than hypotheses testing) because it allows different interpretations of a particular phenomenon to emerge. Figure 2 provides some examples of possible interpretations highlighted by this particular observation extract, a number of which raise issues which have yet to be fully explored through medical education research. From this we can see how the idiosyncratic, interpersonal nature of a particular staff-patient exchange can direct us towards research issues, which in turn may have implications for future research questions in medical education.

Alternative interpretations within research paradigms

'During fieldwork you are surrounded by a multitude of noises and activities. As you choose what to attend to and how to interpret it, mental doors slam shut on the alternatives.' (Agar39)

The purpose of presenting the research account and its associated interpretations ( 1, 2) is to demonstrate some of the practical ways in which the underlying research paradigm influences the research design and data gathering methods. The data gathering techniques outlined above present a particular contrast to those we would expect to see in a study conducted within the positivist paradigm. This section explores these differences.

Within the interpretivist paradigm, knowledge generation happens when 'relevant insights emerge naturally through researcher-participant discourse'.40 Therefore, it is a basic assumption that the researcher's perspective is inextricably bound up within the findings of a study because 'meaning is constructed in the researcher-participant interaction in the natural environment'.27 This is a natural characteristic of knowledge building within this paradigm (the hermeneutic cycle), which is seen as an inherently social act. Interpretivism assumes that a study can never be bias-free; therefore eliminating bias would not be a research intention. Instead, one of the aims of a study conducted from an interpretivist perspective would be to attend to how the researcher's thoughts, feelings, opinions and experiences might influence what he or she observes and records. Within this particular study, the data capture sheet distinguished between what was observed, the inferences drawn from those observations, the reactions and responses of the researcher, and any pre-existing assumptions or expectations the researcher had about the community he or she was preparing to observe. This reflexivity regarding how the researcher jointly constructs knowledge with participants is crucial to the critical interpretation of the data. This demonstrates how paradigms that assume a subjective ontology create a different type of knowledge because participant experiences are considered for the new issues and nuances they highlight.41 Individual accounts of the world are valuable for their idiosyncrasies in much the same way that case studies would be in a clinical setting.

This approach contrasts sharply with that of a positivist perspective, which assumes overarching patterns of human behaviour and would therefore see little value in captured in-depth information about the experiences of individuals or small groups. Research within this different paradigm would avoid data collection in naturalistic settings because this introduces further 'variables'. Similarly, given that research from a positivist paradigm aims to measure predetermined characteristics of a particular phenomenon, there is no methodological need to be responsive to participants in the same way during data collection. All of these characteristics of data gathering reflect the ontological assumption that reality exists objectively and the epistemological assumption that it can be most accurately described using deductive reasoning. These design characteristics reflect the ontological and epistemological assumptions that are particular hallmarks of the positive paradigm.

These assumptions are further illustrated by the questions researchers ask of a study. Some questions (e.g. What hypothesis is being tested? How do we know the participant is telling the truth? How do we know the researcher hasn't biased the data? How can one person's experience be representative of that of the wider population?) reflect the assumptions that there is an objective account of reality that we can gather information about and that we can judge the truth value of that reported information. However, other questions (e.g. What is the nature of the experience described by the participant and how has he come to understand it in this way? What aspects of the researcher's own experience has she brought to the data gathering and interpretation? To what extent does this description of reality resonate with others? What new hypotheses and concepts are being generated?) reflect the assumption that meaning is mediated through multiple (and often competing) ways to understand lived experience. These two very different sets of questions reflect diverse research paradigms, which are sometimes found in opposition.

These diverse beliefs within the interpretivist and positivist paradigms are just one example of how assumptions regarding ontology and epistemology often provoke much disagreement in research circles and methodological debates are ongoing within medical education research.42 The extent to which researchers are comfortable with particular research methods and believe they generate valuable evidence tends to be an indication of the paradigm they are working within and the related assumptions they make within their research. Those who hold different research perspectives look for different criteria of quality in research evidence; these may include criteria pertaining to reliability, generalisability, reflexivity or resonance. However, it is common to all paradigms that rigour itself is a product of the soundness of the theory, the transparency of the research assumptions and the integrity of the research processes for data gathering and analysis. Indeed, regardless of the research assumptions, the central issue concerns the trustworthiness of the researchers in identifying the limitations of the work and disclosing information that could influence the interpretation of the findings. As medical education research continues to develop, it will be useful to articulate these research paradigms and understand the embedded assumptions to avoid asking or being asked the 'wrong' questions and reliving well-worn arguments within the discipline.

Conclusions

This paper argues that if medical education journals are to continue developing academic legitimacy, the discipline must be able to engage in epistemological discussions about the nature of the knowledge medical education research seeks to create. Developing an increased awareness of the paradigms in use within the field is important because we need to demonstrate that significant decisions regarding the provision of medical education and health care are based on a critical understanding of the nature of knowledge itself. The paper argues that research methodology is not simply about data collection strategies, but, more importantly, that it addresses the philosophical beliefs that determine the nature of the research design. Articulating these underlying assumptions is central to the research task if we are to be able to critically engage with the findings.

This paper presents an observational example which allows us to examine the relationship between the underlying research paradigm, its implications for study design, and the question of what constitutes useful data within different paradigms. It discusses what the differences in research paradigms can mean in practice and demonstrates that arguments within medical education journals over what constitutes 'good' evidence and research practice often indicate a conflict of research assumptions.

Contributors: SB contributed to the conception and design of the study, data collection, analysis and interpretation, and the drafting and revision of the article. DRK contributed to the conception and design of the study and the revision of the article. Both authors approved the final manuscript.

Acknowledgments

Acknowledgements: the authors would like to thank the participants of the study referred to in this paper and Dr P Bowie, Dr P Ciancanelli, Dr A Coulson, Dr B Fitzpatrick, Dr J McKay, Janette McCrae and Eric Greene for their helpful review comments.

Funding: this study was supported by NHS Education for Scotland.

Conflicts of interest: none.

Ethical approval: not applicable.

Abstract

Medical Education 2010: 44: 358-366

Context The growing popularity of less familiar methodologies in medical education research, and the use of related data collection methods, has made it timely to revisit some basic assumptions regarding knowledge and evidence.

Methods This paper outlines four major research paradigms and examines the methodological questions that underpin the development of knowledge through medical education research.

Discussion This paper explores the rationale behind different research designs, and shows how the underlying research philosophy of a study can directly influence what is captured and reported. It also explores the interpretivist perspective in some depth to show how less familiar paradigm perspectives can provide useful insights to the complex questions generated by modern healthcare practice.

Conclusions This paper concludes that the quality of research is defined by the integrity and transparency of the research philosophy and methods, rather than the superiority of any one paradigm. By demonstrating that different methodological approaches deliberately include and exclude different types of data, this paper highlights how competing knowledge philosophies have practical implications for the findings of a study.

Introduction

In recent years, there has been much debate about how to ensure that medical education research is not perceived as the poor relation of medical research.1-4 Various writers have argued that if medical education is to fulfil its research potential and enjoy academic legitimacy, the discipline must develop a clearer sense of purpose,5 and stronger theoretical frameworks6, 7 and be able to engage in epistemological discussions about the nature of the knowledge medical education research seeks to create.4 Similarly to the development of other research disciplines, these hallmarks of academic activity are crucial to the professionalisation process the discipline is currently undergoing.8

As part of this debate, an increasing number of editorials, commentaries and letters on the subject have been published within medical education journals.3, 9-11 Some of these have argued that medical education research is (and should be) constructed as a social science7 and therefore must engage critically with the questions of research philosophy that are central to that tradition.4 Medical education is a complex, diverse field and effective practice is often defined by contextual factors; similarly, it relies on powerful networks of personal relationships. Unsurprisingly then, a number of writers have expressed an explicit or implicit challenge to the dominant positivist paradigm within medical education research and the prevailing use of experimental methods.12, 13 The work of Albert8, 14, 15 problematises this debate as a struggle between competing groups to define legitimacy in the research perspectives and practices in operation in the field of medical education research itself.

