The aim of this study was to identify the most common barriers and facilitators physicians perceive regarding their role in the promotion of mobility in older adults hospitalized for medical illness as part of on an intervention to promote mobility. Twelve physicians at two medical departments were interviewed face-to-face using semi-structed interviews based on the Theoretical Domains Framework. The physicians’ perceived barriers to promoting mobility were: the patients being too ill, the department’s interior does not fit with mobility, a culture of bedrest, mobility not being part their job, lack of time and resources and unwillingness to accept an extra workload. The facilitators for encouraging mobility were enhanced cross-professional cooperation focusing on mobility, physician encouragement of mobility and patient independence in e.g., picking up beverages and clothes. The identified barriers and facilitators reflected both individual and social influences on physicians’ behaviors to achieve increased mobility in hospitalized older medical patients and suggest that targeting multiple levels is necessary to influence physicians’ propensity to promote mobility. In older adults >65 years), low levels of mobility and excessive bed rest during hospitalization have been linked with decreased independency after discharge, institutionalization, readmission and death ,5,6,7,8. years, lInterventions seeking to increase mobility in older medical patients may have the potential to improve function, shorten length of stay in the hospital and lower institutionalization rates ,17,18. HTo increase the likelihood of successful implementation of a mobility intervention, it can be beneficial to tailor the intervention to the context and take all relevant barriers towards change into account . FurtherThe present study is part of the WALK-Copenhagen project (WALK-Cph), which was designed employing a user engagement strategy and thereby tailored to its context and stakeholders. The methods of WALK-Cph have been described in detail elsewhere . BrieflyIn several studies, a physician’s advice has been shown to be effective in promoting exercise among older adults in primary care ,29,30. AThis was a qualitative study using face-to-face semi-structed interviews  to exploTheoretical grounding of implementing interventions to influence behavior in health care professionals is important to assist in understanding and explaining how and why implementation succeeds (or fails) . The TheBetween one and five open questions were developed to address each domain of the TDF, adding to a total of 29 questions . All infPrior to data collection, the interview guide was pilot tested with a non-affiliated geriatrician. This resulted in changes in the wording of some questions to improve understandability and removal of certain questions that appeared to be redundant  at two hospitals (X and Y) in the Capital Region of Denmark. Most patients admitted to the two intervention departments are acutely admitted older medical patients. The two departments are similar in size and staff composition. Department X has 24 beds and 36 staff members  with responsibilities in the department. Department Y has 25 beds and 37 staff members  with responsibilities in the department). All physicians in the two departments are either geriatricians or medical physicians, who provide hospital-based care. At the two hospitals, the therapists are organized differently and have different links with the departments. At Hospital X, the therapists are organized into a separate department and visit Department X to attend to referred patients. At Hospital Y, three physiotherapists are a part of the Department Y staff. We used a purposive sampling strategy with the criterion that all participants were physicians from one of the two intervention departments . We aimeTwo researchers from the research group (J.W.K. and M.M.P.) performed 12 interviews between February and June 2018. Both had previous interviewing experience and a comprehensive understanding of the target behavior. The interviews were conducted in the participating physician’s department in an undisturbed office. Each interview lasted approximately 30 to 45 min and was conducted in Danish. The interviewers conducted the first two interviews together to provide mutual feedback and thereby ensure consistency in interviewing. The remaining 10 interviews were conducted individually. The interviews were audio-recorded and transcribed verbatim after each interview by one of two research assistants. Throughout the data collection period, transcriptions were read by the interviewers to identify inadequate domain coverage so that the interview guide could be refined if necessary. Fortunately, this was not necessary. The transcripts of the interviews were assigned with a code number to allow tracking and development of a coding approach.We conducted a qualitative directed content analysis with a focus on manifest content ,43,44. AWe analyzed the interviews using a directed content analysis as described by Hsieh and Shannon  and deduAs stated, the aim of the analysis was to identify the barriers and facilitators that were most common. Therefore, inspired by Hsieh and Shannon , we consFor example, under the “Beliefs about consequences” domain the responses “I think it’ll be the effect of a physician mentioning it”, and “Well, I have to say, if I talk about it, being a physician, then I think that for a busy nurse it will be prioritized a little more. Or maybe it’ll put a focus on remembering mobility” were grouped under the belief statement “Patients and staff will focus more on mobility if the physician mentions mobility”. The frequency of occurrence of meanings units within each belief statement across all interviews was counted. Another researcher (J.W.K.) subsequently reviewed the belief statements to confirm these.Prior to each interview, we provided information about the background, aim and methods of the study. Oral and written informed consent was obtained from all physicians according to the Helsinki Declaration. We ascertained full anonymity throughout the whole analysis process by allocating an ID-number to each physician instead of using their names. The physicians’ names were only accessible to the members of the research group. According to Danish law, ethical approval is not mandatory for studies not involving biomedical issues and was, therefore, not obtained. However, each interview was conducted by taking the situational ethics into account—e.g., by considering the context’s specific circumstances . Thus, bNone of the research members had a working relationship with any of the participating physicians. The study was approved by the Danish Data Protection Agency .n = 2); (2) 5–10 years (n = 2); (3) 10–20 years (n = 2); and (4) +20 years (n = 6).Twenty physicians were invited to be interviewed and twelve physicians accepted the invitation . Six of the physicians were employed at X and 6 at Y. The physicians’ working experience ranged from little experience to extensive experience. Their years of experience were as follows: (1) <5 years .After the consensus discussions on the meaning units abstracted from the 12 interviews, consensus was obtained for a total of 411 meaning units covering the 14 domains of the TDF. All 14 domains of the TDF were represented in the physicians’ responses regarding mobility. When inspecting the number of responses within each domain, however, the domains Knowledge, Social/Professional role and Identity, Beliefs about consequences, Optimism and Environmental context and resources each contained at least 5 percent of the total responses and were, therefore, as mentioned, defined as domains of high importance . In totaThe meaning units were grouped into 26 belief statements with similar underlying beliefs . All belief statements and examples of meaning units for the 5 high importance domains are presented in For example, the following statements were coded under the domain “Beliefs about consequences”: “Cross-disciplinary co-operation will be strengthened for sure, because when we prescribe… focus will be put on mobility and we will discuss it. no doubt, it will strengthen our focus and cross-disciplinary co-operation”.