Valuing All Voices Framework embodies these theoretical concepts through four key components: trust, self-awareness, empathy, and relationship building. The goal of this framework is to provide the context for research teams to conduct patient engagement through the use of a social justice and health equity lens, to improve safety and inclusivity in health research. The aim of this study was to revise the proposed Valuing All Voices Framework with members of groups whose voices are traditionally less heard in health research.Critical stakeholder-identified gaps in current health research engagement strategies include the exclusion of voices traditionally less heard and a lack of consideration for the role of trauma in lived experience. Previous work has advocated for a trauma-informed, intersectional, and critical reflexive approach to patient and public involvement in health research. The A qualitative descriptive approach was used to conduct a thematic analysis of participant input on the proposed framework. Methods were co-developed with a patient co-researcher and community organizations.Group and individual interviews were held with 18 participants identifying as Inuit; refugee, immigrant, and/or newcomer; and/or as a person with lived experience of a mental health condition. Participants supported the proposed framework and underlying theory. Participant definitions of framework components included characterizations, behaviours, feelings, motivations, and ways to put components into action during engagement. Emphasis was placed on the need for a holistic approach to engagement; focusing on open and honest communication; building trusting relationships that extend beyond the research process; and capacity development for both researchers and patient partners. Participants suggested changes that incorporated some of their definitions; simplified and contextualized proposed component definitions; added a component of “education and communication”; and added a ‘how to’ section for each component. The framework was revised according to participant suggestions and validated through member checking.Valuing All Voices Framework provides guidance for teams looking to employ trauma-informed approaches, intersectional analysis, and critical reflexive practice in the co-development of meaningful, inclusive, and safe engagement strategies.The revised Valuing All Voices Framework, and met with people who identify as members of some of these groups to help define the key parts of the framework , to tell us what they liked and disliked about the proposed framework, and what needed to be changed. Input from participants was used to change the framework, including clarifying definitions of the key parts, adding another key part called “education and communication”, and providing action items so teams can put these key parts into practice.Patient engagement in health research continues to exclude many people who face challenges in accessing healthcare, including (but not limited to) First Nations, Inuit, and Metis people; immigrants, refugees, and newcomers; and people with lived experience of a mental health condition. We proposed a new guide to help researchers engage with patients and members of the public in research decision-making in a meaningful, inclusive, and safe way. We called this the  Patient engagement (PE) in health research has been defined as the meaningful and active involvement of people with lived experience  in all stages of the research process, including governance, priority-setting, conduct, and knowledge translation , 2. PE sHowever, through a one-day workshop in 2015 and ongoing discussions with over 50 Manitoba stakeholders , we have heard firsthand about gaps in current PE practice –19. AddiWhile Shimmin et al.’s work provides an important foundation for the evolution of PE, there is a need to formally incorporate these ideas with existing PE concepts in an organized way that can be used to inform, plan, and carry out PE in practice. A conceptual framework, the end result of bringing together a number of related concepts to explain or predict a given event, or give a broader understanding of the phenomena of interest , can helPatient Engagement Framework  we don’t think of ourselves as privileged – in comparison to a lot of other people, we are” (IM06). Another participant felt that “self-knowledge increases group or collective knowledge” (IM04), to the benefit of a research team or partnership. Action items to cultivate self-awareness included practicing honesty with one’s self and others, adopting trauma-informed practice, creating safe spaces, and employing cognitive behavioural therapy to address undesirable thought patterns and behaviours.The majority of self-awareness definitions spoke to practicing self-reflectionnot: it is not enabling, but rather helping people become empowered, and it is acceptance of other cultures, not just tolerance. In terms of why empathy is important, one participant stated “it breaks down us vs. them” (MH02) and allows us “to gain greater appreciation for others’ feelings” (MH03). Suggestions for how to cultivate empathy included sharing stories and experiences, and balancing with critical evaluation.Participants found empathy the most difficult to define. As one participant stated, “[empathy] is a feeling, not an action – how can you define a feeling?” (MH02). Most described empathy as “understanding” (as an adjective and a verb). Several used the idiom “putting yourself in someone else’s shoes/moccasins” . Participants who identified as people with lived experience of a mental health condition emphasized the difference between empathy and sympathy/ pity, concepts that are often confused. Several participants described empathy as an innate characteristic – that it must be genuine, and cannot be forced or taught. It also seemed to be linked to morality - that empathy “conjures up the idea that you must care about other people, and maybe that’s not quite it” (MH01). Participants also described what empathy is “… as a researcher, that’s a very fine balance – is being empathetic, but also being able to be critically evaluative … the other danger with empathy is that you’re identifying so much with the persons researched – well, for lack of a better word – it’s like getting drawn into their madness.” –MH04.Participants defined relationship building in terms of behaviors, feelings, and relationship characteristics Fig. . One par“Sometimes you can do all the research you want, but if you haven’t actually been through what someone else has been through it’s just a different perspective. And I think sometimes as a researcher you have to take a step back and say ‘okay, in this specific instance their perspective is more valuable than mine because [they’ve] gone through it’.” –MH03.why relationship building is important in PE included the need to feel cared for, creating a “shared vision” (MH04) for research, and improving adherence, compliance, and follow-up with partners and participants. In terms of how to build relationships, suggestions included spending time together sharing experiences and leisure activities; open and ongoing communication, honesty, and self-disclosure; and awareness and sensitivity to cultural differences.Participants described relationship building as intertwined with the other components, particularly with trust. Relationship building was described by some as a skill set - working with people from different cultures/ backgrounds, assessing and navigating interpersonal situations, and recognizing opportunities for growth and collaboration. One participant described relationship building as a “hierarchy” (IM07), speaking to how relationships between countries, and those in power, influence the potential for relationship building at lower levels. Reasons Valuing All Voices was seen as inclusive, though most identified the language used in the proposed definitions  and believing that people are generally good –“assuming the best intentions” (MH01). In the context of healthcare and health research, confidentiality was of particular importance to participants, and was added to the revised framework, along with definitions of communication, the two-way nature of trust, and all definitions created in the Inuit group interview Table .In the proposed definition “acknowledging privilege”, participants were divided on the use of the word “privilege”. Some opposed its use, describing it as unclear, and a “big” (IM04) or “horrible” (MH02) word; others appreciated its use. The definition was revised to “acknowledging privilege and biases” for clarity. Other changes included simplification (e.g. changing “understanding the impact of discrimination” to “understanding one’s self”) and specificity around what aspects of the self people should be aware of .Suggested changes included valuing and appreciating others – such as “acknowledging cultural differences” (IM05). Many participants suggested clarifying the concept of empathy to ensure its clear distinction from sympathy/ pity. Other suggestions included “balancing empathy with critical evaluation” (MH04), and adding descriptions of what empathy is not - “acceptance, not tolerance” (Inuit group) and “empowerment, not enabling” (MH05). Some participants felt uncomfortable with the title ‘empathy’ itself, suggesting ‘understanding’ and ‘acceptance’ as alternatives; the component title was changed to ‘understanding and acceptance’.In the proposed definition “understanding construction of social norms”, the word “norm” was seen as “negative”, or “labeling” (IM05) and participants suggested it be changed to “social expectations” . Other suggestions focused on emphasizing communication and accountability.Based on suggestions from participants, participant-created definitions and changes to proposed definitions were incorporated into the revised framework summary Table . Where sValuing All Voices Framework in a number of ways. This included challenging the language used in the proposed framework and clarifying definitions to make them more accessible. Collectively, participant input emphasized the need for a holistic view of engagement that goes beyond the research process, exemplified by the focus on open and honest communication; the creation and maintenance of trusting relationships; and capacity development for both researchers and patient partners to engage fully and meaningfully. In particular, the use of emotions in framework definitions by the Inuit and newcomer groups indicates a focus on the bigger, more important picture of how we relate to one another on a personal level. Participants highlighted the complexity and inter-relatedness of the proposed components, in part through how they seemed to blur the lines in defining and discussing framework components. One example is the focus on clarifying the various “levels” to which definitions for trust and relationship building refer  by members of the newcomer group and participants identifying as immigrants. As the intent of the proposed framework was for use by academic researchers, descriptions of the proposed language as inaccessible for participants was not surprising. This was even more prominent for those whose first language is not English. Although interpreters were present in the group interview with newcomers, concepts such as trust or empathy may not translate directly in their meaning or definition. Thus, time