As yet, this discussion has not widely influenced the studies published in dedicated medical education journals. Explicit references to theoretical frameworks are becoming more common;16 however, most peer-reviewed medical education studies (both quantitative and qualitative) still make no mention of the research paradigm or epistemological assumptions underpinning the work. The term 'methodology' is most often used to refer to an applied approach to a particular issue(e.g. 17, 18 ⁾ and is rarely used within medical education journals to describe research methodology and the related epistemological and ontological perspectives. It is important to note here that this is not necessarily true of the entire field of medical education; educational research published in social science journals and notably in nursing journals is more likely to be underpinned by non-positivist research assumptions and to make those assumptions explicit to the reader. For example, one recent exception is McNamee et al.'s19 inductive phenomenological approach, which describes the research paradigm to contextualise the findings and inform the reader of the underlying assumptions of the work. Most commonly, however, empirical studies in medical education journals continue to focus overwhelmingly on the techniques used for data collection and analysis.20

This is problematic for a number of reasons. Lingard4 argues that: '...while we emphasise the tools when we teach qualitative research, the tools themselves are not the essence of the qualitative paradigm.' Instead, she outlines the importance of the research 'orientation':

'What kind of knowledge are the researchers setting out to make? What are their views on knowledge, their epistemology? Are they conducting the study from an ethnographic, a critical theory, or a case study approach? These dimensions matter much more than the methodological tools, because they shape the way the research question is asked.'4

Academic research stems from a philosophical tradition of systematic knowledge development, the underlying premise of which is that any knowledge claim is only defensible within a wider set of assumptions about the nature of reality.21 Bordage6   observes that the conceptual framework within a study 'will dictate, whether you are conscious of it or not, what you choose to do and how you interpret your outcomes and results'. This is similarly true for the research paradigm, which is itself a grand theory.22 As medical education research hopes to extend into wider scope and influence, it will be important to articulate these research assumptions to the wider academic community so that it can critically consider the nature of the knowledge claims within the discipline.

To this end, this paper aims to position itself as a bridge between the meta-commentary in medical education regarding research paradigms and how these issues are present in everyday research studies within the field. The following sections outline four major research paradigms and present an example of how the underlying ontological and epistemological assumptions of a study ultimately influence the nature of the knowledge claims that are constructed. When introducing the 2005 series on qualitative research methods in medical education, Britten23   observed: '...there is an overwhelming choice of textbooks on qualitative research, aimed at a wide variety of audiences. What are missing are succinct and accessible explanations of the major methods in qualitative research, and their potential application to the kinds of research questions that practitioners would like to investigate.' We propose that the same is now true of research paradigms and this paper aims to address that need.

The authors' research perspective

Before continuing, it is important to note that the overall position of this paper is a constructionist one, which can be broadly characterised as interpretivism. This perspective has two central elements:

1
it uses a subjective epistemology which anticipates multiple, diverse interpretations of reality rather than seeking to reveal an overarching 'truth', and

2
it is associated with an interpretive effort to gather a range of in-depth accounts with the aim of building a detailed picture of how a particular phenomenon is understood by those who have personal experience of it.

We assert that there is no one superior research approach within the research paradigms outlined here; all are valid and informative when used sensitively in context to answer an appropriate research question. However, this paper describes the underlying research philosophy of interpretivism in particular depth because this approach is often the least familiar to those who have trained as educators and researchers in the positivist medical tradition. As a result, we observe that interpretivist research approaches can be a genuine source of conflict in research discussions because the underlying philosophy of interpretivism is less widely understood and accepted. The data gathering example presented later in this paper is drawn from a study underpinned by interpretivism and again describes this perspective as a useful research position. In these ways, the paper promotes interpretivism (a constructionist position) and discusses the strengths of this perspective as a way to increase understanding between researchers who hold and use different beliefs in their research thinking. This paper is directed at medics, medical educators and medical education researchers whose research perspectives and experiences have been predominantly shaped by the philosophy of research knowledge associated with medical science in the positivist tradition. We aim to clarify some areas of debate and misunderstanding that often occur when researchers from this realist tradition meet colleagues with a constructivist perspective.

Research paradigms in medical education

'Paradigms are sets of beliefs and practices, shared by communities of researchers, which regulate inquiry within disciplines. The various paradigms are characterised by ontological, epistemological and methodological differences in their approaches to conceptualising and conducting research, and in their contribution towards disciplinary knowledge construction.'27

Table 1 outlines four major paradigms currently in use within medical education research and describes the assumptions about ontology (the nature of reality), epistemology (the nature of knowledge), methodology (the nature of research) and the related research methods for each of these perspectives.21, 25-30 The term 'paradigm' is used within this paper to refer to what Morgan describes as an epistemological stance.31 (See Morgan31 for a full critique of this position.)

Positivism

Post-positivism

Interpretivism

Critical theory

Ontology: What is the nature of reality?

Reality is static and fixed The world is ordered according to an overarching objective truth

Reality is subjective and changingThere is no one ultimate truth

Reality may be objective but truth is continually contested by competing groups

Epistemology: What is the nature of knowledge?

Objective, generalisable theory can be developed to accurately describe the worldKnowledge can be neutral or value-free

Objective knowledge of the world is not necessarily fully accessibleSeeks to establish 'probable' truth

Knowledge is subjectiveThere are multiple, diverse interpretations of realityThere is no one ultimate or 'correct' way of knowing

Knowledge is co-constructed between individuals and groupsKnowledge is mediated by power relations and therefore continuously under revision

Methodology: What is the nature of the approach to research?

The aim is to discover what exists through prediction and controlTheory is established deductivelyUses scientific method to develop abstract laws to describe and predict patternsLooks for causality and fundamental laws

Seeks to develop knowledge through the falsification of hypothesesEmphasis on well-defined concepts and variables, controlled conditions, precise instrumentation and empirical testing

Focus on understandingUses inductive reasoningMeaning is constructed in the researcher-participant interaction in the natural environmentGathers diverse interpretations (e.g. grounded theory, ethnography)

Focus on emancipationResearch is used to envision how things could change for the betterSeeks representation of diverse and under-represented viewsCharacterised by continual redefinition of problems and cooperative interaction (e.g. action research)

Methods: What techniques can be used to gather this information?

Tends to use quantitative methods, often including statistical testing of hypotheses (e.g. randomised controlled trials, questionnaires)

Quantitative and qualitative methods: systematically gathered and analysed data from representative samples (e.g. surveys, interviews, focus groups)

Tends to use qualitative methods to capture various interpretations of a phenomenon (e.g. naturalistic observation, interviews, use of narrative)

May use both quantitative and qualitative methods, usually in a participatory wayOften uses iterative research design (e.g. case studies, focus groups, participant observation)

The existing literature demonstrates that each of research paradigms generates valuable informing information.32, 33 However, medical education research, and indeed medical research, has historically been dominated by positivistic philosophies of knowledge, whereas interpretive and critical methodologies have enjoyed less popularity. Now, more than ever, there is an increasing diversity in research approaches; yet, from the literature published within medical education journals, discussion with colleagues and international conferences, we observe that positivism is still the dominant framework for many medical educators, researchers and practitioners. It is important to note here that this is not necessarily true of the entire field of medical education; educational research published in social science journals and notably in nursing journals is more likely to be underpinned by non-positivist research assumptions and to make those assumptions explicit to the reader.