“It’s not at all unlikely that it (red.: Prescription of WALK-plans) will lead to more communication between physicians and physiotherapists. If one has prescribed intensive mobility and the physiotherapist thinks that the patient is unable then, of course, there’ll be communication about it”. Both statements were considered to reflect the same overarching belief that the intervention would induce improved cross-professional cooperation. Additionally, the following statements, which were considered to reflect opposing views on the same overarching belief, were grouped together under the “Optimism” domain as a belief statement regarding a belief or disbelief in the effect of the intervention: “I have my doubts (red.: about the effect of the intervention). I have my doubts. I have my doubts…”. “I have a lot of positive thoughts about it (red.: the intervention). And hmm, I will not doubt your knowledge that a higher degree of mobility during hospitalization probably will expedite discharge and better the prognosis for the patient”. n = 8)  . Knowledn = 8). Some also underlined the necessity of explaining the importance of mobility to patients and relatives, as well as clarifying for patients what they can do while being hospitalized (n = 3). Thus, the physicians were knowledgeable about the intervention and its purpose and found instructions to and knowledge sharing with patients necessary.Furthermore, the majority was aware that inactivity during hospitalization increases the risk of functional decline and the risk of hospital-acquired side effects, and that mobility is important to counteract these possible negative effects (n = 4), although bed rest for some patients and relatives seems to be a part of a cultural understanding of what comes with being hospitalized, and some patients, therefore, consider their bed a “safe nest”.As regards the Social/Professional Role and Identity domain, several belief statements evolved: “Bed rest is part of a cultural understanding of what comes with being hospitalized, but patients respect the physician’s words”, “Physicians do not focus on mobility and it’s not their task”, “The communication between physicians and physiotherapists is non-verbal” and “The physiotherapists should assess mobility potential, but the nurses are the main staff in mobilizing the patients”. Firstly, one third of the physicians was confident that patients respect and follow physicians’ recommendations and would be active if a physician told them to be (n = 6), and some physicians (n = 5) clearly expressed that focusing on functioning, mobility and getting patients out of bed was not a job to be undertaken by physicians (n = 5). One informant said:The physicians were aware that getting the patients out of bed was difficult due to both physical and cultural challenges, and they were confident that the chances of getting the patients up and about were better if encouraged by physicians, as prescribed by the intervention. However, in practice, they did not encourage the patients and did not find this a part of their tasks; they considered this to be a task for other health care professionals. Half of the physicians expressed that their focus as a group was not on mobility and getting the patients out of bed, but on medications, diagnostics, getting the patients well and on discharge . If they’re admitted with pneumonia or diabetes, then that’s what we’ll concentrate on”. n = 2):However, a few felt that the physicians could play a role in motivating patients n = 4). Cooperation between nurses and physicians was considered well-functioning, whereas cooperation with the physiotherapists was mostly on a more non-verbal level, through journal notes and prescriptions (n = 5). Additionally, there was a clear perception of the necessity of physiotherapists, as opposed to nurses and physicians, to evaluate the patients’ mobility status. Partly because physicians only see snapshots of the patients’ days, whereas the physiotherapists see them daily. However, the nurses were considered the main staff in getting the patients out of bed (n = 8). One informant expressed:To the physicians, their job was to prescribe mobility and let physiotherapists and nurses follow up Thus, the physicians had a clear view on the different roles of different health professionals. They expressed that one challenge in increasing mobility might be a cultural understanding that bed rest is part of being hospitalized. They were confident, however, that patients respect and abide by the physician’s words. They also expressed that physicians do not consider patient mobility one of their tasks, and should not focus on functioning, mobility and getting patients out of bed—this should be undertaken by physiotherapists and nurses following physician prescriptions.n = 6), leading to faster and better evaluation of the patient’s abilities to the benefit of the patient. Additionally, some expressed that both patients and staff would be more inclined to focus on mobility if the physician mentioned the importance of mobility (n = 4), whereas one physician believed that the effect would be equally as good if presented by a nurse or a physiotherapist. The Beliefs about Consequences domain revealed the following belief statements: “The intervention will cause improved cross-disciplinary cooperation”, “Patients and staff will focus more on mobility if the physician mentions mobility”, “The intervention will have/will not have positive effects”, “Prescription of WALK-plans will give the physicians more work to do”, and “The physicians will not do it by themselves” . The phyn = 5), and on the other hand, they found that only a minority of their patients would be well enough to comply with the intervention and some would be confused by too much activity in the hall ways (n = 4). Furthermore, one third of the physicians expressed concerns about the extra workload in prescribing WALK-plans and believed that they would only do their part of the job if either a nurse or a physiotherapist reminded them to do so (n = 4). The physicians expressed conflicting beliefs about the effect of the intervention. On one hand, they found that the intervention would enable patients to get out of their beds at an earlier stage and recover faster . They expressed that movement is important and that the intervention would be able to put a focus on mobility. Nevertheless, they doubted that enough resources were available. Furthermore, half of the physicians expressed that the intervention would result in enhanced mobility and prevent loss of function and readmissions (n = 6). However, two of these physicians expressed doubts about an effect on mobility and an effect of prescribing WALK-plans (n = 2). Likewise, one physician found it unrealistic to expect relatives to help (n = 1), and another expressed that self-service on clothes would be an infectious time bomb (n = 1). Additionally, the physicians doubted that patients in their department, who were believed to be more and more ill, would be able to carry out the intervention (n = 5). Several physicians were opposed to having the responsibility for prescribing WALK-plans due to lack of time, an opposition to adding more to the physicians’ work-load, prescribing something evident and adding more things to register in the electronic patient journals (n = 6) and found it unrealistic to think the physicians would remember the prescriptions:In the Optimism domain the following six belief statements evolved: “The intervention is relevant and important”, “I believe/I doubt that the intervention will be effectful/have an effect on mobility”, “The patients are too ill/unable to comply with the intervention”, “It is unrealistic to think that the physicians will prescribe / Prescription is a good idea”, “It’s positive to plan cross-disciplinarily” and “It’s a good idea to use colors on the WALK-plans / The WALK-path is visually appealing” . Three o“Prescription of mobility will be neglected very quickly—first comes medications, blood samples, food etc. So, I do not think a prescription is enough – I think it’ll be thrown into the corner”. n = 4). Furthermore, one third of the physicians found cross-disciplinary evaluation of patients with regards to WALK-plans to be good for cooperation between nurses, physicians and physiotherapists (n = 4).On the other hand, a few said it was worth the try and a good idea The physicians were optimistic about the relevance of the intervention, but were uncertain about the effect on mobility, since they found the patients too ill, and were uncertain about whether they would take time to prescribe mobility. They were also optimistic about cross-disciplinary planning and about using colors to indicate levels on WALK-plans.n = 