taken to clarify concepts, address power in the research process, and answer critical reflexive practice questions before diving into definitions and suggested changes was an important aspect of the process.Participants refined and enriched the Participant input also identified and refined critical elements of trauma-informed practice and intersectional analysis that are important to people with lived experience, including those whose voices are traditionally less heard in health research. For example, emphasis on aspects of self-worth and compassion for one’s self and others speaks strongly to the principles of trauma-informed practice. Participants added other critical elements related to the foundational theory of the proposed framework, such as using strengths-based approaches and acknowledging resilience; an understanding of the bi-directional nature of relationships, including research partnerships; and the importance of accountability and self-disclosure (i.e. sharing one’s own lived experience) in research relationships. Participants also emphasized the importance of breaking down ‘othering’ in research, and clearly outlining expectations in the early stages of research partnerships. These elements speak to the need for researchers and patient partners to work together to challenge traditional modes of knowledge production and engagement from perspectives that are traditionally less heard in health research.Valuing All Voices Framework complements pre-existing frameworks by delving further into the principles of inclusivity and diversity put forth by participants as actual skills and behaviours required for meaningful engagement of voices traditionally less heard. The Valuing All Voices Framework is an important and unique framework for PE in health research in that (i) it was created in response to gaps identified by patients and members of the public; (ii) it has involved patients and members of the public both as members of the research team and as study participants; and (iii) it addresses the need for safety and critical reflexive practice in employing a social justice and health equity lens, through which issues around healthcare, services, and health research can be viewed. The Valuing All Voices Framework provides guidance for teams looking to employ trauma-informed approaches, intersectional analysis, and critical reflexive practice in the co-development of meaningful, inclusive, and safe engagement strategies.Of the 65 PE frameworks reviewed by Greenhalgh et al. , many rePositive impacts of engagement included leveraging existing relationships for methods co-development and recruitment; capacity-building for researchers and academics involved regarding communication and decision-making with patient and public partners; as well as inclusion of an Indigenous Inuit non-academic perspective in decisions throughout the research process. Engagement resulted in more relevant and appropriate methods and interpretation of findings, particularly the effective use of storytelling in data collection and sharing of preliminary findings at conferences and keynote lectures. Challenges related to engagement primarily included unanticipated delays, and underestimation of the time and resources required to conduct research-related activities.Contributions to the framework around the concept of safety focused primarily on emotional, spiritual, and cultural safety, though we must not neglect other important aspects of safety in PE . For example, attention to patient and public partners’ physical needs during engagement activities, especially those that require travel or long hours (e.g. availability of foods for people living with diabetes and celiac disease) and accessibility issues  are aspects often neglected in engagement in research, leading to unsafe situations or exclusion of certain individuals.Acknowledging challenges inherent in conducting research with voices traditionally less heard in health research, such as extended timeframes, increased costs, and the need for community partnerships , feasibiValuing All Voices Framework can help inform the development of training for PE in health research, particularly in terms of building meaningful and sustainable research partnerships in areas such as critical reflexive practice, compassion, empathy, establishing trust, self-care, and addressing trauma in lived experience. If used as intended, the framework can help facilitate dialogue between researchers and patient and public partners about expectations and roles in research partnerships, while emphasizing the importance of a social justice and health equity lens in conducting transformative research. The framework can also inform development of evaluation dimensions  for PE in health research. Though this study focuses on inclusion of voices traditionally less heard in health research, the refined framework should be applied in broader contexts of PE. The underlying theories and principles of trauma-informed intersectional analysis are of benefit to all teams seeking to build meaningful and trusting relationships with patient and public partners. Ongoing internal and external projects and programs examining PE in health research and healthcare services are adapting the refined Valuing All Voices Framework with various groups - expanding its reach and applicability and providing additional opportunities for continued refinement of the framework and its components. The Valuing All Voices Framework will continue to inform the advancement of inclusive and meaningful patient-oriented research by helping the broader health research community recognize both the importance of trauma-informed approaches and intersectional analysis, as well as their practical day-to-day application.The refined Additional file 1: Appendix 1. The proposed Valuing All Voices Framework that was discussed and revised with study participants.Additional file 2: Appendix 2. Participant Interview GuideAdditional file 3: Appendix 3. Demographic Questionnaire


We also consider the impact of these issues on progress in the field of expertise, focusing on the empirical testability and falsifiability of the deliberate practice view. We then discuss a multifactorial perspective on expertise, and how open science practices can accelerate progress in research guided by this perspective.The question of what explains individual differences in expertise within complex domains such as music, games, sports, science, and medicine is currently a major topic of interest in a diverse range of fields, including psychology, education, and sports science, to name just a few. Ericsson and colleagues’  Psychological Review article, deliberate practice, which they stated “includes activities that have been specially designed to improve the current level of performance” (p. 368). In studies of violinists (Study 1) and pianists (Study 2), Not infrequently, a single theoretical perspective becomes extremely influential in an area of scientific inquiry, shaping the trajectory of research in the field for years or even decades. More than 25 years ago, K. Anders Ericsson and colleagues proposed what has arguably become the most influential theoretical perspective in the scientific literature on expertise and expert performance. In a pivotal Applying their framework to several domains of expertise, [H]igh levels of deliberate practice are necessary to attain expert level performance. Our theoretical framework can also provide a sufficient account of the major facts about the nature and scarcity of exceptional performance. Our account does not depend on scarcity of innate ability  , p. 392.Harvard Business Review, Reiterating this perspective, deliberate practice view, has had a monumental impact on expertise research. As of this publication, the Outliers: The Story of Success and Daniel The Talent Code, Ericsson and colleagues’ research has also had a profound influence on the public’s thinking about the origins of expertise. Taking his inspiration from Peak: Secrets from the New Science of Expertise, Ericsson wrote, “Deliberate practice can open the door to a world of possibilities that you may have been convinced were out of reach. Open that door” . This point was amply illustrated by some of Ericsson and colleagues’ earliest research. For example, in a classic study, between individuals could be positive (top panel), indicating higher levels of performance for individuals who have engaged in more training; negative (middle panel), indicating lower levels of performance for individuals who have engaged in more training; or zero (bottom panel).The controversial question in research on expertise is not whether some form of training is necessary to explain intraindividual  increases in expertise (it must be), or whether these increases can be massive (they can be). Rather, the controversial question is the extent to which interindividual  differences in accumulated amount of training explain interindividual differences in expertise ” ” , p. 1333work as engagement in activities for external rewards , play as participating in activities for pleasure , and deliberate practice as a “highly structured activity, the explicit goal of which is to improve performance” . This latter statement indicated that deliberate practice, as must be designed by a teacher, then presumably it cannot also be designed by performers themselves.However, Ericsson and colleagues have been inconsistent on critical elements of the definition of deliberate practice, and consequently it has been unclear what activities do and do not qualify as deliberate practice. For example, not the case, commenting that “it is important to point out that organized team training may be quite effective in improving performance, but it does not meet all the criteria for deliberate practice” (p. 6). This is another apparent shift in the definition of and criteria for deliberate practice, creating still more confusion about what the “correct” definition is. In short, it is unclear what activities do and do not qualify as deliberate practice.As another example of definitional confusion, it is unclear from Ericsson and colleagues’ writings whether deliberate practice must be a solitary activity, or whether it can also be a group/team activity. Citing research on team sports , EricssoThis confusion surrounding the definition of deliberate practice is not a minor matter—it directly impacts how deliberate practice is measured in empirical studies and what evidence  should be included in a meta-analysis. These decisions, in turn, directly impact the evaluation of the deliberate practice view: whether evidence is concluded to support the view or not. Certainly, definitions of theoretical constructs can and do evolve over time as science progresses, but the shifts in the definition of deliberate practice reflected in r = 0.42). This is a sizeable correlation by psychological standards—a “medium” effect size in r = 0.10, small; r = 0.30, medium; r = 0.50, large). However, this finding also challenges the deliberate practice view because it means that deliberate practice left a large amount of the total variance in chess ratings unexplained. To be exact, a correlation of r = 0.42 between two variables indicates that one variable explains 18% of the variance in the other variable . In the present case, it must be assumed that some of this unexplained variance reflects random measurement