Although positivist paradigms are invaluable frameworks within which to answer certain questions, the literature increasingly recognises that the related experimental design research methods (e.g. randomised controlled trials) 'are inadequate tools for studying complex, unstable, non-linear social change'.34 By contrast, research underpinned by other paradigms, such as interpretivism or critical research, provides very good ways to study complex, unstable, non-linear change. For medical education research, which explores diverse, contextually dependent issues, these alternative paradigm perspectives are useful because they reflect the ambiguous quality of the research questions themselves and allow for a degree of uncertainty within the study design. Therefore, research approaches with epistemological and ontological assumptions that reflect change and complexity are well suited to inform medical education research.

An observational example: methodological assumptions at work

To demonstrate what these ideas mean in practice, it is useful to explore an example. Figure 1 provides a written account of a conversation with a practice administrator that took place during an observational visit to a research site. This visit was part of a qualitative study into collective learning in primary care teams35 and the account was written up by the researcher based on detailed field notes. This research asked: 'How do collective learning and change happen in primary care teams?' The study adopted observational research methods, used qualitatively, and supporting interviews with key participants. These methods were used ethnographically36 and extended data gathering visits took place over a 1-year period. (See Bunniss and Kelly34 for a more detailed description of the stages of data collection and analysis.) In this study, SB was an overt observer and the data gathering methods were 'naturalistic';27, 37, 38 that is, data were gathered with participants in their natural working environment as they went about their everyday work. All participants were aware of the purpose of the research and provided prior consent in keeping with normal research ethics procedures.

Research of this nature is often referred to as generative (rather than hypotheses testing) because it allows different interpretations of a particular phenomenon to emerge. Figure 2 provides some examples of possible interpretations highlighted by this particular observation extract, a number of which raise issues which have yet to be fully explored through medical education research. From this we can see how the idiosyncratic, interpersonal nature of a particular staff-patient exchange can direct us towards research issues, which in turn may have implications for future research questions in medical education.

Alternative interpretations within research paradigms

'During fieldwork you are surrounded by a multitude of noises and activities. As you choose what to attend to and how to interpret it, mental doors slam shut on the alternatives.' (Agar39)

The purpose of presenting the research account and its associated interpretations ( 1, 2) is to demonstrate some of the practical ways in which the underlying research paradigm influences the research design and data gathering methods. The data gathering techniques outlined above present a particular contrast to those we would expect to see in a study conducted within the positivist paradigm. This section explores these differences.

Within the interpretivist paradigm, knowledge generation happens when 'relevant insights emerge naturally through researcher-participant discourse'.40 Therefore, it is a basic assumption that the researcher's perspective is inextricably bound up within the findings of a study because 'meaning is constructed in the researcher-participant interaction in the natural environment'.27 This is a natural characteristic of knowledge building within this paradigm (the hermeneutic cycle), which is seen as an inherently social act. Interpretivism assumes that a study can never be bias-free; therefore eliminating bias would not be a research intention. Instead, one of the aims of a study conducted from an interpretivist perspective would be to attend to how the researcher's thoughts, feelings, opinions and experiences might influence what he or she observes and records. Within this particular study, the data capture sheet distinguished between what was observed, the inferences drawn from those observations, the reactions and responses of the researcher, and any pre-existing assumptions or expectations the researcher had about the community he or she was preparing to observe. This reflexivity regarding how the researcher jointly constructs knowledge with participants is crucial to the critical interpretation of the data. This demonstrates how paradigms that assume a subjective ontology create a different type of knowledge because participant experiences are considered for the new issues and nuances they highlight.41 Individual accounts of the world are valuable for their idiosyncrasies in much the same way that case studies would be in a clinical setting.

This approach contrasts sharply with that of a positivist perspective, which assumes overarching patterns of human behaviour and would therefore see little value in captured in-depth information about the experiences of individuals or small groups. Research within this different paradigm would avoid data collection in naturalistic settings because this introduces further 'variables'. Similarly, given that research from a positivist paradigm aims to measure predetermined characteristics of a particular phenomenon, there is no methodological need to be responsive to participants in the same way during data collection. All of these characteristics of data gathering reflect the ontological assumption that reality exists objectively and the epistemological assumption that it can be most accurately described using deductive reasoning. These design characteristics reflect the ontological and epistemological assumptions that are particular hallmarks of the positive paradigm.

These assumptions are further illustrated by the questions researchers ask of a study. Some questions (e.g. What hypothesis is being tested? How do we know the participant is telling the truth? How do we know the researcher hasn't biased the data? How can one person's experience be representative of that of the wider population?) reflect the assumptions that there is an objective account of reality that we can gather information about and that we can judge the truth value of that reported information. However, other questions (e.g. What is the nature of the experience described by the participant and how has he come to understand it in this way? What aspects of the researcher's own experience has she brought to the data gathering and interpretation? To what extent does this description of reality resonate with others? What new hypotheses and concepts are being generated?) reflect the assumption that meaning is mediated through multiple (and often competing) ways to understand lived experience. These two very different sets of questions reflect diverse research paradigms, which are sometimes found in opposition.

These diverse beliefs within the interpretivist and positivist paradigms are just one example of how assumptions regarding ontology and epistemology often provoke much disagreement in research circles and methodological debates are ongoing within medical education research.42 The extent to which researchers are comfortable with particular research methods and believe they generate valuable evidence tends to be an indication of the paradigm they are working within and the related assumptions they make within their research. Those who hold different research perspectives look for different criteria of quality in research evidence; these may include criteria pertaining to reliability, generalisability, reflexivity or resonance. However, it is common to all paradigms that rigour itself is a product of the soundness of the theory, the transparency of the research assumptions and the integrity of the research processes for data gathering and analysis. Indeed, regardless of the research assumptions, the central issue concerns the trustworthiness of the researchers in identifying the limitations of the work and disclosing information that could influence the interpretation of the findings. As medical education research continues to develop, it will be useful to articulate these research paradigms and understand the embedded assumptions to avoid asking or being asked the 'wrong' questions and reliving well-worn arguments within the discipline.

Conclusions

This paper argues that if medical education journals are to continue developing academic legitimacy, the discipline must be able to engage in epistemological discussions about the nature of the knowledge medical education research seeks to create. Developing an increased awareness of the paradigms in use within the field is important because we need to demonstrate that significant decisions regarding the provision of medical education and health care are based on a critical understanding of the nature of knowledge itself. The paper argues that research methodology is not simply about data collection strategies, but, more importantly, that it addresses the philosophical beliefs that determine the nature of the research design. Articulating these underlying assumptions is central to the research task if we are to be able to critically engage with the findings.

This paper presents an observational example which allows us to examine the relationship between the underlying research paradigm, its implications for study design, and the question of what constitutes useful data within different paradigms. It discusses what the differences in research paradigms can mean in practice and demonstrates that arguments within medical education journals over what constitutes 'good' evidence and research practice often indicate a conflict of research assumptions.

Contributors: SB contributed to the conception and design of the study, data collection, analysis and interpretation, and the drafting and revision of the article. DRK contributed to the conception and design of the study and the revision of the article. Both authors approved the final manuscript.

Acknowledgments

Acknowledgements: the authors would like to thank the participants of the study referred to in this paper and Dr P Bowie, Dr P Ciancanelli, Dr A Coulson, Dr B Fitzpatrick, Dr J McKay, Janette McCrae and Eric Greene for their helpful review comments.