10), which would be forgotten in the everyday bustle and downgraded compared to other tasks—i.e., dispensing medicine (n = 7). However, some stated that it should be feasible and just be a matter of taking the time (n = 4):As regards the Environmental Context and Resources domain the belief statements were: “Due to lack of time, mobility will be forgotten in the bustle”, “The interior of the department does not fit with mobility”, “The patients are too ill”, “The physicians only see the patients very briefly and need the physiotherapists to evaluate function”, “We only get a snapshot of the patients because they have to be discharged fast”, “Too much time is used in front of the computer”, and “Self-service on clothes can spare time but is against regulations and a contagious bomb” . A gener“Most physicians are busy doing rounds on a lot of patients but telling a patient that it would be beneficial to get up and walk a bit, I mean, if that’s all you have to say and not much more, it only takes 20 s. So, it should be possible to take out time for that, I guess”. n = 10). One expressed it this way:Most of the physicians believed that the department’s interior did not fit with a wish to enhance mobility due to uninspiring and faulty décor, and lack of space, which would make the patients insecure in the hallway n = 2). In addition, some of the physicians found the patients admitted to the department were too old and ill to focus on mobility (n = 3). A few, on the contrary, expressed that there was room for walking in the hallway and a WALK-path would be used (n = 4), partly because the physiotherapists should hand out walking aids, and partly because the physiotherapists know more about the patients’ functioning and have more competencies in evaluating function than the physicians, who only come by on supervision (n = 4).Additionally, some physicians expressed that they only see the patients very briefly due to how they are organized (consulting patients in more departments). Therefore, they depend on an assessment by a physiotherapist prior to mobilization (n = 3), along with an excessive amount of time spent in front of the computers (n = 4). Thus, the physicians agreed that they lacked both time and resources, and spent too much time in front of computers, which is why they would forget about mobility. They expressed a need for physiotherapists to evaluate the patients’ function, since they only saw the patients very briefly themselves. They also found the department unfit for mobility, but believed that self-service could spare time.The fact that the patients are discharged quickly, partly for economic reasons, was a factor believed to counteract a focus on mobility , and they doubted that the department’s interior was suitable for promoting mobility . They expressed conflicting thoughts about the likelihood that their patients would be able to follow the intervention and that sufficient resources were available . Despite a belief in a physician effect, their focus was on other tasks—i.e., medication, diagnostics and discharge , and they believed that lack of time and resources would hinder a physician focus on mobility . Several physicians were also opposed to putting more workload on the physicians’ shoulders and doubted that they would remember to do their part of the job unless reminded to do so . They expressed mixed feelings about the responsibility for promoting mobility and did not consider functioning and mobility as part of their job , which they expected other health care professionals to handle . Particularly the physiotherapists were considered to be responsible for assessing mobility status and evaluating what could be expected of each patient, whereas nurses were considered the main staff in securing mobility, but the physicians mainly communicated with the physiotherapist at a non-verbal level . Concerning facilitators, most of the physicians expressed an awareness of the negative consequences of inactivity during hospitalization (Knowledge), and they believed that the intervention could promote faster recovery (Beliefs about consequences). They expressed that enhanced focus on mobility was important, a good idea and would prevent loss of functioning and readmission of their patients (Knowledge). They also saw the intervention as a means of improving collaboration and communication between physicians, nurses and physiotherapists , and they were confident that the patients would get out of bed if the physician told them to. The same response would be elicited by nurses and physiotherapists who would focus more on mobility if the physician asked them to do so . In this study, we used the TDF  to exploIn the present study, the physicians were aware of the necessity and relevance of focusing on in-hospital mobility. Despite a belief in a “physician effect”, they thought that nurses should be the main staff responsible for mobility after physiotherapist assessment of functioning. In line with this, nurses have previously been identified as the key health care professionals in promoting mobility in hospitalized patients as they are the health care professionals spending most time with the patients .AdditionThe physicians in the present study stated that patients respect the physicians’ words and would move about if told to do so by a physician. This is confirmed by studies reporting that older adults find it important that a physician tells them to prioritize mobility ,56,57,58Additionally, as stated by Casanova et al., the professional cultures of nurses and physicians have led to different role perceptions and an imbalance in authority, where physicians assume a directive role founded on the science of medicine, whereas nurses take on a more accommodating role with a focus on care of the individual patient—disparate roles that present challenges to effective cross-professional collaboration . HoweverThe physicians mentioned several factors that they considered barriers for patient mobility—e.g., a cultural understanding of bedrest as a part of being hospitalized, the patients’ illness, the hospital environment, lack of time and resources and professional roles . These barriers are well in line with previous studies investigating health care professionals’ attitudes and behaviors concerning in-hospital mobility in older medical patients. Barriers for patient ambulation have been reported to be lack of time and staffing ,31,33,63Additionally, the physicians stated that much time was spent on administrative tasks in front of computers at the expense of other tasks. According to Danish law, physicians are required to register all treatment and contacts in the patient’s electronic journal. In 2017, a new Health care Platform for all registrations was implemented, and therefore, extensive changes were made to the workflow regarding journaling—i.e., the physicians should now register all their actions directly in the electronic journal instead of asking a secretary to transcribe what had been dictated. This change has led to physicians spending more time on journaling than previously. This study has several strengths worth mentioning. Firstly, the study uses a validated theoretical framework as the basis of investigating physicians’ barriers and facilitators for promoting mobility in older adults. This framework provides a satisfactory theoretical coverage of potential implementation determinants—i.e., barriers and facilitators to successful implementation of practice changes, therefore providing a relevant basis for developing the interview guide . SecondlThe study has several limitations, which should be considered when interpreting the findings. Firstly, we saw a low initial agreement between coders , which can be a sign of complex statements . After cIn conclusion, we used the Theoretical Domains Framework to investigate the barriers and facilitators of physicians concerning mobility in hospitalized older medical patients. The physicians expressed barriers for mobility in older medical patients to be patients who are too ill, an unfit department, a culture of bedrest, professional roles and responsibility , lack of time and resources and unwillingness to accept an extra workload. The facilitators for mobility mentioned by the physicians were enhanced cross-professional cooperation focusing on mobility, physician encouragement of mobility towards other health care professionals as well as patients  and patient self-service to relieve the health care professionals. These barriers reflect different system levels of influences on physicians’ behaviors, from the individual physician  and the profession  to the broader context in which the physicians work . Thus, it is recommended that future interventions aiming to increase mobility in hospitalized older medical patients should target multiple levels to influence physicians’ promotion of mobility.