error, because neither a measure of deliberate practice nor a measure of performance can be assumed to be perfectly reliable (we discuss this issue further below). However, the correlation was not large enough to suggest that, even after taking this psychometric artifact into account, participants at similar levels of chess skill would have reported similar amounts of deliberate practice. Instead, it suggests that the chess players varied substantially in the amount of deliberate practice they required to reach a given level of skill. Indeed, according to the data, they did: As Notwithstanding this confusion over the definition of deliberate practice, there have been numerous attempts to test the deliberate practice view. One of the first noteworthy tests came from a study of chess expertise by largely be accounted for by differential amounts of past and current levels of practice” . We identified six studies of chess and eight studies of music that reported a correlation between a measure of deliberate practice and performance. The average correlation was r = 0.49 for chess and r = 0.43 for music before applying the standard psychometric correction for measurement error variance (unreliability) of the constituent measures. For deliberate practice, we assumed a reliability coefficient of 0.80 based on information we could find about the reliability of this variable, as well as on most of the variance in expertise, and evidence suggests it does not.In our own first effort to test the deliberate practice view , we reanSubsequently, we set out to test the importance of deliberate practice as a predictor of individual differences in expertise, by way of a formal and comprehensive meta-analysis , p. 1615still an important predictor of performance differences at the elite level. In their own words, “Individual differences, even among elite performers, are closely related to assessed amounts of deliberate practice”  found that solitary deliberate practice was closely related to performance, whereas the amount of social dart activities did not predict performance , p. 191.2.In chess, Charness and his colleagues  have found that the amount of solitary chess study was the best predictor of performance at chess tournaments, and when this type of deliberate practice was statistically controlled, there was no reliable benefit from playing chess games , p. 1912had collected data on deliberate practice:Another inconsistency was In that study we  collected data on ‘deliberate practice.’ We found that ‘Grittier spellers engaged in deliberate practice more so than their less gritty counterparts, and hours of deliberate practice fully mediated the prospective association between grit and spelling performance’ (p. 6).In a commentary on a subsequent meta-analysis of deliberate practice in sports performance, Peak: Secrets from the New Science of Expertise, naïve practice as “essentially just doing something repeatedly, and expecting that the repetition alone will improve one’s performance” (p. 14), and purposeful practice as an activity that has well-defined, specific goals and involves feedback, but which is self-directed rather than teacher-directed. and informed” . They further explained that “some approaches to training are more effective than others” (p. 85) and that deliberate practice is “the most effective method of all…. The gold standard, the ideal to which anyone learning a skill should aspire”  as providing “the most compelling and detailed evidence for how designed training (deliberate practice) is the crucial factor in developing expert chess performance” (p. 237). Nevertheless, in their recent article, purposeful practice for chess skill” . As another example, Duckworth, Ericsson, and colleagues’ spelling bee study . Yet the recent purposeful practice in preparation for competitions in spelling” .Using this new framework, Ericsson and colleagues reinterpreted studies they had once used to argue for the importance of “deliberate practice” as studies of the less effective “purposeful practice,” but without explicitly acknowledging and justifying the reinterpretation see . As an eee study  focused explicitly acknowledged, explained, and justified. In the absence of such transparency, the reader will be led to think that the empirical support for the original theory was stronger than it is or ever was.In another instance, Ericsson and colleagues went from arguing that activities exist that meet the criteria for deliberate practice in the boardgame SCRABBLE, to arguing that it is not possible to engage in deliberate practice in SCRABBLE. Specifically, referring to r = 0.40 for “deliberate practice” , and an average correlation of r = 0.21 for what they deemed “non-deliberate practice.” However, as we pointed out in a reply . Then they noted, “Still, something about our analyses [sic]. One might think there would be a ‘meeting of the minds’ when the estimates from their analysis and ours returned such similar results” (p. 289). In a recent reply, while not addressing the coding issue, analyses ” . So, to be clear, not define deliberate practice as such. Contradictory statements such as these lead to confusion about what the definition of deliberate practice is—and even whether there is a fixed definition at all.According to this statement, 3. However, as shown in describe individualized sessions with a coach or teacher, with no specification of the lower limit on the amount of supervision and guidance. As they explained:Compounding the issues already discussed, Ericsson and colleagues’ standard for evidence concerning deliberate practice has apparently shifted yet again. For their main analysis, For coding purposeful versus deliberate practice, we looked for explicit mentions within the original study methods of individualized sessions with coaches or teachers as being included as part of the estimate of solitary practice. If a study did describe individualized instruction sessions as being part of the practice estimate it was considered to be deliberate practice , between purposeful practice and performance , and between deliberate practice and performance . As can be seen, the strength of the correlations varies depending on the reliability estimates, with larger corrections for lower reliability estimates. For example, if reliability is assumed to be rxx = 0.80 for deliberate practice . Thus, conclusions will vary considerably depending on what values are used as the reliability estimates in the psychometric correction.practice  and ryy rxx = 0.60 and ryy = 0.60), then a strong version of rxx = 0.80 and ryy = 0.70), then a weaker version of the claim would be supported. If deliberate practice explained an even smaller amount of the variance—for example, 39% (assuming even higher reliabilities of rxx = 0.90 and ryy = 0.90)—then an implication would be that factors other than deliberate practice explain more of the variance in performance than deliberate practice does. These different variance estimates might then lead to different priorities in expertise research. For example, the first scenario (87% of variance explained) might prompt an exclusive focus on training history, whereas the third scenario (39% of variance explained) might prompt a broader focus on multiple determinants of performance differences . Elsewhere, we have argued that based on extant evidence, research should indeed investigate the role of a wide range of factors in explaining individual differences in expertise  in xpertise .rdeliberate > rpurposeful). r = 0.56 for deliberate practice and r = 0.51 for purposeful practice, a non-significant difference (p = 0.64). We further note that, if they were taken at face value, Again, how important is deliberate practice as a predictor of individual differences in expertise? It is somewhat difficult to say given the ambiguity over the definition of deliberate practice, but we can at least summarize evidence from meta-analyses by different groups of researchers that have attempted to answer this question. Along with the aforementioned reanalysis of chess and music studies , there hThe Logic of Scientific Discovery, the philosopher of science Karl In view of the issues discussed in the preceding pages, it seems reasonable to ask whether the deliberate practice view is scientifically defensible—that is, whether deliberate practice can be conceptualized and tested empirically in a consistent manner by the research community. In his book scientific theory, at least in the Popperian sense. The theory is always “right” and cannot be evaluated against competing theories. When a theory becomes unfalsifiable, it ceases to be a Is the deliberate practice view falsifiable? We will leave it to readers of this article to draw their own conclusions. At the very least, it seems difficult to deny that there are serious problems with the deliberate practice view, as Ericsson and colleagues have presented it over the past 25 years. As we have documented here, Ericsson and colleagues have described deliberate practice in contradictory ways, creating major confusion about the definition of deliberate practice. Furthermore, Ericsson and colleagues’ standard for evidence—the specific criteria that need to be satisfied to use a study to argue for the importance of deliberate practice and even the criteria themselves—has appeared to shift multiple times.not made in a transparent manner, then in Lakatos’ terminology a theory can be endlessly adjusted and readjusted to keep it “alive.” The program of research then shifts from “progressive” to “degenerative”  permit no more than relative statements about the degree to which a person is attending to one task (or stimulus) versus some other task(s). Except for subjective self-reports, we are also unaware of attempts by Ericsson and colleagues themselves to measure concentration level during practice. If a criterion for a theoretical construct  either cannot be achieved or cannot be empirically verified, then imposing that criterion makes the theory unfalsifiable. This sort of flexibility in the deliberate practice view, along with the definitional confusion we have discussed, presents an additional problem for its scientific viability.On a related note, the concept of deliberate practice is arguably underspecified in ways that leave open the opportunity for numerous n” e.g., . HoweverWhy is it important for researchers to comment publicly when a theory in their research area appears to be degenerating? It is important because a degenerating theory—especially if it is influential—impedes actual progress in an area of research. The value of research to test the theory becomes questionable, because evidence is accepted as valid only if it supports the theory and rejected if it fails to support the theory. In turn, practical recommendations and applications based on the theory will lack a scientific foundation, because even conflicting recommendations and applications can be supported. If conclusions from this research do not have a solid empirical foundation, then recommendations based on the theory may be wasteful, counterproductive, or even harmful.To be certain, we do not think that the concept of deliberate practice should be abandoned. Deliberate practice is a vital area of research in psychological science and other fields. However, given the issues we have discussed at length in this article, we do believe that it would be highly beneficial to expertise