Funding: this study was supported by NHS Education for Scotland.

Conflicts of interest: none.

Ethical approval: not applicable.

# data[].attributes.attachment_link.title
Research paradigms in medical education research

# data[].attributes.attachment_link.description
Suzanne Bunniss, NHS Education for Scotland, 2 Central Quay, 89 Hydepark Street, Glasgow G60 5JP, UK. Tel: 00 44 7766 056816; Fax: 00 44 141 223 1480; E-mail:  Suzanne.bunniss@nes.scot.nhs.uk Medical Education 2010: 44: 358-366 Context The growing popularity of less familiar methodologies in medical education research, and the use of related data collection methods, has made it timely to revisit some basic assumptions regarding knowledge and evidence.

# data[].attributes.body
https://www.sciencedirect.com/science/article/pii/S0140673612601986

# data[].attributes.attachment_link.readable_text
Author links open overlay panel Robin L Peterson PhD a , Bruce F Pennington PhD a

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Summary

Dyslexia is a neurodevelopmental disorder that is characterised by slow and inaccurate word recognition. Dyslexia has been reported in every culture studied, and mounting evidence draws attention to cross-linguistic similarity in its neurobiological and neurocognitive bases. Much progress has been made across research specialties spanning the behavioural, neuropsychological, neurobiological, and causal levels of analysis in the past 5 years. From a neuropsychological perspective, the phonological theory remains the most compelling, although phonological problems also interact with other cognitive risk factors. Work confirms that, neurobiologically, dyslexia is characterised by dysfunction of the normal left hemisphere language network and also implicates abnormal white matter development. Studies accounting for reading experience demonstrate that many recorded neural differences show causes rather than effects of dyslexia. Six predisposing candidate genes have been identified, and evidence shows gene by environment interaction.

Section snippets

Definition

Individuals with developmental dyslexia have difficulties with accurate or fluent word recognition and spelling despite adequate instruction and intelligence and intact sensory abilities. ¹ The ultimate goal of reading is comprehension. Dyslexia is defined by difficulties with decoding, whereas by comparison comprehension is more intact. So-called poor comprehenders show the opposite profile of adequate decoding but poor understanding of what is read. ² Although some previous nosologies have

Prevalence

Prevalence estimates depend on the definition of dyslexia. A common definition sets the cutoff for reading achievement 1·5 standard deviations below the mean for age and identifies 7% of the population as dyslexic; a similar IQ-achievement discrepancy definition identifies a similar proportion. ⁹ A small but significant male predominance exists (1·5-3:1); ¹⁰ however, the sex difference in referred samples is higher (3-6:1). ¹¹ Boys with dyslexia come to clinical attention more often than girls,

Neuropsychology

Early theories of dyslexia postulated a basic deficit in visual processing and focused on the reversal errors commonly made by individuals with the disorder-such as writing 'b' for 'd' or 'was' for 'saw'. ³¹ Vellutino ³² reported that such reversal errors in dyslexia were restricted to print in a person's own language, and thus were linguistic rather than visual in nature. Since then, much research has made clear that dyslexia is a language-based disorder whose primary underlying deficit involves

Functional findings

Because reading is a linguistic skill, we would expect it to involve activation of brain structures used in oral-language processing and some additional structures associated with visual-object processing and establishment of visual-linguistic mappings. A large number of functional imaging studies have shown aberrant activation patterns in these regions in dyslexia. The most common findings, as described in several qualitative reviews, encompass abnormalities of a distributed left hemisphere

Causes

Like all behaviourally defined disorders, the cause of dyslexia is multifactorial and is associated with multiple genes and environmental risk factors (panel 5). Dyslexia is familial and moderately heritable ¹⁰⁹ and has been linked to nine risk loci (DYX1-DYX9) through replicated linkage studies,110, 111 although not every study has replicated these results.112, 113

The main advance in the genetics of dyslexia since the previous Lancet Seminar ⁷⁵ has been the identification of six candidate genes (

Treatment

The development of evidence-based treatments for dyslexia has benefited from our understanding of the neuropsychology of the disorder, and the best interventions provide intensive, explicit instruction in phonological awareness, the alphabetic principle and phonics, word analysis, reading fluency, and reading comprehension.118, 119 Much more is known about effective remediation of reading problems in younger than in older children. Accuracy difficulties seem to be easier to treat than issues

Conclusion

Of all the neurodevelopmental disorders, dyslexia has been the most studied and is the best understood. The specialty continues to benefit from reciprocal relations between basic and clinical neuroscience, and there has been considerable progress over the past 5 years in understanding dyslexia's cross-cultural manifestation, causes, neuropsychology, and neurobiology. Much of the most exciting work includes an interdisciplinary focus across these different specialties. This research has helped

Search strategy and selection criteria

References (128)

B Rodgers
The identification and prevalence of specific reading retardation

Dyslexia and other specific learning disorders

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Cited by (480)

Perchlorate, thiocyanate, and nitrate are sodium iodide symporter (NIS) inhibitors that disturb iodide uptake into the thyroid and have been implicated in child development. However, no data are available on the association between exposure to/related with them and dyslexia. Here, we examined the association of exposure to/related with the three NIS inhibitors with the risk of dyslexia in a case-control study. The three chemicals were detected in urine samples of 355 children with dyslexia and 390 children without dyslexia from three cities in China. The adjusted odds ratios for dyslexia were examined using logistic regression models. The detection frequencies of all the targeted compounds were 100%. After adjusting for multiple covariates, urinary thiocyanate was significantly associated with the risk of dyslexia ( P-trend = 0.02). Compared with the lowest quartile, children within the highest quartile had a 2.66-fold risk of dyslexia (95% confidence interval: 1.32, 5.36]. Stratified analyses showed that the association between urinary thiocyanate level and the risk of dyslexia was more pronounced among boys, children with fixed reading time, and those without maternal depression or anxiety during pregnancy. Urinary perchlorate and nitrate levels were not associated with the risk of dyslexia. This study suggests the possible neurotoxicity of thiocyanate or its parent compounds in dyslexia. Further investigation is warranted to confirm our findings and clarify the potential mechanisms.

Developmental dyslexia (DD) and developmental coordination disorder (DCD) are two common neurodevelopmental disorders with a high co-occurrence rate. This led several authors to postulate that the two disorders share, at least partially, similar neural underpinning. However, even though several studies examined brain differences between typically developing (TD) children and children with either DD or DCD, no previous study directly compared DD, DCD and children with both disorders (COM) using neuroimaging. We acquired structural and resting-state functional MRI images of 136 children (TD = 42, DD = 45, DCD = 20, COM = 29). Difference between TD children and the other groups was assessed using univariate analysis of structural indexes including grey and white matter volumes and functional indexes quantifying activity (fraction of the amplitude of the low frequency fluctuations), local and global connectivity. Regional differences in structural and functional brain indexes were then used to train machine learning models to discriminate among DD, DCD and COM and to find the most discriminant regions. While no imaging index alone discriminated between the three groups, grouping grey and white matter volumes (structural model) or activity, local and global connectivity (functional model) made possible to discriminate among the DD, DCD and COM groups. The most important discrimination was obtained using the functional model, with regions in the cerebellum and the temporal lobe being the most discriminant for DCD and DD children, respectively. Results further showed that children with both DD and DCD have subtle but identifiable brain differences that can only be captured using several imaging indexes pertaining to both brain structure and function.

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# data[].attributes.attachment_link.description
Dyslexia is a neurodevelopmental disorder that is characterised by slow and inaccurate word recognition. Dyslexia has been reported in every culture s...