While a few physicists have designed new plan check automation solutions for their clinics, fewer, if any, managed to adapt existing solutions. As complex and varied as the systems they check, these programs must gain the full confidence of those who would run them on countless patient plans. The present automation effort, planCheck, therefore focuses on versatility and ease of implementation and verification. To demonstrate this, we apply planCheck to proton gantry, stereotactic proton gantry, stereotactic proton fixed beam (STAR), and IMRT treatments.PACS numbers: 87.55.km, 87.55.Qr, 87.55.T‐, 89.20.Bp I.basic.net, and visual basic 6.0. The need for a meta‐check (a check of a check) was already clear to these authors, who had one of their modules, called “RTP‐filter”, check the work of the other, “LEX”. Another, even larger scale automation effort followed in Yang et al.Efforts to automate plan checks began even before electronic charts were utilized.In spite of these efforts, highly trained and educated physicists of most departments continue to spend large amounts of time manually cross‐checking numbers between planning and record and verify (R&V) systems. At our institution, physicists cross‐compare a plan PDF, uploaded into MOSAIQ R&V, against the latter and against an in‐house treatment planning data base (TPDB). Manual checks prevail because considerable upfront effort is required to build, adapt, and test automations for specific combinations of continually evolving platforms and modalities.The present automation effort addresses this difficulty by placing much more emphasis on versatility and ease of implementation and verification. Our solution, planCheck, is a universal framework for organizing, acquiring, checking, and displaying data, as well as for verifying integrity of checks. Versatility of plan data acquisition is afforded by a robust PDF parsing facility, given that all planning systems output PDF reports. Versatility and strength of software verification is afforded by a universal facility for failure mode analysis. With over 11 different types of radiation treatments, six planning systems, four vendors, and proton therapy technology that spans multiple eras, the workflow environment at our institution is as good as any to test planCheck's versatility. We currently use it for initial, weekly, and final checks of four treatment types that include both photon and proton modalities.II.A.A.1basic.net. Good programming practices alone go a long way towards ensuring its ease of implementation and adaptation. By creating a hierarchy of patient classes — general, proton, photon, gantry, fixed beam, stereotactic, etc. — we avoid code repetition through inheritance and restrict properties and methods. These restrictions appear in the design process through IntelliSense , an early debugging program that prevents the exponentially more time‐consuming usual form of later debugging.PlanCheck is written in visual To further avoid code repetition, we consolidate as much code as possible into class definitions, as opposed to object instantiations of these classes. Consider, for example, our “param” class, instantiated for each parameter as a member of either a patient class or one of its beams. In its “source” properties, param stores potentially different values obtained from different sources . Code for cross‐comparison of these values and for issuing warnings when mismatches are detected is stored in the param class definition itself, so that it is not repeated for each of its instantiations. We refer to such cross‐comparisons as implicit checks (more on this later) to distinguish them from the more customizable checks made explicit by checkboxes . The automatic explicit checks are typically more complex and involve more than simple cross‐comparison. Nonetheless, code for much of their work  is, again, not repeated for each check, and is placed in a myCheckbox class definition, derived from Microsoft's checkbox control.A.2Given a patient's unit number, planCheck lists in its top left panel see  the newePatient param values from different sources are tabulated in the Patient panel See . When deB.The goal of a plan check  is to ensure that the radiation oncologist's intentions, officially recorded in the signed plan document and R&V prescriptions, match what is to be (or has been) delivered. The plan document is typically a PDF, and is assumed here to have been uploaded into the R&V. . It is ultimately this PDF, not any DICOM RT file, that must be checked by the physicist against what is to be delivered; oncologists do not review or sign DICOM RT files.While this PDF may lack the universal structure afforded by the DICOM RT standard, this is a blessing in disguise. Detailed knowledge of the DICOM RT standard for the many types of constantly evolving treatments at our institution and of the many systems that output them is not required for the present effort. We need only develop a single set of PDF parsing tools that can then be applied to any document from any system  for any type of treatment. These tools notably include a powerful and easy‐to‐learn language for robust parsing called Regular Expressions.All that is required to run planCheck is the username and password to the R&V database, the IP address to this database, and the path to the data folder containing uploaded PDFs. The connection established with the R&V database is read‐only. However we are aware of the possibility of infinite loop readouts crashing the R&V. We have two measures protecting against such a problem. First, upgrades involving the R&V readout are always run first on a test database that is a backup copy of the clinical R&V database. Second, these upgrades are performed during after‐hours.C.One of the main objectives of verification is to ensure that planCheck does indeed catch the errors it claims to catch. It is important to realize that in‐field testing alone, however, would not be sufficient, since these errors arise at very low frequencies in the clinic. Verification, instead, requires failure mode analysis and self‐testing, as implemented below.vb.net) before running its checks. If the user checks the “Simulate errors” checkbox . This is often done by comparing displays to those of the earlier version.III.A set of explicit checks is defined for each treatment type. The next 12 automatic checkboxes in In XiO, a target structure is defined for each beam. The next checkbox determines, from the plan PDF, whether beams with the same target have the same isocenter. Note that there are legitimate exceptions to this rule, such as when isocenters for abutting beams are shifted at different “levels” of treatment to reduce overlap dose.Depending on field size, different snout sizes are used in proton nozzles. Snout changes are time consuming, and should be avoided within the same treatment session when possible. The next checkbox determines, from plan PDF, whether all beams in the plan have the same machine and snout size.When uncertainty margins are included, the range and modulation may differ from prescribed values. The next two checkboxes determine whether the difference is reasonable. The current 1.5 cm threshold on these two checks is admittedly too large, though we are awaiting recommendations from another physicist at our institution on how to refine these two checks.The next checkbox determines, from the plan PDF, whether some parameters specific to the proton XiO algorithm were set to default values.Proton snouts extend along the beam axis. In order to avoid collision, these extensions must not exceed machine dependent values. The next checkbox ensures this is the case, again using the plan PDF. Note that this check failed for the plan results displayed in When the full daily dose to a target is delivered by a single proton beam that is neither a “patch”, a “thru”, nor an “abutting” beam, this beam is called “single”; otherwise, it is called a “split”. The next two checkboxes determine whether doses and coefficients stored for the plan's beams in the MOSAIQ database make sense based on beam type.The in‐house database, TPDB, is necessary for