researchers (and scientists from other research areas interested in expertise) for proponents of the deliberate practice view to fully address and resolve the apparent inconsistencies and shifts in the definition of and standard of evidence for deliberate practice that we have documented here—and which raise serious concerns about the viability of the deliberate practice view as a scientific theory. This would allow other researchers to empirically evaluate the importance of deliberate practice as a predictor of individual differences in expertise, both in individual studies and meta-analyses, and to compare its predictive validity to that of other factors  and the conditions of practice .To this point, in the following sections, we summarize key evidence for the role of a diverse range of factors in explaining individual differences in expertise, and then discuss in broad terms what we believe are fruitful directions for future research to develop comprehensive models of expertise.What might explain individual differences in expertise, beyond any contribution of deliberate practice? We direct readers to recent theoretical/review articles in which we discuss this issue at length . Here, wearly specialization view argues that the earlier the training can begin, the better. The logic of this view is straightforward: Because it is both physically and psychologically taxing, a person can engage in only a few hours of deliberate practice a day  than the non-medalists. Moreover, the average starting age was later by approximately a year-and-a-half for the medalists compared to the non-medalists. One possible explanation for this finding is that a starting age that is too early increases the risk for injury and/or burnout. Another possible explanation is that starting later allows for more early diverse experiences, increasing the likelihood that the individual will find a sport that is a good match to his or her profile of performance-relevant traits . Furthermore, measures of deliberate practice have not always been found to be stronger predictors of individual differences in expertise than measures seeming to meet the definition of “work” and “play.” For example, in a study of insurance salespeople, rcurrent = 0.21 and raccumulated = 0.13) were not stronger than the correlation between sales performance and a measure fitting the description of work for this domain—the number of cases handled .circumvention-of-limits hypothesis  precluded any strong conclusions from those few studies. Providing what might be considered the strongest evidence for the hypothesis, one of these three studies that seem to support the circumvention-of-limits hypothesis was a meta-analysis of chess studies (r = 0.32) than in higher-skill chess players (avg. r = 0.14). However, it is important to note that skill level was highly confounded with age , limiting the strength of the evidence in support of the circumvention-of-limits hypothesis.For complex tasks of interest to expertise researchers, evidence for this claim, which we termed the pothesis , is weakpothesis , we searr = 0.25, p < 0.05), but not in university music majors (r = 0.24) or conservatory students (r = 0.12). However, the critical question is not whether the lower-skill group correlation is statistically significant while the higher-skill group correlations are not. Rather, it is whether the former correlation and the latter correlations are significantly different from each other, as determined by the appropriate statistical test. As it happens, in the z tests for differences in correlations are statistically non-significant). Thus, the results of fail to support the hypothesis that ability-performance correlations diminish with increasing skill.We also note that results that have sometimes been used to argue that the influence of general cognitive ability on expertise diminishes with increasing skill do not warrant this conclusion. For example, r = 0.34 to r = 0.21; z test for difference = 3.60, p < 0.001), but then stabilized and remained statistically and practically significant , an estimate of the proportion (0 to 1) of the total variance in a trait that can be attributed to genetic  variance within a sample of individuals  the effect of an environmental factor on an outcome. As one example of G × E, analyzing data from the National Merit Twin Study, Genetic factors and environmental factors may not only correlate with one another; they may interact in influencing behavioral outcomes—what is known as no way implies that training is unnecessary to develop a high level of expertise, or that training is beneficial to only some people. Training is necessary and essential for developing a high level of expertise in a domain, and except when a condition rules out some type of training , anyone would be expected to benefit from proper training. Second, heritability does not imply immutability. For example, in adults, height is highly heritable and relatively fixed, whereas weight is similarly heritable but can be modified through an environmental intervention—namely, dieting. Third, environmental interventions that change individual differences will also change heritability. For example, if an environmental intervention were introduced that allowed nearly everyone to reach about the same level of skill in some task, heritability would be expected to decrease. In a similar manner, heritability can differ across populations  to describe how these factors relate to one another and to serve as a guide for future research on expertise , ability factors , non-ability factors , and background factors . In recent articles, we have proposed the xpertise . As illuEricsson and colleagues’ deliberate practice view has had a monumental impact on the field of expertise, and is important in the history of psychology, more generally. However, in our assessment, it is not clear that the deliberate practice view is defensible as a scientific theory. As described here in some detail, Ericsson and colleagues have defined deliberate practice in inconsistent ways see  and the open science movement, we believe that the path ahead is for expertise researchers to work together to develop testable theories that take into account a much wider range of potentially relevant causal constructs than have often been considered in previous research, and to use rigorous empirical methods to evaluate these theories. The open science movement promotes normative values aimed at increasing accuracy, openness, and fairness in scientific research and scholarship  and in data analysis . Collaboration can facilitate collection of large samples and help to ensure that multiple theoretical perspectives are considered in study design. The time is also ripe for a preregistered “adversarial collaboration”—a study in which researchers with differing views agree on an empirical test to resolve a theoretical dispute that is designed to provide a fair test of both views  is “construct pure.” That is, a score collected by an instrument  designed to measure a given hypothetical construct may reflect that construct to some degree, but it will certainly reflect other, construct-irrelevant factors, such as participants’ familiarity with a particular method of assessment  and psychological states that may affect their responding . There is no perfect way to deal with this problem, but when multiple measures of a construct are obtained, it becomes possible to use data-analytic techniques  that are explicitly designed to deal with this issue by allowing researchers to model latent variables that are closer to theoretical constructs of interest than observed variables are.The third recommendation is that the sample of participants from the targeted domain should ideally represent a wide range of performance rather than extreme groups. As we have noted elsewhere , categorThe final recommendation is for expertise researchers to begin large-scale longitudinal studies. Longitudinal studies are expensive and, by their very nature, time-consuming. At the same time, they are common in psychology. For example, there are longitudinal studies in the area of cognitive aging that have been running for many decades, such as the Seattle Longitudinal Study . There igrounded expertise components approach (GECA) is to identify predictors of individual differences in expertise in a theoretically neutral manner to minimize bias in findings from research concerning the relative importance of one class of factor versus another . The approach begins with exploration: administering a survey to a large sample of performers in domains, with questions about their level of engagement in training activities, as well as education, interests, hobbies, careers, accomplishments, and other characteristics that may be informative about potential predictors of expertise . The survey data are then analyzed to identify a candidate set of potential predictors of expertise. Finally, a study is conducted to estimate the relative contributions of the factors to the prediction of individual differences in expertise. Programmatic research can then proceed on this basis.We also offer one more specific recommendation for future research on expertise. The goal of A major goal of the GECA is to identify activities that consistently correlate to a practically and statistically significant degree with measures of expertise. These activities may differ across domains. More specifically, for some domains, the activities may meet the ultimate criteria for deliberate practice, whereas for other domains, they may include unstructured activities that do not fit the definition of deliberate practice, purposeful practice, or even naïve practice. Furthermore, within a domain, there may be multiple “routes” to developing expertise. That is, one performer may achieve a given level of expertise by engaging in one set of activities, whereas another performer may achieve the same level of expertise by engaging in a different set of activities. As an illustration, In short, the search for activities using past time—for the nature vs. nurture debate to be over in the field of expertise, as it has been in most areas of psychological research for decades (and nurture) will, as For decades, the field of expertise has focused on environmental factors as the major determinants of individual differences in expertise, whereas genetically influenced factors are assumed to play a relatively unimportant role, if any role at all . Environ decades . EmbraciAs we were editing the page proofs for this article, we received the sad news of Anders Ericsson’s passing. It is difficult to imagine the field of expertise without Anders—he was a pioneer. But his ideas will live on and continue to inspire scholarship and debate that will lead to greater understanding of the subject about which he was so passionate. We hope that Anders found our work as stimulating as we found his. He forced us to think critically about our most basic assumptions concerning expertise, and to try to put our best case for our perspective forward. We are in his debt, and extend our sincere condolences to his family, friends, students, and colleagues.DH was the primary author and conceived the article. BM and FO provided extensive comments and edits on multiple drafts. All authors contributed to the article and approved the submitted version.The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.