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https://journals.sagepub.com/doi/abs/10.1177/1362361300004003008
(INTERPRETIVISM)

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Effectiveness of the Healthy Lifestyles Programme (HeLP) to prevent obesity in UK primary-school children: a cluster randomised controlled trial

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Why do children and adolescents (not) seek and access professional help for their mental health problems? A systematic review of quantitative and qualitative studies

Abstract

Mental health disorders in children and adolescents are highly prevalent yet undertreated. A detailed understanding of the reasons for not seeking or accessing help as perceived by young people is crucial to address this gap. We conducted a systematic review (PROSPERO 42018088591) of quantitative and qualitative studies reporting barriers and facilitators to children and adolescents seeking and accessing professional help for mental health problems. We identified 53 eligible studies; 22 provided quantitative data, 30 provided qualitative data, and one provided both. Four main barrier/facilitator themes were identified. Almost all studies (96%) reported barriers related to young people's individual factors, such as limited mental health knowledge and broader perceptions of help-seeking. The second most commonly (92%) reported theme related to social factors, for example, perceived social stigma and embarrassment. The third theme captured young people's perceptions of the therapeutic relationship with professionals (68%) including perceived confidentiality and the ability to trust an unknown person. The fourth theme related to systemic and structural barriers and facilitators (58%), such as financial costs associated with mental health services, logistical barriers, and the availability of professional help. The findings highlight the complex array of internal and external factors that determine whether young people seek and access help for mental health difficulties. In addition to making effective support more available, targeted evidence-based interventions are required to reduce perceived public stigma and improve young people's knowledge of mental health problems and available support, including what to expect from professionals and services.

Introduction

Almost one in seven young people meet diagnostic criteria for a mental health disorder [ 1]. Untreated mental health disorders in children and adolescents are related to adverse health, academic and social outcomes, higher levels of drug abuse, self-harm and suicidal behaviour [ 2, 3, 4] and often persist into adulthood [ 5]. Indeed, half of the lifetime mental health problems start by the age of 15 and nearly three quarters by the age of 18 [ 6], creating a substantial global socioeconomic burden [ 7]. These short and longer term negative outcomes associated with youth mental health problems emphasise the importance of early detection and prompt access to professional treatment.

Effective, evidence-based treatments for mental health disorders in young people exist [ 8]. However, less than two-thirds of young people with mental health problems and their families access any professional help [ 9]. In general, young people are more likely to get professional help if they are older (i.e. adolescents more likely than children), Caucasian, experiencing more than one mental health problem and suffering from behavioural rather than emotional disorders [ 10, 11]. Besides from factors associated with treatment utilisation (e.g. gender and race), a detailed understanding of the reasons that young people (rather than parents or professionals) do not seek and access professional help is crucial to address the gap between the high prevalence of mental health disorders in young people and low treatment utilisation. A recent systematic review of parent-reported barriers to accessing professional help for their child's mental health problems identified barriers related to systemic/structural obstacles (e.g. costs, waiting times), attitudes towards the service providers and psychological treatment (e.g. trust and confidence in professionals, the perceived effectiveness of treatment), knowledge and understanding of mental health problems and the help-seeking process (e.g. recognition of the problem, knowing where to get help) and family circumstances (e.g. other responsibilities and family's support network) [ 12]. Amongst general practitioners (GPs), who often act as 'gatekeepers' between families and specialist services, commonly perceived barriers include difficulties identifying and managing mental health problems (e.g. confidence, time, lack of specific mental health knowledge) and making successful referrals for treatment (e.g. lack of providers and resources) [ 13].

As young people can take an active role in help-seeking, particularly as they get older, it is important to ascertain their own views on the barriers to seeking and accessing help for their mental health problems. A previous systematic review that focused on young people's views found that young people most commonly fail to seek help because of stigma, embarrassment, difficulties with recognising problems and a desire to deal with difficulties themselves [ 14]. However, this review only considered help-seeking for anxiety, depression and general 'mental distress' and, therefore, does not capture barriers in the context of other mental health disorders, or more recent literature published since 2009. Furthermore, the review included samples of young adults (e.g. university students), making it hard to know the degree to which the reported barriers/facilitators are relevant for children and adolescents specifically.

It is now widely recognised that high demands on specialist services, limited available provision and long waiting lists present key barriers to accessing child and adolescent mental services [ 15]. This has prompted a range of recent initiatives designed to increase the availability and accessibility of specialist services (e.g. Children and Young People's Improving Access to Psychological Treatment (CYP-IAPT) Programme in the UK, KidsMatter in Australia), support within schools [ 16, 17], and public resources (e.g. YoungMinds, ReachOut). However, it is critical that efforts to improve access to support and services consider young people's views on help-seeking, and by doing so address the barriers that are pertinent to them.

This study provides an up-to-date systematic review of all studies where children and adolescents were asked about barriers and facilitators to help-seeking and accessing professional support in relation to a wide range of mental health difficulties, to inform ongoing and future interventions designed to improve treatment access. To fully address the complexity of the process of seeking and accessing professional help in young people, results from quantitative and qualitative studies were analysed and combined. By focusing on children and adolescents with a mean age of 18 years or younger (and excluding any studies which only included young adults over 21 years) findings will be especially relevant to the school context, and youth services for under 19s.

Methods

A systematic review was conducted following PRISMA guidelines [ 18] and was registered in the international prospective register of systematic reviews (PROSPERO), number 42018088591, on 13/02/2018. A PRISMA checklist is provided in Online Resource 1.

Literature search

The initial search strategy and preliminary inclusion/exclusion criteria followed a recent review of parent-perceived barriers and facilitators to help-seeking and accessing treatment for their children [ 12]. The search terms captured four major concepts: (1) barriers/facilitators, (2) help-seeking/accessing, (3) mental health, and (4) children/adolescents and parents (see Online Resource 2 for details of the search strategy). The original search was launched in October 2014 [ 12] and replicated using the same strategy in October 2016 and in February 2018. We used the NHS Evidence Healthcare database, combining Medline, PsycINFO and Embase, and the Web of Science Core Collection separately. Additionally, we used hand-search methods to check the reference list of articles included in the full text screening stage, and performed backward and forward reference searching of key papers to identify further studies of interest.

Eligibility criteria

A study was included if child and/or adolescent (mean sample age up to 18) participants reported barriers and/or facilitators to seeking and accessing professional help for mental health problems. Studies reporting only parental/caregiver's perceived barriers and facilitators, and studies including only young adults (e.g. university students) were excluded. Similarly, studies that only reported factors associated with treatment utilisation and studies reporting barriers/facilitators related to ongoing treatment engagement (not initial access to treatment) were excluded. The full list of inclusion/exclusion criteria is available in Online Resource 3.

Study selection

We selected the studies for the current review through an initial search in October 2014 conducted within the Reardon et al. [ 12] review, and two updated searches using the same search terms (October 2014-October 2016; and October 2016-February 2018). In total, 3682 studies published since October 2014 were identified from database searches and hand searching. After duplicates were removed, two independent reviewers from the team (JR, CT, GEB, and PL) screened 2582 abstracts, and 385 full texts. In cases of disagreement, a third reviewer was consulted (TR) to reach a final decision. In total, 53 studies were included in the current review. Thirty studies provided qualitative data, 22 provided quantitative data and one study provided both. For two included studies, relevant results were reported in two separate papers, which were all included in a current review [ 19, 20, 21, 22].

The full process of study selection is presented in the PRISMA flowchart (Fig. 1).