proton planning, since it facilitates data transfer to the machine shop that fabricates apertures and range compensators. It also stores (meta‐)data on DRRs. Plan data is exported by the planners into TPDB. The next checkbox determines, by querying TPDB, whether at least one DRR was exported for each beam.The next checkbox determines, again by querying TPDB, whether the dose scaling for each beam is reasonable. The per‐beam normalization process at our institution is specific to proton beams.In contrast to photon treatments, the same proton daily dose is often delivered by different beam combinations on different treatment fractions. Nevertheless, patch‐thru beam pairs must always be scheduled together. In other words, if the planner scheduled a patch beam for Tuesday's treatment, he/she should also have scheduled the “thru” beam of the pair on Tuesday. The next checkbox determines whether these beams always appear in pairs in the treatment schedule stored in the MOSAIQ database and that the pairing is consistent. This check would be very time‐consuming and tedious if performed manually. Parings confirmed by planCheck are displayed in the bottom left panel of Fig 1. Note that the plan checked in A fiducial for stereotactic plans is typically digitized on up to three CT slices and the final coordinates are obtained through a weighting procedure. The next two checkboxes confirm consistency of the process, using the plan PDF. These two checks are specific to stereotactic plans and appear for the treatment types displayed by Figs. 2 and 3. An additional report sheet is generated for stereotactic plans, and is designated by planCheck as a data source in and of its own, called rmIso . It stores isocenter coordinates transformed to the treatment room frame of reference, a transformation needed for all proton stereotactic plans. Note that the implicit (across‐row) check of these coordinates failed  in the manual checkboxes panel of planCheck's display. Human checkers are also encouraged to occasionally use the failure mode analysis facility (the check of the check). This is only automated to an extent, of course. The user still has to check the “simulate errors” checkbox, edit in errors, and examine the results.Future efforts may involve design of quantitative methods to evaluate efficacy, but care must be taken to avoid proving the obvious. Are we proving that a human checker may forget to check a certain aspect of the plan? We all agree that they will do so in the limit of infinite plan checks. Are we proving that the errors caught by planCheck actually occur in the clinic? In our experience with planCheck, this is certainly the case. In fact some of the checks were designed with historic precedence in mind, and the reader can judge the clinical relevance of included checks (which are highly customizable) based on his/her experience.Supplementary MaterialClick here for additional data file.


School-based multi-component physical activity (PA) promotion is advocated; however, research has indicated that a multi-component approach may not always be effective at increasing adolescent PA. Evaluation of the GoActive 12-week multi-component school-based intervention showed no effect on adolescent PA. A mixed-methods process evaluation was embedded to facilitate greater understanding of the results, to elicit subgroup perceptions, and to provide insight into contextual factors influencing intervention implementation. This paper presents the reach, recruitment, dose, and fidelity of GoActive, and identifies challenges to implementation. The process evaluation employed questionnaires (1543 Year 9s), individual interviews , focus groups , alongside GoActive website analytics and researcher observations. GoActive sessions reached 39.4% of Year 9s. Intervention satisfaction was relatively high for mentors (87.3%) and facilitators (85.7%), but lower for Year 9s (59.5%) and teachers (50%). Intervention fidelity was mixed within and between schools. Mentorship was the most implemented component. Factors potentially contributing to low implementation included ambiguity of the roles subgroups played within intervention delivery, Year 9 engagement, institutional support, and further school-level constraints. Multiple challenges and varying contextual considerations hindered the implementation of GoActive in multiple school sites. Methods to overcome contextual challenges to implementation warrant in-depth consideration and innovative approaches. The health benefits of physical activity are widely demonstrated in the literature ,2. For yIn an effort to increase physical activity among young people, researchers have developed and tested various physical activity interventions, many of which have been implemented in schools. Schools are seen as a powerful site to promote physical activity programmes and interventions  due to tCapitalizing on the school site, the Get others Active (GoActive) study  evaluatePrevious research on school-based physical activity interventions highlighted the need to critically examine the delivery of each component and the processes of any complex intervention . ProcessFor GoActive, previous analysis of Year 9 participant satisfaction found that some intervention components were liked, for example, mentorship, but implementation issues undesirably impacted satisfaction . AdditioEthical approval for the process evaluation was obtained from the University of Cambridge Psychology Research Ethics Committee (PRE.2015.126). All adult participants provided written informed consent, while children (under 16 years old) gave written informed assent and their parents provided passive consent.The GoActive intervention, described in detail elsewhere ,24,25,26The trial methods were published in the study protocol , as wellDetails of all aspects of the mixed-methods data collected and the levels of response can be found in Direct observations of two GoActive sessions per school were arranged by contact teachers. Teachers were informed of when observations would take place, as well as most mentors. Data collected during observations comprised detailed notes describing what took place, where in the school setting, any informal conversation, the observed role of the mentor, teacher actions, and level of engagement from Year 9s.Website analytics included individual points logged, rewards claimed, activities selected, and messages from mentors. All mentors and facilitators were asked to complete intervention delivery logs via the GoActive website. These logs sought information on, for example, the date each lesson took place, how long it lasted, how many Year 9s were active in their participation, and any comments about the delivery of the session.Here, we present process evaluation data collected at mid-intervention  and post-intervention  . AnecdotThe T2 questionnaire allowed Year 9 students at intervention schools to indicate whether they would be happy to be contacted about taking part in an interview. Year 9 students who responded positively were provided with an additional information sheet to clarify the interview procedure .The whole-year level approach of GoActive aimed to avoid stigmatisation of targeting particular groups. The development of the intervention involved listening to the voices of people with characteristics that were deemed to be common in individuals who were hard to reach in physical activity interventions, including girls and individuals with high levels of shyness and inactivity . ParticiFocus group participants were grouped based on tertiles of website usage as a proxy for intervention engagement (150 points (high), 10–100 points (medium), ≤  10 points (low)), and purposively sampled to aim for a mix of sexes, with participants from a variety of tutor groups.All mentors, contact teachers, and facilitators were invited to interview. All teachers were provided with questionnaires via the contact teacher at the school. The number of participants and data collection methods are provided below and summarised in Quantitative process evaluation data were extracted from the student questionnaires, teacher questionnaires, and facilitator questionnaires. Website analytics were extracted from the GoActive website database more than a year after active intervention delivery had ceased . Website analytics were recorded in Microsoft Excel and imported into Stata  for procQualitative data from individual and focus group interviews were voice recorded and transcribed verbatim. Data from the