A challenge facing the Arctic region is the disengagement of both education and work among its youth. Only by supporting young people who are struggling with mental and physical health challenges can we begin to address this societal challenge. Education, mental health and social inclusion are prominent factors for future employment, income and independent living for young people. The aim of this study was to describe and understand the experiences of good conditions for health and learning in schools in the Arctic region. The 5-D appreciative inquiry method was used to explore 47 students’ and professionals’ experiences and future visions of their school. A phenomenological analysis resulted in three themes: “Standing as one”, “Having an apple a day”, and “Finding the end of the rainbow”. The findings revealed the necessity of promoting health and learning simultaneously in school and viewing health holistically. Health-promoting relationships permeate the findings of good conditions for health and learning. We argue for considering mandatory health education to increase students’ health literacy and making student participation and staff collaboration a priority in schools in the Arctic region. These findings, their practical implications, and future research directions are discussed. A challenge facing the Arctic region is the disengagement of both education and work among its youth. Only by supporting young people who are struggling with mental and physical health challenges can we begin to address this societal challenge. Education, mental health and social inclusion are prominent factors for future employment, income and independent living for young people . AlthougTowards promoting health in the educational arena, school staff can use a disease-prevention approach that focuses on risks, challenges and disparities identifying problems and potential solutions. Another option is a health-promotion perspective, described in the World Health Organisation’s Ottawa Charter . This apThe Arctic regional context has been taken into consideration in research and reports describing healthy schools in Canada, Finland, Norway, and Sweden that highlight what makes good, equitable, and healthy schools possible. Studies point towards a holistic approach where equity between students and teachers helps to provide a nurturing environment for good health and thus good learning. For example, findings from an HPS initiative in rural Nova Scotia, Canada suggest a supportive school ethos with positive teacher-student relationships enables student well-being in school . The SweAccording to Swedish school law and the national curriculum, the school should promote learning and harmonious development for all students while paying attention to health and lifestyle issues : 19, 20.The authors have used appreciative inquiry (AI) which involves asking positive questions and using the answers as a starting point for development . An apprThis method has been recommended as a strength-based model to improve school climate . The 5-DThe participants were divided into small groups of 4–5 that were balanced regarding age, gender, profession, and nationality. The data collection process included:1) Define: A topic of inquiry  was selected by the principal and school board and then communicated to the two authors. 2) Discovery: The participants were asked to consider examples of when health and learning intertwine at school and discuss why these situations were valuable and important. 3) Dream: Participants formulated visions and document future positive scenarios when health and learning go hand in hand. 4) Design: The participants planned out potential HPS development strategies by setting goals and suggesting new school activities and improvements. Each participant was asked to take notes about their experiences and then discuss these and responses to steps 2 and 3 in their small group. 5) Destiny: Finally, the participants cut and pasted pictures and written text from magazines and onto poster boards (1 per group) to visually represent a future in which their formulated goals and activities (step 4: design) align with their visions and positive scenarios (step 3: dream).This study was carried out in one municipality in the county of Norrbotten, located in the Arctic region of Sweden . The annual school evaluation 2016 indicated students’ health and academic achievement were decreasing. From 2017 to 2019, a research group that included the two authors was charged by the municipality with developing activities to promote student health and learning and collecting data for research studies. The present study was undertaken in the first year of this project to document and examine students’ and professionals’ experiences and perspectives regarding conditions conducive for good health and learning.All students and professionals in the municipality’s upper secondary schools were invited to participate, which, at the time, included approximately 150 students, 30 school staff, and 12 school politicians. A total of 47 participants, both students and professionals, took part in the study. The 27 students  were in grades 7, 8, 9, and the introductory language program for young immigrants. The 20 professionals  included teachers, teaching assistants, school nurses, principals, and politicians. The participants came from all three schools in the municipality, which has a large number of immigrants. This study included individuals from Afghanistan, Finland, Somalia, Sudan, Sweden, and Thailand. Due to the risk of identifying the municipality and the participants, we have refrained from supplying additional information.The municipality’s development manager distributed the invitations to participate to all students and professionals in the municipality’s upper secondary schools. The researchers provided oral and written information about the study to all potential participants, as outlined in the Helsinki Declaration . Oral anreflectively appropriating, we considered all of the data as a whole by reviewing the text and collages repeatedly to provide an overview of the participants’ lived experiences. The two authors coded the data based on their independent reflections and then compared and discussed these to create several codes reflecting their combined picture.The analysis was based on a hermeneutical phenomenological approach to lived-experience research in three phases . The parclarifying, the authors grouped the codes based on the similarities and differences among the data and used a mind map to determine how these codes were connected. In the third and final phase, making explicit the structure of meaning of the lived experience, the earlier phases of the analysis were used to create themes that explained the patterns within the data. Each of the three themes includes variations among the participants’ perspectives. Illustrative quotations were chosen to exemplify each theme, give voice to the participants, and enhance the study’s credibility  influence.” Within the classroom, participants mentioned peer review as an example of an activity that promotes health and learning. Another group wrote, “We all need appreciation … so the next time, you work harder.” However, it was not always about being active together. The participants describe sharing moments of silence and relaxation with other students as health-promoting.The participants highlighted the teachers’ contribution to students’ health and learning. One group mentioned how important the teachers are for the students “by supporting and being nice to us.” The participants suggested designating a room for students to do their homework with support from teachers during and after the school day. The participating professionals described collegial support and a willingness to co-create. One group envisioned a future in which “teachers are happy when they come to school, share, learn, and cooperate with each other.” Another group wrote that they appreciated “ … when a student spontaneously comes up to you and helps out, when you have your hands full.” Taken together, the data consistently indicate that being surrounded by kind people supports good health and effective learning.According to the participants, conditions conducive to good health and effective learning include many activities, tools, places, and spaces that encourage health and learning opportunities. The reported activities included a variety of physical exercises, both invigorating and relaxing, such as walking, biking, dancing, and sports . The participants mentioned a teacher who consistently takes 20-minute outdoor walks with the students before the day’s lessons, referred to as the “Maria walkabout.” The participants described this physical activity as social, invigorating, and positively impacting the students’ studies. One group wrote, “The Maria walkabout – we go outdoors in the refreshing air, which makes us more energetic and our brains work better.” Some physical activities were described as promoting both physical and mental well-being; for example, yoga, which consists of easy-to-learn body positions and breathing techniques that can reduce stress and anxiety. Another group wrote, “Micro breaks – yoga and movement during lessons.”The participants experienced time as an important element of health-promoting activities. They described the practical execution of activities between lessons or as a part of mandatory lessons as a supportive measure to increase educational achievement. One group wrote about the importance of “relaxation in the schedule, time for peace and quiet.” The participants described relaxing activities, such as massages and longer breaks between lessons, or, as one group explained, the need for “an empty hour – taking the time for a peaceful moment.” However, some participants also asked for the opposite, namely shorter school days instead of “empty hours” in the schedule. One group suggested that spending less time in school is health-promoting: “School until 1 PM on Fridays ….” Another time-related aspect mentioned in this study was flexible hours or, as they called it, “flex-time,” that entails school days begin earlier or later based on the individual student’s optimal time of day for learning.The participants also described tools to promote health. For example, physical health was enhanced by comfortable, ergonomically-tested chairs and gadgets to reduce stress and increase learning. One group wrote, “Students in grade 1 use balance balls as a way to increase concentration.” The participants described the need for practical activities that were within their subject areas and allowed for working with their hands. Another health-promoting aspect that the participants described was designating spaces where students, school staff, and politicians can meet. The participants suggested a physical room, like a café, where there is space to eat snacks and socialise. One group wrote, “The café has been worth gold – we hope it will be [open] in the future too.” Other physical rooms that were mentioned were a room in which to do homework. However, the participants also asked for the opposite describing a place to not work as one group wrote, “A room for rest and contemplation, designed with comfortable couches and cozy lighting … [with] a sign on the door – ‘Do not disturb! Relaxation room!’”Additionally, clean showers and dressing rooms to use after physical education classes were noted as promoting health in school. The participants highlighted “nature” as a health-promoting aspect and suggested using nature as a place to play, relax, and learn. One group suggested “[placing] tables outdoors so we can work outside.” The data on including nature ranged from spending time outdoors during the school day to taking a trip to the mountains for extended time in nature.Nutrition was mentioned by the participants as a valuable aspect of promoting health and learning. They described food as a tool and eating as an activity, which were connected to places in their school. In terms of eating breakfast together as part of the school day, having fruit available or healthy snacks for sale in the cafeteria was suggested. An “ice cream stand” was also on one group’s wish list. Food was not only a matter of nutrition but also described as a social activity and an opportunity to learn about a healthy lifestyle – for example, by connecting a healthy breakfast with academic achievement.Actively choosing what food to eat was health-promoting according to the participants. One group wrote, “Food choices make you happy.” Happiness was connected to having a choice in general, as well as to learning. Another group wrote, “The students come to school happy, want to learn, and are included in decisions.” Similarly, one group wrote, “It is fun to learn.” The connection between health and learning was evident in the participants’ experiences. The participants described the sense of wholeness and their experiences of when health and learning were integrated. One group wrote, “When I feel well all over, I study and learn better.”The