Data extraction

We used the data extraction form developed by Reardon et al. [ 12], with minor amendments to reflect the fact that study participants were children/adolescents rather than parents. The form included the following information: (1) methodology used (qualitative, quantitative or mixed methods), (2) country of study, (3) study setting (e.g. school, mental health clinic), (4) child/adolescent characteristics, including age range, gender, ethnicity, area of living (e.g. rural, urban), (5) type of mental health problem addressed/focus of the study and method of mental health assessment, (6) characteristics related to service use, and (7) key findings relating to perceived barriers and facilitators, supported by quantitative or qualitative evidence. Where applicable, details regarding barrier/facilitator measures were recorded for quantitative studies. For qualitative studies, we recorded details about the methods used (e.g. focus groups, interviews) and the areas of relevant questioning. Data extraction was undertaken by two independent reviewers (JR and GEB/PL/TR).

Quality rating

In line with the approach used by Reardon et al. [ 12], we used two adapted versions of quality rating checklists developed by Kmet et al. [ 23]. One checklist was used to evaluate the quality of quantitative studies and another to evaluate the quality of qualitative studies. Quality checklists addressed the research question, study design, sampling strategy and data analysis. The quantitative checklist also addressed the robustness of the barrier/facilitator measure, and the qualitative checklist addressed the credibility of the study's conclusions (see Online Resource 4). The quality of the study that provided qualitative and quantitative data [ 24] was assessed using both scales. Two independent reviewers (JR and GEB/PL/TR) assessed the quality of each included study. Based on the total score, each study was classified as 'low' (0-12 for quantitative and 0-11 for qualitative studies), 'moderate' (13-16 for quantitative and 12-15 for qualitative studies) or 'high' (17-20 for quantitative and 16-18 for qualitative studies) quality. Discrepancies between the reviewers were discussed with a third reviewer (TR/CC). Each study was included in the review, regardless of its quality.

Data synthesis

We conducted a narrative synthesis following ESRC guidance [ 25], which outlines three main steps of analysis: (1) developing a preliminary synthesis, (2) exploring relationships between and within studies, and (3) assessing robustness of the synthesis. We chose this approach because of the high methodological variability across studies and the predominantly descriptive nature of the results. Consequently, statistical meta-analysis was not feasible.

A preliminary synthesis was done separately for quantitative and qualitative studies Each individual perceived barrier or facilitator reported in each quantitative study was assigned a code, and we reorganised the data according to these initial codes (e.g. 'assured confidentiality', 'concerns around confidentiality', 'worrying that information about me will be shared with others'). We then used an iterative process to refine codes, to group codes into families of codes (e.g. 'perceived confidentiality'), and finally to group families of codes into overarching barrier/facilitator themes (e.g. 'relationship factors'). Extracted qualitative data were coded and organised following the same procedure. Next, we developed a single-coding framework capturing barriers and facilitators across quantitative and qualitative studies. Codes generated in the preliminary synthesis of qualitative and quantitative studies were combined and refined in this step, and organised into 22 subthemes and 4 themes. To address the heterogeneity of the quantitative studies and to facilitate comparison across studies, we 'transformed' the data [ 25]. In line with the ESRC guidance, we developed a 'common rubric' to summarise the quantitative data. After examining the percentages of participants who endorsed each specific barrier/facilitator across studies, we categorised each barrier/facilitator into one of three groups ['low' (endorsed by 0-10% of participants), 'medium' (endorsed by 10-30% of participants) and 'high' (endorsed by more than 30% of participants)]. These groups reflect the relative distribution of the percentage of respondents who endorsed each barrier/facilitator across studies. Where applicable, Likert-scale responses were converted into 'percentage endorsed' by summing positive responses (e.g. 'agree' and/or 'strongly agree') before categorisation. Three studies reported only means and standard deviations for each barrier/facilitator and no frequencies. In these cases, we applied data standardisation and categorised responses into the three corresponding categories using percentile and z scores. To minimise the impact of barriers/facilitators reported by only a small minority (< 10%) of participants, barriers/facilitators categorised as 'low' frequency were not included in subsequent analyses. As results from qualitative studies were descriptive (non-numerical), this kind of data transformation was not appropriate for qualitative studies.

We used graphical methods to present the percentage of included studies that reported each specific barrier/facilitator, and the corresponding percentage for qualitative and quantitative studies separately. Next, we explored the relationship between study characteristics (e.g. qualitative/quantitative methodology, country, use of a mental health assessment to identify participants) and sample characteristics (e.g. mental health status, gender, area of living), and barrier/facilitator themes and subthemes. Where we identified a pattern related to study/sample characteristics, details are reported below.

We performed a sensitivity analysis to establish the review's robustness by examining the impact of 'low' quality studies on the findings. These studies were removed and results related to themes, subthemes and conclusions re-examined to determine whether they stayed the same or not.

All analyses were led by the primary author (JR), with regular discussions with other reviewers (TR/PW/CC) to agree with the interpretation of codes and themes.

Results

Study description

In total, 53 studies were included in the review, with 22 providing quantitative data, 30 providing qualitative data, and 1 study providing both [ 24]. Therefore, the total number of studies and corresponding percentages in the results refer to 54 included samples (23 quantitative and 31 qualitative). Study characteristics are provided in Tables 1 and 2.

Table 1 Characteristics of quantitative studies

Table 2 Characteristics of qualitative studies

Studies varied widely on sample size (from 6 to 10,123), participants' age (from 7 to 21 years), country (with 48% of studies conducted in North America, 24% in Europe, 20% in Australia and 8% in Asia), demographic profiles (with 20% of studies focused on specific ethnic/gender groups and others with more varied samples), recruitment setting (with 72% of studies conducted in schools, 17% in (mental) health settings, and the others in varying community settings) and the type of mental health problem that was a focus of the study (with 30% of studies focused on mental health in general and the remaining studies focused on specific mental health problems, such as depression, anxiety, suicidal ideation and ADHD). In half of the studies participants' mental health was assessed (all of these studies assessed young people's mental health using questionnaire measures, with the exception of four studies that used a standardised diagnostic assessment). Similarly, studies addressed various types of professional support, with some (9%) focused on school-based (mental health) services and the majority of remaining studies focused on any professional help (50%) or on support available in a specific (mental) health setting (40%). In 41% of studies, participants' service use was not reported or assessed, and in others, some (2-57%) or all participants had received professional help for their mental health problems.

In quantitative studies, young people were most commonly asked to endorse the presence or absence of barriers from a list, or rate barriers using a 4-7 point Likert response scale. Three quantitative studies asked open questions about help-seeking [ 26, 27, 28]. Less than a third (30%) of quantitative studies reported facilitators to help-seeking, with two of those studies reporting facilitators only [ 29, 30].

The majority of qualitative studies used one-to-one interviews (45%), focus groups (32%), or both (16%) to collect data, with the exception of two studies where they applied a qualitative approach to analyse responses to open-ended survey questions [ 19, 20, 31]. Unlike quantitative studies, more than a half (58%) of qualitative studies reported facilitators to help-seeking, as well as barriers.

Quality ratings

Overall, the quality of the studies varied, ranging from 'low' to 'high', with 65% of quantitative and 52% of qualitative studies rated as 'high' quality, and 4% of quantitative and 13% of qualitative studies rated as 'low' quality. The weak aspects of qualitative studies tended to relate to methodological issues, such as clarity and appropriateness of sampling strategy (e.g. insufficient detail on how study participants were selected), data collection and analysis methods (e.g. only a very brief description of data analysis), whereas quantitative studies most commonly failed to describe the barrier/facilitator measure's robustness (e.g. no details given about the measure's psychometric characteristics).