observations were originally recorded in a notebook, and typed into a narrative using Microsoft Word on the day of observation.Qualitative and quantitative data were analysed separately, producing two sets of findings, and mixed during interpretation. Descriptive summary statistics  were calculated using an intention to treat approach for a number of quantitative variables.All interview data were analysed by the process evaluation lead in NVivo 12 , using aGiven the project’s multiple datasets and the need to generate an integrated set of findings, two researchers worked together to compare and integrate findings from the datasets. Initially, the findings were sorted based on the process evaluation components: reach, recruitment, dose delivered (completeness), dose received (exposure), fidelity, and dose received (satisfaction) . FindingDescriptive findings of quantitative assessments of reach, recruitment, dose delivered (completeness), dose received (exposure), fidelity, and dose received (satisfaction) findings are presented. Qualitative data provide a nuanced picture to contextualise the questionnaire data, and will be presented in the section below, alongside key quantitative results. The final section of the results will focus on the perceived challenges to intervention implementation.The reach, or proportion of participants who attended at least one GoActive session during tutor times, calculated from a self-reported Year 9 student questionnaire during the distant support phase, was 39.4%.Procedures to attract and maintain participant involvement in the intervention included rewards. On a 5-point Likert scale ranging from “Do not like it at all” (1) to “Like it a lot” (5), 38.3% of Year 9 students reported liking rewards (mean of 3.8 (standard deviation (SD) 1.4)). Additional ‘thank you’ gifts were provided after each measurement session. These included pens, earphones, mints, and stationery, which may have facilitated sustained involvement. In turn, 87% of Year 9 students were retained at mid-intervention (T2), 80% post-intervention (T3), and 76% at 10 months post-intervention (T4).The top three reasons for mentors joining the programme reported from the questionnaire data were (1) the incentives/prizes (£20 vouchers and a hoodie), (2) to be more active themselves, and (3) because a teacher encouraged them to. In the focus group discussions, mentors suggested that their continued involvement was linked to ‘fun’ and enjoyment, or the social aspect of spending time with their peers. Others stated that they believed in the aims of GoActive, and that their involvement was linked to perceptions that GoActive was ‘good for their (Year 9s) health’.The dose delivered (completeness), or the number of GoActive intervention components implemented, differed between and within schools. This was typified in interviews across Year 9s and mentors, in particular in relation to in-class peer leaders and the ability to log website points. Focus groups with subgroups explained that changes in the delivery of GoActive sessions in particular was in response to competing school priorities, which impacted resourcing, such as school space availability, a lack of time, or engagement issues. One contact teacher explained:When it’s exam season it’s exam season for [Year] 9, 10 and 11, so we had to stop for a certain point… we had to stop because of the sports hall and gym were being used and we couldn’t get the kids out during registration because their exams started at nine o’clock.The complete GoActive programme was not implemented by any school. The reported dose received (exposure) of engaging with at least one GoActive class session in the last two weeks during the distant support phase ranged from 11.2% to 63.2% between schools, as reported by Year 9s . This coInterview data indicated that the dose received (exposure) changed throughout the intervention, primarily linked to difficulties implementing the GoActive sessions consistently. Engagement with GoActive sessions varied per school, with many mentors describing boys as being more likely to engage and interact within the GoActive sessions. However, there were a number of factors that impacted student engagement. As one example, student behaviour was a constant factor that impacted others’ participation in the sessions. One mentor described (School H):A lot of the boys just like didn’t co-operate very well and they were just trying to be, like, silly with their friends and weren’t bothered.This sentiment around behaviour and disengagement was reiterated across all mentor focus groups, and in interviews with facilitators, who articulated the challenges presented to them from mentors.From the data presented in Each of the four GoActive essential elements  will be Qualitative data from individual and focus group interviews indicated that most schools attempted to implement the GoActive sessions as planned. Most descriptions of the GoActive sessions included the class going to a location within the school , and mentors facilitating an activity session. One Year 9 participant described:We normally like go into form and we get told where to go and then we meet the mentors where we were supposed to be.A Year 9 participant from School E describes a similar process:We usually just go on the field and do like rounders, football, any sport on the GoActive website, and just go on the field and do it as a form.The time for GoActive varied between schools due to contextual school differences in timetabling. Most schools used their form time (registration/tutor time) at the beginning of the day, which varied from 15 to 25 min. One school used their afternoon form time, and another school implemented after school sessions in line with their after-school clubs.Quantitative and qualitative data on GoActive sessions present dissonance between datasets. As one example, 55.4% of Year 9s from School G reported receiving at least one GoActive session in the last two weeks . HoweverAs we packed up the equipment and walked over to the gate I met one of the form tutors. In the absence of older mentors, I asked, ‘Do you have any older mentors helping to run GoActive?’ She replied ‘No’.The role of the mentor: some mentors were given greater responsibility to organise, run and facilitate the delivery of the session than others. Some teachers employed greater control over the organisation and delivery of the session than others.An omission of the mentor roleCombined class GoActive sessionsGender segregated GoActive sessionsNon-GoActive activities selected for GoActive sessionsSeparate activities for those who did not want to participate in the main session, e.g., some Year 9s were asked to walk around the playing fields if they did not want to participate in the main activityOn observation, many schools implemented the GoActive sessions as intended in the design of the intervention ; howeverSchool B amended the GoActive sessions to account for vertical forms . Instead of conducting an activity with the whole form, the mentors recruited Year 9s via a sign-up sheet to different GoActive activities run throughout the week. Year 9s were required to sign up, remember the date of the session, and turn up at the time and place where it was held, before participating. In turn, this led to some Year 9s reporting that ‘I wasn’t really asked’ to participate in the session, and as such, they did not participate. Quantitative results offer a complimentary perspective as Year 9 participants at School B reported the fewest class sessions (11.9%) . DespiteNoteworthy, some Year 9 students described that they did not receive any GoActive sessions. One participant stated, ‘We didn’t do anything’ . This is reflected in the quantitative data, with only 13.7% of Year 9s at School H reporting participating in a GoActive session in the last two weeks when schools were still meant to be running GoActive .Data from the observations, and Year 9 and mentor focus group interviews revealed that each tutor group had between two and seven mentors . Mentor The mentor walked over to the boy who stood in the corner and gave him a ball. He looked to encourage the boy to participate, and urged the boy to throw the ball at an opposing player. The mentor moved away and the boy moved forward to throw it.Observational data revealed diverse actions of the mentors between schools. The following is an excerpt from an observation at School D:We walked over to the sport shed. The contact teacher had given their keys to a Year 10 