participants’ visionary thoughts about promoting health and learning included fundamental values of ethics permeating structures within the organisation. They described how ethical values are needed in all activities and approaches to building a health-promoting culture. According to the participants, important values included but were not limited to aspects of general human rights and, more specifically, children’s rights. They described student participation as a natural part of activities and approaches in their dream school. For example, the students co-created a school schedule with teachers, and one group gave voice to the principal: “The student council’s work is important to me as principal, taking students’ thoughts and opinions seriously, allowing students to truly participate and be able to have an influence.”The participants described their school as a place where trust, security, and safety were not only encouraged but self-evident. One group envisioned that “everyone would feel safe at school and everyone would be seen.” The school of their dreams was described as an arena in which everyone’s attitudes enforced tolerance and where hopefulness and inclusion were fundamental values that were practiced daily. They described a safe place where people are accepted for who they are, making it more likely that they will dare to venture outside of their comfort zone, open up to cooperate with others, and learn from each other.The participants described how openness to diversity is a prerequisite for having everyone feel comfortable and everyone’s responsibility. One group envisioned that “we feel well and show respect.” Another group suggested using the golden rule as a starting point, writing, “Do unto others as you would have them do unto you.” Supporting diversity was described in terms of mixing groups of professionals and students, boys and girls, and students from different countries and ages in activities as a way to learn about and from each other. One group wrote about “having a joint activity one day each term uniting students from all grades.” They stressed the importance of school being safe and inclusive. In their descriptions of the school of their dreams, appreciation, friendliness, and kindness were commonly practiced among school staff and students and also towards oneself; as one group wrote, “It is time for ‘self-kindness.’”The notion of democracy in school was described and exemplified by the participants as genuine participation reflective of the students as important co-creators. They described opportunities for students to partake in not only daily work but in the long-term development within the school organisation. They described values that included respect for each other and responsibility for the shared space and encounters. The participants gave examples of fundamental values that were practiced within the school’s physical and social environment. They argued that student participation contributes valuably to creating the conditions necessary for promoting health and learning in school. One group described a future in which students were able to make decisions on things that they view as valuable, such as “organising groups of furniture in a creative fashion where we can share knowledge and learn together.” Another group envisioned student participation taking the form of “planning the school day, the current schoolwork, and activities together with the teachers.”The participants connected learning to different school subjects that included maths and general learning strategies. According to the participants, knowledge of effective learning strategies provides a helpful understanding of how we learn. One group highlighted that “knowing about and sharing different strategies to learn is much appreciated.” The participants stressed the importance of taking control of their learning process by identifying individual short- and long-term goals connected to the curriculum. According to the participants, learning new strategies and sharing experiences with other students inside and outside of the classroom made the learning process easier, which resulted in a sense of well-being. One group remarked, “Working together in a group makes it easier.” The participants described fundamental values, including empowerment, appreciation, and sustainability as instrumental in creating conditions that encourage good health and learning. One group provided the following metaphor: “[We] wish that school were a greenhouse where we grew outstanding pumpkins, allowing everyone to succeed.”The participants described school as a place where students develop life skills and embrace fundamental values that inform healthy choices throughout life. The participants described HPS development as the process of enabling conditions that promote good health and learning. Some suggestions were direct and without much preparation, such as allowing everyone to participate and become involved in for example planning health promoting activities. Other changes, such as fostering a school culture where trust, security, and safety are readily apparent, require more time. One group wrote, “Don’t be afraid of the slow progress but watch out for stagnancy.”The findings revealed the necessity of promoting health and learning simultaneously in school and viewing health holistically. Health-promoting relationships permeate the findings of good conditions for health and learning. We argue for considering mandatory health education to increase students’ health literacy and making student participation and staff collaboration a priority in schools in the Arctic region.These findings, their practical implications, and future research directions are discussed below.Having an apple a day, the participants described outdoor walkabouts that were experienced as social and invigorating, which is comparable to recent research that found that peers can offer paths to successfully promote physical activity [Having an apple a day, situations resulting in feelings of happiness was connected to health. These included instances when the students were included in decisions, chose the school lunch menu, and when the students and teachers came to school feeling happy. These data support the discovery of happiness in education as crucial for effectively integrating health and social aspects, which includes the right to be treated equally and school being a place where people’s dignity is valued [The findings point to the necessity of promoting health and learning simultaneously in school and viewing health holistically. According to the participants in this study a prerequisite for students reaching their educational goals while feeling well is that the students, staff, school leaders, and politicians understanding that school is an environment in which learning and health are intertwined. Interestingly, in line with previous studies, the participants described many places and spaces that are connected to their ability to learn, and their experiences suggest that physical, mental, social, and existential dimensions of health affect their learning , 39. Vieactivity . Anothers valued . “Develos valued .Finding the end of the rainbow encompassed the participants’ vision of the future and revealed what they find meaningful, their hopes, and their optimism, which are all existential dimensions of health according to the WHO. The WHO described eight existential dimensions of health associated with high quality of life: spiritual connection, meaning and purpose in life, experience of awe and wonder, wholeness and integration, spiritual strength, inner peace, hope and optimism, and faith [The theme nd faith . These end faith .Having an apple a day and Finding the end of the rainbow, the participants’ experiences and visions of their dream school consistently involved kindness in terms of friendliness, being nice, helping out, and being supportive. These findings reflect the notion of doing good for others and argument that what we teach in school today represents what we will see in tomorrow’s society [Health-promoting relationships permeate all of the themes constructed in this study. The participants’ visions of good conditions for health and learning were clearly connected to interpersonal interactions and relationships that extend beyond age, profession, and physical space. This echoes the fundamental need for social interactions and meaningful encounters with others in school to strengthen the feeling of belonging, which is instrumental in promoting health among students . Further society . Buildin society .Standing as one and Having an apple a day, the participants frequently mention maximising inclusivity. They report that activities that include everyone not only promote health and well-being but also strengthen the dedication to and actualisation of equality, which may likely increase creativity and collaborative learning. These findings revealed that health-promoting activities supported student learning in traditional school subjects, which can be compared to earlier studies [In the themes  studies . They su studies . A socia studies . School  studies . This is studies .Standing as one highlights the need for caring relations in school not only promotes students’ health and learning but is also positive for professionals – a win-win situation for everyone.The agency recommends an inclusive and safe climate with positive relationships and a school culture that promotes learning. The theme Based on the findings of this study, to increase students’ health literacy, we suggest including health education as a mandatory subject or a distinct part of other subjects in Swedish school curriculums and making student participation and staff collaboration a priority in schools in the Arctic region. The concept of health literacy, as described by the World Health Organization , can be Standing as one, strategies for giving students a stronger voice included taking the students’ thoughts and opinions seriously. This was described as a context in which democracy is brought into practice, which would allow students to have an influence. This aligns with the arguments that an ethical and open school community in which everyone has an equal voice will enable health education to promote health literacy of [In Finland, the national school curriculum includes mandatory health education to increase students’ health literacy , 55. Thieracy of .Finding the end of the rainbow, student participation was considered a natural part of school activities and educational approaches that echo both human and children’s rights. Similarly, the Universal Declaration of Human Rights [In the envisioned dream school presented in the theme n Rights  states tn Rights , states n Rights . This san Rights ,20. TherStanding as one points to students as co-creators who truly participate and influence the daily work of their school. This is similar to the arguments that there is a need for a new order of practice acknowledging the value of students’ active participation [The theme cipation . Schoolscipation . Similarcipation . Furthercipation .Standing as one and Finding the end of the rainbow emphasise that engaged teachers improve students’ social environment. Teachers’ roles in HPS development warrants further examination because teachers are the primary agents of change in academic environments but not experts in health promotion [Taken together, data from the themes romotion . Teacherromotion . Findingromotion ,63. NoneStanding as one, the participants described cooperation across professions towards promoting health and learning simultaneously in their school. Similarly, earlier research found that cooperation within the school and also between local schools facilitate the implementation of an HPS’s mission [In the theme  mission . To educ mission . Collabo mission .Unfortunately, previous research shows that the conditions that enable collaboration across occupations are lacking in Swedish schools today , Also, pFinding the end of the rainbow highlights the connection between health and learning, where fundamental values, such as democracy, equality, and inclusion, are practiced throughout the entire school organisation. Viewing health promotion as an effective way to improve educational outcomes will help to intertwine health and learning in school, as described in the Swedish national curriculum [The theme rriculum ,20. The rriculum ,5,6. Therriculum . Add tharriculum . Neverthrriculum , 66. Simrriculum .The following three implications for practices illuminate the participants’ experiences of conditions that foster good health and learning in schools. These are connected to the Swedish national curriculum and founded in democracy to address health and lifestyle issues in school , 20.1) First, for students to reach their educational goals while also feeling well, students, staff, school leaders, and parents must understand that school is where learning and health intertwine. To educate and promote health and well-being simultaneously, these concepts need to be firmly embedded in educational policies, acted on in school practices, and shared with students and parents.2) The participants’ visions of the conditions conducive for good health and learning involved interpersonal interactions and relationships that transcend age, profession, and physical space. A school-wide commitment to practicing inclusion and participation, which are health-promoting factors, promotes impactful partnerships between students and staff. A mutual understanding between the education and health sectors builds trust and the capacity to make HPSs successful within a national educational system. More cooperation among school staff across professions in school and practice-based research on this topic are warranted.3) Include health education as a single, mandatory subject or a distinct part of other subjects to increase health literacy. This focus on health literacy within the educational arena should work to prevent health problems and ensure health promotion, which are linked with improved academic performance.Finally, for HPS interventions to improve young people’s social and emotional well-being, the interventions need to be effectively adopted and integrated into school practices and sustained over time . Add tha