Barrier/facilitator themes

Four barrier/facilitator themes were identified from both the qualitative and quantitative studies. The themes relate to (1) young people's individual factors, (2) social factors, (3) factors related to the relationship between the young person and the professional and (4) systemic and structural factors. Barrier and facilitator themes and subthemes are summarised below. Barrier and facilitator themes and subthemes identified in each study are available in Online Resource 5.

1.
Young people's individual factors

The majority (96%) of studies reported barriers and facilitators related to individual factors. Subthemes and their distribution across all studies, and across qualitative and quantitative studies separately are outlined in Fig. 2.

2.
Social factors

The second theme describes barriers and facilitators related to social factors and this theme was reported in 92% of studies. Subthemes in this category are outlined in Fig. 3.

3.
Relationship factors

A large proportion of studies (68%) reported barriers and facilitators related to the relationship between the young person and a mental health professional. The distribution of subthemes across studies overall, and among qualitative and quantitative studies, is outlined in Fig. 4.

4.
Systemic and structural factors

Barriers and facilitators related to systemic and structural factors were reported by 58% of studies overall. We identified six subthemes which are outlined in the Fig. 5.

Robustness of data synthesis

Sensitivity analysis was performed by excluding four 'low quality' studies (three qualitative and one quantitative) and re-examining the distribution of themes and subthemes among the remaining studies. There was minimal change in relation to the distribution of barrier/facilitator subthemes across qualitative and quantitative studies, and the overall results remained similar and conclusions unchanged.

Discussion

This review identified 53 studies addressing barriers and facilitators to seeking and accessing professional help for mental health problems as perceived by children and adolescents. We identified four themes across the studies. Barriers and facilitators related to young people's individual factors and to social factors were identified in the vast majority of the studies. Young people also commonly reported barriers and facilitators related to the relationship between them and professionals and to systemic and structural factors.

Among barrier/facilitator subthemes, young people most frequently endorsed barriers and facilitators related to societal views and attitudes towards mental health and help-seeking, such as perceived public stigma and embarrassment associated with mental health problems. Young people also often perceived a lack of knowledge about mental health and the available help as a barrier to help-seeking. Young people with a prior experience of mental health difficulties reported that, during their difficulties, they had not recognised the need for professional help and had not perceived their problems as not serious enough to require help. Young people's negative expectations and attitudes towards professionals, and perceiving help-seeking as a sign of one's weakness, were commonly reported across studies as well. The latter subtheme was almost always reported in studies which included only male participants, highlighting potential gender differences in perceived barriers [ 54]. Adolescents also often endorsed a preference to rely on themselves when facing mental health difficulties rather than seeking professional help, which was again especially prominent in studies where participants had previous experience of mental health difficulties. Notably, this subtheme was far more commonly reported in quantitative than qualitative studies. Compared to qualitative studies, quantitative studies also more commonly reported barriers and facilitators related to a commitment to the process of help-seeking, such as not perceiving a problem as serious enough and waiting for the problem to improve on its own. Lastly, the extent to which young people believed information shared between them and professionals would be treated as confidential seemed to play a significant role in whether young people decide to seek help or not.

This review's findings are broadly consistent with the previous review by Gulliver and colleagues that focused on young people's help-seeking for anxiety, depression and distress [ 14]. Our review makes a significant further contribution to the existing literature by including young people's perceived barriers for a wider range of mental health difficulties. In line with our findings, Gulliver et al. [ 14] identified that the most common barriers and facilitators related to public, perceived and self/stigmatising attitudes, mental health knowledge, young people's preference for self-reliance and perceived confidentiality. However, Gulliver et al. [ 14] reported that structural factors (e.g. logistical factors and costs related to professional help), anxiety symptoms, and characteristics of mental health service providers were more common than we found in this review. Furthermore, while Gulliver et al. [ 14] found that past positive experiences of help-seeking was the most frequently reported facilitator across studies, we found that (1) positive attitudes and encouragement from young people's support network and (2) positive perceptions of the contact between them and professionals were the most commonly reported facilitators. These observed differences are likely to reflect the larger number of studies included in the current review than the previous review, with nearly two-thirds of included studies published since the review by Gulliver et al. [ 14]. Furthermore, the current review excluded studies with only young adult participants (e.g. university students), who may well perceive different barriers and facilitators to seeking help than younger adolescents.

Implications

Our findings highlight many potential ways to improve access to treatment for young people experiencing mental health difficulties. First, the review highlights the ongoing need to minimise perceived mental health stigma among young people. There are a growing number of large-scale public health initiatives (e.g. Time to Change in the UK and Opening Minds in Canada) and school-based interventions [ 76] that are designed to reduce stigma and improve young people's mental health and help-seeking literacy. Once the effectiveness of such programmes has been demonstrated, widespread dissemination is critical, making constructive conversations about mental health a part of the daily school routine. Our findings indicate that these interventions should focus on improving young people's knowledge and understanding of mental health problems, [ 54], equipping young people with self-help skills and strategies [ 34], normalising mental health problems and the process of help-seeking [ 63, 74], 'demystifying' professional help [ 72], explaining which problems require help and which may not [ 20], and informing young people about where to find help and what to expect from it [ 30, 40], including explaining the therapeutic 'ground rules' (e.g. confidentiality). If we want to close the gap between high prevalence of mental health disorders and low treatment utilisation, sufficient service provision and professional support must be widely available for young people. Providing services within the school environment could address the systemic and structural barriers by minimising the effort required to access youth mental health services. Further, this could help reduce the barriers related to logistical factors, such as lack of time and transportation difficulties. Indeed, hundreds of schools in the UK already work collaboratively with local child and adolescent mental health services to offer specialist support and treatments to young people, teachers and parents at school [ 77]. With careful implementation, this may also be less stigmatising than a clinic environment [ 16], potentially helping greater numbers of young people to seek and access evidence-based treatments [ 78]. In addition, young people should be as equipped as possible to help themselves. Digital tools might be a means to increase access to support for mental health problems, and young people in studies in our review identified benefits of, for example, text messages [ 63, 67] to self-refer and to communicate with professionals directly Similarly, young people suggested using computerised psychological treatments [ 58], which might be especially appropriate for those who find it hard to talk about their feelings in person, and may help improve young people's perceived independence. Equally, ensuring services are free at the point of use would minimise financial barriers to help-seeking/accessing. As young people's support networks, especially families, seem to play the most important facilitative role in their process of help-seeking/accessing, professionals should be mindful about seeking appropriate family involvement, whilst balancing this against young people's desire to make their own decisions about receiving help. It is clear that wherever interventions are provided, they must promise young people privacy [ 65] and promote their agency, control and self-determination [ 72].

Strengths and limitations

This review provides a comprehensive overview of the most common reasons given by young people about why they may or may not seek and access professional help when experiencing mental health difficulties. The inclusion of qualitative studies provided additional contextual information and more detailed insight into young people's experiences than was commonly captured in quantitative studies. By including all recent studies focusing on a wide range of mental health difficulties, it provides an update to and extension of the previous review published nearly a decade ago. Although the eligibility criteria for this review were narrower (i.e. excluding the studies with only young adults), there were twice as many studies included in this review as in the previous one, highlighting the rapid development of this field and the need for an updated review. Finally, the review was conducted using rigorous and systematic methodology. Nevertheless, the review has some limitations. Due to the high variability of included studies it was not possible to carry out detailed group comparisons in relation to the type of mental health problem, source of professional help, study setting and participants' treatment utilisation. Furthermore, only four studies used a standardised diagnostic assessment to assess participants' mental health, and many studies did not report/assess participants' mental health at all, making it hard to perform reliable comparisons of findings among adolescents with different mental health problems. Another limitation relates to the fact that the review only includes studies published in English in peer-reviewed journals and, therefore, findings from studies published in other languages and in alternative publications were not captured here. Finally, it is important to acknowledge that the systematic search used to identify studies for inclusion in this review was conducted in February 2018 and, therefore, any relevant studies published since this date were not included in the review. Similar to previous research [ 12], our review identified that existing quantitative barrier/facilitator questionnaire measures are (1) more focused on barriers than facilitators and (2) tend to overlook some barriers/facilitators, especially those related to the role of young people's support network and the characteristics of the relationship between young people and professionals. Results from the quantitative studies might, therefore, at least partly reflect the fact that young people were not asked about certain barriers and facilitators. These limitations of quantitative studies highlight the importance of including qualitative studies as well.