mentor in order for them to gather the equipment they needed. The two mentors were throwing a Frisbee between themselves. They did not appear to speak to any Year 9 students, nor give any eye contact to anyone. They purely played between themselves.Interview data from Year 9 students further depicted the disparity of the implementation of the mentor role. Some Year 9s reported that they had not seen their mentors ‘for a couple of weeks’, or that they only ‘sometimes turned up’. At some schools, disorganisation was another factor that resulted in the GoActive sessions not being implemented:A couple of times they’ve (mentors) shown us the cards [Quick Cards–GoActive resources] with the different selection of activities and we’ll talk about which ones we want to do…but then they don’t book a place to do it or they don’t have a football next time so we don’t end up doing it.Contact teachers, mentors and facilitators reported that all schools found it difficult to implement the in-class Year 9 peer leader GoActive component. Observations suggested that no schools had implemented in-class Year 9 peer leaders. Reports from Year 9 individual interviews and focus groups, as well as individual interviews with contact teachers, supported this. A contact teacher from School D explained their rationale for taking the focus off in-class Year 9 peer leaders:I think we haven’t had any Year 9 Peer Leaders, I think that’s a difficult thing to try and do because it’s difficult to lead your own peer group, and some, it’s something that I would maybe explore further next time. If I’m honest I haven’t invested much time into that aspect of it, I invested more time in the coordination of it and the Year 10 Leaders (mentors) going out. I can see how some peer leaders do encourage and motivate some others, you know, the enthusiastic ones, that might help, but I think it’s, that’s, it’s another thing for teachers or leaders to have to do, who’s going to be the leader next time and rotate it round, it’s just another extra thing which I’m not sure is necessarily needed.Conversely, quantitative data from Year 9 questionnaires suggest some implementation of in-class peer leaders at every school, with the lowest implementation in two sessions .Engagement with the recording of points varied by school, for both the percentage of Year 9s who recorded points, and the average points that were claimed . Overall… because some people did log at home, like I think I logged on at home once, one week and then between like four weeks I didn’t log my points, I had to log on the fifth week my points from the four weeks.Year 9 participants from all schools claimed GoActive rewards. However, there was great variation in claimed rewards from participants by school . For exaIn most of the individual and focus group discussions, Year 9s acknowledged the GoActive rewards. There was confusion with who to contact about claiming rewards from the website, and who would distribute the rewards. Year 9s reported disappointment with the time it took to receive the reward after logging points and claiming the reward online. One student reported:Ours tried (referring to mentors), they wrote down like who’d received the jumpers and stuff, but then they didn’t give us them one week, the next week they didn’t again, and then the next week they were off on exams so we haven’t actually seen them since then.There was additional confusion about how the rewards worked generally. For example, some Year 9s did not understand the process of claiming the rewards. A few Year 9s stated that they were saving their points to claim a GoActive hoodie, instead of claiming the other GoActive rewards along the way. In another focus group, one Year 9 asked if they were required to buy the rewards. The other Year 9s in the focus group were able to inform them of the process of acquiring rewards.Dose received (satisfaction) was monitored for Year 9s, mentors, teachers and facilitators. Questionnaire data revealed 59.5% of Year 9 students thought that GoActive was fun. Qualitative data were resoundingly positive, revealing that Year 9s found the programme fun, and preferred it to how they traditionally used their form time. Of the mentors, 87.3% thought that participating in the programme was enjoyable. Half of the teachers, 50% (10/20), reported that they enjoyed facilitating GoActive, and 70% (14/20) indicated that they would recommend it to a colleague. The vast majority  of facilitators indicated that they would recommend the GoActive programme to a colleague.Based on observations, and individual and focus group interview data, primary factors that may have contributed to the lack of implementation include: ambiguity of the roles subgroups played within GoActive, Year 9 disengagement, a lack of institutional support for contact teachers, and school level constraints, e.g., uniform requirements, limited facility space, resources and time. Additional school-level constraints negatively impacting implementation included teacher absence, and the timing of the intervention within the school year. These will be discussed in greater detail below.One of the key factors contributing to the lack of implementation fidelity appeared to be the uncertainty of the roles that each subgroup played. Most of the contact teachers stated that they were tasked with their role in implementing GoActive by their Senior Leadership Team (SLT), or one of the Heads of Year. A few contact teachers stated that some members of the SLT were extremely supportive and proactive, taking a keen interest in physical activity:Because our school are very proactive, the Head Teacher likes the idea of physical activity and our Heads of Year are engaged with it, they are happy for a form time to be used in that manner.Other contact teachers indicated that their SLT did not fully comprehend the intervention. Most of the time, responsibility of the intervention remained solely with this member of staff:Initially, I didn’t realise how much was involved and, to be honest, I don’t think my Head knew how much was involved, I think he thought it would be, I don’t think he’d maybe read the information through and he didn’t realise, I think he thought it might be a month or two thing, done, he didn’t realise it was going to go on.This was reinforced by the Contact Teacher at School G:I’ve found that that has been the biggest pressure of it, that I may… Because I am the Head of Year by myself, I haven’t got an assistant, I haven’t got anyone else helping me and I’ve found that this has been, not something that, but I just haven’t been able to impart as much of my time on this as maybe I want to but I’m just unable to do that, so again, maybe someone else within the school could have taken it on but they’re so busy, staff are so busy so I would say that’s because of my tutor team and I’m relying on them to be more proactive with it and they’re not.At School D, the contact teacher held an SLT role within the school, aligning with health and wellbeing. The contact teacher at School D felt that their position within the school helped to facilitate intervention implementation, and whole year level adoption of GoActive. For example, they were able to use their presence in the team to facilitate staff engagement, and schedule GoActive sessions into their timetable, creating a sense of routine, which was highly valued by Year 9s.Year 9s held mentors and tutors responsible for the successful implementation of the GoActive programme. The following comment exemplifies this:I think our form tutors were relying on the mentors to come and get us but because our mentors didn’t, our form tutors just forgot that we had to do it.Actions of tutors described by Mentors and Year 9s also indicated that more responsibility was placed on the mentor. Year 9s relied on the mentors to be competent at the GoActive activities, prepare the equipment, explain the rules, interact with those who were not engaging, and continuously encourage those who did not participate. Furthermore, mentors felt that they had to manage the classroom, and Year 9 student behaviour. For some tutor groups, if mentors or tutors did not organise an activity, the GoActive sessions did not take place:We tried to (organise) but we’re a bit wimpy and our form tutor doesn’t really want to and then our Year 10 leaders [mentors] aren’t very good so we don’t really get to actually do it.A Year 9 focus group from School F further reiterated this ambiguity of responsibility:I think more on like our side of the school as opposed to the actual project because we just haven’t really done it like done much.