The Gaelic Athletic Association (GAA) is a major stakeholder in promoting smoke-free policies in Ireland. Several GAA clubs have adopted smoke-free policies, and there is a growing interest among other GAA clubs to also become smoke-free. As such, the purpose of this study is to explore the process of how GAA clubs adopt, implement, and enforce smoke-free policies in order to discover best practices that other clubs could replicate. Representatives from 15 smoke-free clubs were interviewed regarding how their club became smoke-free. Interview data were analyzed, in which four major themes emerged: (1) process , (2) barriers , (3) enforcement , and (4) impact (observation of policy compliance and decrease in cigarette litter). The study’s findings indicate a general ease of becoming smoke-free with minimal barriers. As such, the GAA should urge each club to become smoke-free and to use the effective methods used by current smoke-free clubs for communicating and enforcing smoke-free policies. Smoking is a major public health problem in Ireland. It is the leading cause of preventable death, killing over 5000 Irish people each year, which is nearly one out of every five deaths ,2. Each An evidence-based approach to reducing and preventing smoking is to implement smoke-free policies. The World Health Organization recommends the implementation of policies that ban smoking in indoor and outdoor areas . FortunaA key stakeholder in promoting smoke-free policies in Ireland is the Gaelic Athletic Association (GAA). The GAA was founded in 1884 in order to encourage Irish people to play sports that were traditional and indigenous to Ireland. Today, there are over 1600 GAA “clubs” located across each of Ireland’s 32 counties, and another 400 international clubs set up by Irish diaspora. Clubs are located in Irish communities and consist of administrators, community volunteers, athletes, and sporting grounds that promote the sports of hurling, Gaelic football, handball, rounders, ladies football, and camogie among all age groups. Clubs also encourage Irish culture, including the use of Irish music, song, dance, and the Irish language. In all, GAA clubs are an influential force within Irish society ,6.In 2013, the GAA’s Community and Health Department (CHD) began the Healthy Club Project (HCP). The GAA’s HCP has partnered with Healthy Ireland, the Health Service Executive (HSE), the National Office for Suicide Prevention, with Irish Life as corporate social responsibility partners, with an aim to “make every GAA club in Ireland a hub for health, capable of providing their members and communities with programs that support their physical, emotional, and social wellbeing” . One of The HCP’s goal of GAA clubs becoming smoke-free is in alignment with the European Healthy Stadia Network’s recommendation for smoke-free stadiums. The European Healthy Stadia Network  was formed during the 2000s by several sports stadiums in the United Kingdom that were implementing public health programs and policies to improve the health of players, fans, and surrounding community members. This movement was later funded by the EU’s public health programme and formally established Healthy Stadia with the purpose of advocating and providing resources, for sports stadia to become environments that promote health . One of Unfortunately, there is limited research regarding the process of how sporting facilities become smoke-free. Several studies have assessed the public’s approval of smoke-free stadiums in various countries ,13,14,15Given the strong influence of GAA clubs in Irish communities, the growing interest of GAA clubs to become smoke-free, and the general lack of research on this topic, there is a need to study how smoke-free policies have been adopted by GAA clubs. By doing so, best practices can be discovered for other clubs to effectively transition to becoming smoke-free. As such, the purpose of this study is to explore the process of how GAA clubs adopt, implement, and enforce smoke-free policies, while also discovering any barriers that clubs experienced in that process.Club representatives who were familiar with how their club became smoke-free were recruited via e-mail or telephone from contact information that was provided by the GAA HCP. Individuals from 15 smoke-free clubs agreed to participate in the study. The participants included nine health and wellbeing officers, three healthy club committee members, two chairman of healthy clubs, and a club treasurer. Those that participated in the research study were from clubs that reflected a broad representation of all the GAA’s clubs in Ireland in terms of location and size. Specifically, the clubs were from urban, rural, and suburban areas, with a membership bridging from the hundreds to the thousands. Before recruitment and data collection took place, the Institutional Review Board (IRB) at Appalachian State University, in Boone, North Carolina, reviewed and approved the ethics of the research project’s methods.Interviews were conducted one-on-one, in person and by telephone. The interviews were recorded and then transcribed verbatim. All identifying information was not included in the transcriptions. The study’s interview questions were formed through discussion with the GAA HCP leadership and included the following items: (1) How did your GAA club became smoke-free?, (2) Did the club experience any barriers when trying to become smoke-free?, (3) How do you communicate your smoke-free policy and any smoking cessation resources?, (4) How have the members in your club felt about the club becoming smoke-free?, (5) Do you think the policy has been effective in reducing smoking in the clubs?, (6) Do you think that people are complying with the policy?, and (7) How is the policy enforced? After transcribing the data, two researchers immersed themselves in the data by reading the interview transcripts several times during and after data collection . During There were four distinct themes that emerged from the data, including Process, Barriers, Enforcement, and Impact.Theme #1: ProcessOverall, participants described a common process of adopting a smoke-free policy. This process tended to include joining the HCP, forming a committee, and then discussing a smoke-free policy among committee members and club leadership. Some of the clubs did not seek outside resources in this process:“We first joined the Healthy Club [Project] group, and then as part of that, we decided to become smoke-free. So to do that, we got buy in from members, club executive, and basically plowed on from there.” - Participant #1“We would have monthly meetings as a committee like and going completely smoke free had come up a few times and then we just decided that we were going to do it.” - Participant #14“…we discussed ideas just at the health and wellbeing committee, just discussed it (going smoke-free) causally. Just at our own committee stage and then in November, we brought it to the Senior Executive of the club and we discussed it there and weighed out the pros and cons and discussed problems that could happen. You know the impact that it would have on the older members of the club who have been coming along to the games for years and then suddenly have this (smoke-free) policy thrown upon them. So, we did debate it out and revisited even just causally among members after that, and then with a plan in a May to go through with it.” - Participant #7Several clubs used available resources when developing a plan to adopt a smoke-free policy. These resources included encouragement from the GAA’s HCP leadership, other smoke-free clubs, and local general practitioners:“We formed a committee and the majority of the votes were in favour for the smoke-free club, so then we just followed the guidelines given to us by the Healthy Club (Project).” - Participant #11“We were the first (club) in our own county to do it, so I suppose we just put a plan together ourselves. We had our own little team we put together and I would have received some kind of information from St. John’s down in Wexford at the time. I was chatting to the guys there on how they implemented it (smoke-free policy) on their end, you know just did up a rough plan of how we were going to implement it then and basically get approval before we could go forward from it…We would have had the resource there from the wellbeing team in Croke Park. There was a few clubs at the time that were doing it as well, so we were able to bounce ideas off each other.” - Participant #9“So, we first applied to be a Healthy Club and, once we got approved, we decided that one of our goals would be to go smoke-free. One of the things we did was reach out to the local GP  and pharmacies. So, they would have been on board along with the GAA committee and we created our own committee for the healthy club and we voted on the goal of smoke-free.” - Participant #14After adopting a smoke-free club policy, several clubs then communicated the new policy to club members and the local community. There were a variety of ways that clubs communicated the policy, including the use of social media , using the intercom during matches, sending e-mail and text messages to club members, handing out cards/flyers, posting smoke-free signs provided by the GAA, relying on word-of-mouth, and communicating through local newspapers: “We had one big match and we just said on the intercom there that we were a smoke-free club and to go (smoke) outside the gates.” - Participant #2“We gave out little cards at the gate to remind people that the park is smoke-free. We also partner up with the visiting team and get them to put up a notice on their Facebook wall as a reminder that the club is smoke-free.” - Participant #6“First of all, we focused on total membership by texting the members and using the Facebook wall. We were also on the local papers.” - Participant #1“We had a combination of using social media and then sending out messages to our members. As for now, it’s more of we have the (smoke-free) signage up...” - Participant #11In addition, several clubs hosted a “launch” event to draw attention to the policy from club members, communities, and the media. Some of the launch events included having a ribbon-cutting ceremony, inviting speakers to give presentations, and hosting an anti-smoking coloring competition for young club members: “Like we had a launch date and made a big thing of it. So, we got the minister to come down and Aoife from the Healthy Club [Project] in Croke Park came and we got other people from the HSE to come and the local doctor and we had a launch. They each spoke and gave a little presentation. We involved the school as well; we had an art competition.” - Participant #2“When it was implemented the HSE then got involved along with a few other groups and they set up a few stalls on the day of the launch and had displays of how smoking affected people’s health. We also had a local doctor come along and provide a medical opinion on how smoking negatively affects the body.” - Participant #13For several clubs, part of the process of adopting and implementing a smoke-free policy was also to communicate smoking cessation resources to those who smoke, including online resources and quit-lines. However, a few participants stated that there was a low level of interest by smokers in terms of accessing smoking cessation resources:“The Healthy Club [Project] has given us lots of information, posters, and cards on quitting. The local GP and pharmacies are big into it and have lots of support. They always have cards with ways to quit and things. But, yeah, we do have numbers up in the club house and national quit line up on the board as well. So the numbers are there if they want them along with cards if they want to quit.” - Participant #3“We have it [smoking cessation information] on the wee cards as well. It says we are smoke-free, thank you for not smoking. For more information on quitting, go to wanttostop.info. So we have that on the wee card. We have on the social media resource along with other things. There’s a link under health and wellbeing; there’s a whole list of telephone numbers for quitting tobacco and alcohol along with other things.” - Participant #6“We did consider running a smoking cessation course through the HSE but we didn’t get much of an uptake from it.” - Participant #14Theme #2: BarriersRegarding barriers to becoming a smoke-free club, several participants expressed that they did not experience any barriers to overcome in order to adopt a smoke-free policy:“…we didn’t really come to any barriers when implementing the club. Everyone thought it was a good idea to go smoke-free since we were joining the healthy club program.”