Conclusions and further research

The main reasons for (not) seeking and accessing professional help given by young people are those related to mental health stigma and embarrassment, a lack of mental health knowledge and negative perceptions of help-seeking. Young people also reported a preference for relying on themselves when facing difficulties, and issues with committing fully to the process of help-seeking/accessing. Widespread dissemination of evidence-based interventions delivered in schools targeting perceived public stigma and young people's mental health knowledge is needed. Furthermore, the collaboration between schools and mental health services is essential to enable young people and their families to access evidence-based support within settings that minimise the logistical barriers. Mental health professionals should also offer young people different ways to access help on their own, including using digital tools, which have a potential to facilitate help-seeking behaviour and promote young people's agency.

Our review identified a few possibilities for further research. The lack of established self-report quantitative measures of barriers and facilitators of seeking and accessing mental health support for young people highlights the need to develop and evaluate a new questionnaire. Findings from the qualitative studies should be considered when revising the content of the existing questionnaire items to ensure all relevant barriers/facilitators are captured, and their prevalence can be established. To inform mental health services for specific disorders in children and young people, studies examining barriers and facilitators to seeking and accessing professional help for children and adolescents experiencing specific mental health difficulties are required.

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Acknowledgements

JR is funded by the University of Reading through an Anniversary PhD Scholarship. CC, PJL and TR are funded by an NIHR Research Professorship awarded to CC (NIHR-RP-2014-04-018). PW is supported by an NIHR Post-Doctoral Fellowship (PDF-2016-09-092). The views expressed are those of the authors and not necessarily those of the NHS, the NIHR or the Department of Health. The authors thank Caitlin Thompson, BSc student of University of Reading, for help with abstract and full-text screening, and Dr Cyra Neave from the Anna Freud Centre for insight into practical aspects of school-based mental health interventions. The research materials can be accessed by contacting the corresponding author.

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Authors and Affiliations

1. School of Psychology and Clinical Language Sciences, University of Reading, Reading, UK

Jerica Radez, Tessa Reardon & Polly Waite

2. Departments of Experimental Psychology and Psychiatry, University of Oxford, Oxford, UK

Tessa Reardon, Cathy Creswell & Polly Waite

3. School of Psychology, University of Southampton, Southampton, UK

Peter J. Lawrence

4. Slough Community Mental Health Team, Berkshire Healthcare NHS Foundation Trust, Slough, UK

Georgina Evdoka-Burton

Corresponding author

Correspondence to Tessa Reardon.

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Radez, J., Reardon, T., Creswell, C. et al. Why do children and adolescents (not) seek and access professional help for their mental health problems? A systematic review of quantitative and qualitative studies. Eur Child Adolesc Psychiatry 30, 183-211 (2021). https://doi.org/10.1007/s00787-019-01469-4
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Why do children and adolescents (not) seek and access professional help for their mental health problems? A systematic review of quantitative and qualitative studies - European Child & Adolescent Psychiatry

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Mental health disorders in children and adolescents are highly prevalent yet undertreated. A detailed understanding of the reasons for not seeking or accessing help as perceived by young people is crucial to address this gap.

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Abstract

BACKGROUND: Dyslexia is the most common subtype of learning disabilities with a prevalence ranging from 5-10 per cent. The central difficulty in dyslexia is the phonological awareness deficit. The authors have developed a screening test to assess the reading ability of Thai primary school students. OBJECTIVE: 1. To study the prevalence of dyslexia in first to sixth grade students at Wat Samiannaree School. 2. To study the clinical characteristics such as sex, neurological signs, verbal intelligence and comorbid attention deficit hyperactive disorder (ADHD) of the dyslexia group. METHOD: A total of 486 first to sixth grade students were administered "Raven's progressive matrices test" for estimation of intellectual functioning. Those who scored below the fifth percentile were labeled as mental retardation and excluded from the study. The students' reading ability was evaluated by 3 steps; first by classroom teachers using some items of the screening test, second by the researchers examining some more items individually, and third by the special educator assessing more details in reading and phonology. The students who had a reading ability two-grade levels below their actual grades and impairment in phonology were diagnosed with dyslexia. RESULTS: The prevalence of dyslexia and probable dyslexia were found to be 6.3 per cent and 12.6 per cent, respectively. The male to female ratio of dyslexia was 3.4:1. The dyslexia group had significantly lower Thai language scores than those of the normal group (p < 0.05). All of the dyslexia group had a normal grossly neurological examination but 90 per cent showed positive soft neurological signs. Mean verbal intellectual quotient score in the dyslexia group assessed by using Wechsler Intelligence Scales for Children--Revised was 76 +/- 7. The comorbid ADHD was 8.7 per cent in the dyslexia group. CONCLUSION: Dyslexia was a common problem among primary school students in this study. Further studies in a larger population and different socioeconomic statuses are required to determine the prevalence of dyslexia in the general population. The authors suggest evaluating the reading ability carefully by using a test that can detect phonological awareness deficit in all children who have learning problems.

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Highlights

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A large systematic literature review of computer games at primary education.

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Uses a multi-dimensional framework to ensure the quality of the studies analysed.

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Searches through 18,000 papers to identify 105 relevant papers in the field.

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Provides a snap-shot in time and repository in computer games for primary education.

Abstract

Games-based Learning (GBL) has developed a reputation with educationalists it is perceived as a potentially engaging form of supplementary learning that could enhance the educational process and has been used at all levels of education including primary, secondary and tertiary education. Despite this recognition and utilisation there is still a lack of empirical evidence supporting GBL as an approach. This paper presents the findings of a systematic literature review performed from 2000 to 2013 specifically looking at quality empirical studies associated with the application of GBL in Primary Education (PE) categorising studies into: behavioural change, affective and motivational outcomes, perceptual and cognitive skills and knowledge acquisition and content understanding. This paper presents a synthesis of these high quality studies associated with GBL. The studies showed that GBL have been used to teach a variety of subjects to children and young people in PE with mathematics, science, language and social studies being the most popular. However, the analysis shows that more Randomised Controlled Trial (RCT) studies should be performed comparing GBL to traditional teaching approaches to ascertain if GBL is a useful, viable teaching approach at PE level; there is a distinct lack of longitudinal studies and further longitudinal studies are required; further studies are required looking at whether there are pedagogical benefits of using 2D or 3D games at PE level to assess if 3D immersive games are indeed necessary; further studies are also required to perform comparisons between single and collaborative play and to identify the pedagogical benefits.

Keywords

Systematic literature review

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# data[].attributes.attachment_link.title
A systematic literature review of games-based learning empirical evidence in primary education

# data[].attributes.attachment_link.description
A large systematic literature review of computer games at primary education. * Uses a multi-dimensional framework to ensure the quality of the studies analysed. * Searches through 18,000 papers to identify 105 relevant papers in the field. * Provides a snap-shot in time and repository in computer games for primary education.