- Participant #1“When we put it (the smoke-free policy) to the committee, there were no problems, they thought it was a great idea to go smoke-free.” - Participant #2“We thought getting through the committee meeting would be harder because there are some smokers in the club. But, no, there wasn’t too much fuss about us going smoke-free.”- Participant #3Of the clubs that did experience barriers, a common experience was the opinions and behaviors of club members who smoke. There were a few specific populations that were mentioned in the interviews, including smokers who were older in age, caretakers, and others:“…we have a number of old folk events which would include card night and an afternoon kind of event for them and they would be smokers and they are not going to stop smoking like, so, we knew that was always going to be a problem.” - Participant #15“The caretakers were a barrier; we knew they would be the most difficult part. But, we didn’t really allow them to have a say in anything so it wasn’t too much of a barrier. They go outside now to smoke and its fine.” - Participant #5“We had one or two people who weren’t in agreement within our own club who said they find it very frustrating, like, they would be great supporters of the GAA, and the thought of them going to a match and not have their one or two cigarettes there.” - Participant #12Another barrier was the presence of bars that are connected to clubhouses. One participant noted the difficulty of having a smoke-free policy when people are drinking at the bar and go outside of the bar to smoke: “The only time that you see smoking in our club is when there is an event on when the bar is open and you’ll see people go out for a puff then, but generally speaking, you wouldn’t see it in our club.” - Participant #8One participant also stated that barriers to a smoke-free policy were the possibility of making exceptions to the policy by allowing smoking in certain zones in the club or allowing the use of e-cigarettes. At the time of the study, e-cigarette use was not banned in public places, unless an organization voluntarily banned e-cigarettes on its premises:“When we would discuss it, people would be saying, ‘Oh, you know, are we going to have a smoking zone? Like, it’s not fair now for people to come up here and have nowhere for people to smoke.’ Just sort of negative little digs. So, to overcome them, the first couple of times I was going like, ‘Yeah, you’re right, maybe you’re right, maybe we should have a smoking zone.’ But then, the more I thought about it, we have agreed to be a healthy club and be a part of the initiate and it’s for the good of everybody and 99% people support it. The vast majority of people want it so you just have to go with the majority and will what you think it is right.” - Participant #7“The only thing that has come up is the vaping. Can you vape? But, I had to think on my feet a little and just said no to the vaping as well, because it’s about the image and the message you’re sending out as well. No smoking of anything in the club.” - Participant #7Club representatives expressed that a common barrier to their smoke-free policy was visitors and umpires who are unaware of the policy; however, when politely confronted, most visitors become compliant to the policy and stop smoking:“We have had a few visiting people that have persisted smoking, but more so because they didn’t notice the signs, and when brought to their attention that we were a smoke-free club, they stopped.” - Participant #1“...I find that most people (who violate the policy) are people from other teams and although there are signs up, they don’t actually notice them, and then straight away, they are apologetic and say they didn’t notice.” - Participant #2“There was a visiting team and the umpire was smoking at the goal post and he politely asked to put it out and he gave back some verbal abuse. It was one of our club members who asked, and she just said, ‘You know this is a smoke-free club, do you mind putting it out?’ And he not so politely said, ‘Go away.’ But, he did eventually did put it out.” - Participant #6“…like there was an umpire smoking there just the other day and I had to approach him and tell them, and in fairnesss, he just didn’t know so there were no problems.” - Participant #15Theme #3: EnforcementSeveral clubs enforced their smoke-free policy through a community-based style of enforcement. Specifically, the entire community of players, coaches, administrators, and parents were expected to kindly inform those who smoke that the club is a smoke-free environment:“Most parents and even the kids now are aware of it now so if someone does smoke on site, someone is quick enough to come to one of the committee members or approach themselves and tell them (the policy violator) that this is a smoke-free zone, and so it’s been very positive. I have even seen a child go up to someone smoking and telling them that they aren’t allowed to do that in the club. So, I think it has been very effective.” - Participant #1“It’s (enforcing the policy) just really on ourselves. If someone sees someone smoking, they will say something to them. I know there myself I saw somewhere there recently and said something, but like there’s never a huge problem with it.” - Participant #5“Generally any of the members, if they see anyone smoking they just say we’re smoke-free, you know. Just everyone’s responsibility.” - Participant #14Others stated that only the Healthy Club committee had the responsibility for enforcing the policy:“Well, there is a committee of about 20 and we made it primarily their business to enforce it.” - Participant #6“It’s the Healthy Club committee really so we take it (enforcing the policy) in turns, depending how big the match on is. For the smaller events, you’d only need two or three.”- Participant #2The clubs that enforced their smoke-free policy also clarified that when people enforced the policy, they were intentionally non-confrontational and very polite to those who violate the policy: “When we do (enforce the policy), it’s just kind of like a gentle reminder.” - Participant #10“We are no smoking and we are not going to ram it down your throat. We are going to carefully encourage it and make people aware of it.” - Participant #12“We all said that it would be the responsibility of everyone is the club from the players, parents, and committee members to just politely just say to people, ‘Sorry, don’t know if you are aware, but this is a non-smoking club.’” - Participant #9On the other hand, there were clubs that did not actively enforce their smoke-free policy, which may have been due to people feeling uncomfortable approaching smokers to inform them of the policy:“Well, you see, initially, we would have gone up to people but we haven’t really in the past year or so. We don’t have smoke wardens; even if we see someone lighting up, we won’t challenge them. It’s kind of a voluntary thing.” - Participant #4“Am I going to go up to somebody, and ask them to put out their cigarette? I’m probably not going to do that, but I would hope that they wouldn’t in respect for the policy and what we are trying to do. And you know you will always have somebody who is going to break the rules, but that’s life.” - Participant #7“And you know not everyone is comfortable saying, like, ‘Would you mind not smoking around me?’ Because it can start an argument.” - Participant #12Theme #4: ImpactBased on personal observations, those who were interviewed noticed that most people were complying with the smoke-free policy:“Most of the members have been very supportive. Members haven’t smoked on-site, as far as I am aware.” - Participant #1“Most of the time, I would say 98% of the people are in favor of it (the smoke-free policy). We have had very little complaints or objections. You know everyone, there are a lot of smokers, but they do seem to go away or sit in their own cars to smoke because they know the club is smoke-free.” - Participant #3“Now, there’s no point in saying that it would be completely smoke-free zone, that is not the case. You will some people lighting up, but it (the smoke-free policy) has definitely reduced it.” - Participant #4“…that’s becoming more evident than at the start, there would be certain areas where there would be cigarette butts, but now it is less and less. I don’t know when the last time I saw any (cigarette butts), and I go in there (the club grounds) every evening.” - Participant #1“So, as for the grounds, the litter has decreased, but there’s still some outside of the gates.”- Participant #2“Oh yeah, there has definitely been a reduction in the (cigarette) litter.” - Participant #10As an additional indication of reduced smoking, the participants also noticed a reduction in the amount of littered cigarette butts on the club’s grounds:Several practical findings resulted from exploring how GAA clubs adopt, implement, and enforce smoke-free policies. First, given the ease that most clubs experienced in transitioning to a smoke-free club, and given the effectiveness of such a policy, the GAA HCP should urge each club to become smoke-free. Although only a small sample of smoke-free clubs were included in the study, it can be assumed that other clubs that become smoke-free would experience similar positive effects in regards to adopting a smoke-free policy, as well as observing a decrease in smoking behavior and second-hand smoke exposure. For the most part, the clubs involved in this study experienced a straightforward transition in regards to becoming smoke-free. Club leaders observed strong support from within the club, support from resources outside the club, and minimum barriers in the process of becoming smoke-free. As such, this study suggests that any apprehension about pushback from the community members within GAA clubs may be unfounded. Moreover, clubs considering smoke-free policies may plan ahead of time to develop a plan to deal with common potential barriers.Second, it appears that current methods used by clubs for communicating and enforcing smoke-free policies are effective. Specifically, clubs considering the adoption of a smoke-free policy should consider hosting a smoke-free launch event that includes the community, especially young club members, media outlets, and well-known local people . Clubs should also plan to use established methods to inform the community and visitors about the smoke-free policy . Thorough communication of a new smoking policy was also echoed by Healthy Stadia in its case study of the smoke-free 2016 UEFA European Championships that were held in France .In terms of policy enforcement, potential smoke-free clubs should plan to use a friendly, non-confrontational method of enforcement carried out by club leaders and/or the entire club community. Although previous international research indicates that those who attend sporting events in smoke-free stadiums tend to comply with the policy ,19,20, eFinally, potential, and already established, smoke-free clubs should consider making smoking cessation resources available to club community members. Although the findings suggest that smoking cessation resources were not popular among those trying to quit smoking, one of the World Health Organization’s recommended evidence-based strategies to increase quit attempts within a community is warning people about the dangers of smoking and also making cessation resources available . The limitations of the study’s methodology should be considered when interpreting the findings. As with all qualitative data, the themes that emerged from the interviews cannot be generalized to all GAA clubs; however, qualitative findings may be “transferable” , meaningThe findings from this study strongly suggest that there is a general ease of GAA clubs becoming smoke-free, and that smoke-free policies are effective and fairly easy to enforce. As such, given the harmfulness of tobacco smoke and its negative impact on Ireland, the GAA should urge each club to become smoke-free and to use the methods used by current smoke-free clubs for communicating and enforcing smoke-free policies. Ultimately, this would help to support the vision of the Irish government for a healthy, smoke-free Ireland . From a