(Student 1)And I don’t think there’s like that many people like in our form for example like willing to take responsibility for setting it up.(Student 2)Yeah.(Student 1)Because everyone’s like, oh if I don’t do it we won’t have to do the sport.(Student 2)Yeah, I think we’re just like relying on our mentors but then if they don’t…(Student 1)Year 9 student behaviour, attitudes, and disengagement were discussed as a challenge to implementation by mentors and Year 9 students themselves. Age between the year groups, mostly for those mentors who were in Year 10, was constantly cited as an issue for managing attitudes and behaviour within the Year 9 cohort by mentors. Mentors expressed concerns with what they described as a lack of ‘respect’ shown by Year 9 students:They wouldn’t listen to us because we’re just students as well. So you’d tell them what to do and then they’d do it for like five minutes and then it’d just turn into like a free-for-all.One contact teacher (School F) stated that mentors ‘complained of apathy’ and, “Oh, they (Year 9s) don’t want to know, they’re not bothered”’. Another contact teacher commented that mentors reported finding it difficult to ‘motivate’ the Year 9s. Despite some mentors working through disengaged behaviours and attitudes, there were still reported difficulties:Once we kind of got them involved, we kind of had like a few, like maybe 3 or 4 boys that weren’t involved and they were kind of like swaying the whole class.Facilitators and contact teachers encouraged mentors to promote participation from Year 9 students. Concerns were continually expressed about the lack of Year 9 students engaging with activities. One contact teacher (School D) explained how they tried to reassure the mentors:A little bit of worry about what the expectation is as well, so you know, I was sort of saying to them ‘if you decide to do this Zumba session that you did inside and only five people do it, it’s fine, just go with it, you know, you’re not there to make people do it, you’re there to facilitate’, and I think there’s a little bit of a maybe worry with that, like ‘I can’t get everybody to do it’ or an embarrassment maybe as well about being that sort of enthusiastic and then not responding to that maybe, I don’t know.At some schools, there was a trade agreed: if Year 9s did not want to participate in the chosen activity, they were permitted to walk around the activity space to attain GoActive points . The following is an abstract from an observation from one school:A girl approaches one form tutor with a small group of girls and asks ‘Ma’am, do we have to do it?’ with a sad, whining tone. This was followed by a “Yeah” in agreement from her peers. The tutor informs them that they will have to “Ask Sir”, who is running the session. They walk over to the teacher who is surrounded by the group of Year 9 students. He informs them that they can participate in the session, or if they choose not to then they need to walk around the field instead. Some girls leave the group . A different girl watches the girls leave the group, raises her hand to point towards them, and begins to ask “why is everyone…?” She does not finish her question, but she continues to stare at those walking. She stays involved in the main session. Twelve girls in total decide to walk. Two boys also decide to walk around in the opposite direction.The school uniform was a challenge to Year 9 participation that was mentioned by Year 9s, mentors and contact teachers. Many schools required the Year 9s to change into their Physical Education sporting uniform to participate. At observed sessions, this change took approximately 5–10 min of a 15–25 min form time. At some schools, Year 9s were excluded from participating due to not bringing sport shoes. Some schools allowed Year 9s to wear their traditional school uniform during GoActive sessions. However, this brought other challenges that impacted Year 9 participation, including sweating and smelling in their uniform after participating in a GoActive session, or wearing skirts, which was a key barrier to girls’ participation noted by multiple subgroups:Just the fact that girls wear skirts and that can be a bit difficult when you’re like really trying to go for basketball or something, I mean we were just standing around and a ball bounced up a girl’s skirt [laughs], yeah. So I guess it can be embarrassing in that kind of way.An observation at School E further cemented this as an issue for participation for girls:Whilst walking back to the boys game the teacher says “it’s like getting blood out of a stone for some of the girls” … “even the sporty ones”. After a brief interaction he indicated that “its ‘cos of their skirts”. He said that even if they did want to run they were in their school skirts, which made the girls feel uncomfortable.Another challenge mentioned by a number of schools was the resourcing of facilities. Mentors discussed that they ‘didn’t have the equipment’ they wanted to run the activities. Space was limited by exam provision, but also by other form groups using the space at the same time, or the school not having the space to run activities:One of the main frustrations was getting the facilities, because we had like two or three forms all doing dodgeball.Mentors and contact teachers discussed difficulties with booking computer rooms for Year 9s to log points. Schools either lacked the resources, or the computer rooms were used by other form groups during registration time. Mentors also noted that they did not possess the ability to book computer rooms. A contact teacher from School F added that the quality of facilities was also a challenge:Our IT facilities aren’t very good at the moment, and if you want the students to log their points, they may not remember at home because maybe they won’t regard it as extra homework or something, I don’t know, or they might just forget to do it…So, if you want to try and encourage them to log their points, it’s best to book like an IT facility during registration time, which we’ve tried, but because our facility’s quite slow and you’ve only got twenty minutes to do it in, by the time you’ve logged on it’s time to log off again.Exam timings and other school priorities were discussed by contact teachers, Year 9s, and mentors as other key issues that had an impact on implementation. Exam timings created inconsistencies in mentor availability, and where the programme could be run within the school. For some, these challenges contributed to the programme losing momentum. Additionally, an interview with a contact teacher revealed that one school had Ofsted inspections which led to de-prioritisation of GoActive with the school.For a few schools, teacher staffing was an issue for GoActive implementation. Merging of schools through Trusts meant that staff travelled between campuses. One contact teacher explained:The Year 9 tutors, that’s another, I guess, a barrier, in a way, is our Year 9 tutors. There’s only one form who has a consistent tutor throughout the week, all the other teachers have got at least two, perhaps three in some cases, of people coming in taking their register. So, you know, that’s an issue in school itself-that group of teachers, some of them might be teaching at [School 1], which is our other school up the road, in a morning, so they won’t be in [School 2], necessarily. So those people, who obviously have a bit more vested interest for these form groups, haven’t been around so much.As such, the training provided to teaching staff may have only reached a minority of those who were involved. Additionally, staff turnover, or staff absence left supply (relief or substitute) teachers to facilitate running a programme they were unfamiliar with.This paper presents the mixed-methods process evaluation results of the GoActive programme. The results indicate that GoActive was implemented to some extent in all eight intervention schools; however, the complete GoActive programme was not implemented by any school. There was high variability in programme implementation within and between schools. At some schools, the mentor and/or in-class Year 9 peer leader roles were omitted. Reach was low; 37.9% of participants in intervention schools received the GoActive sessions. Despite this, qualitative data exploring dose received (satisfaction) was resoundingly positive, and quantitative data showed that 59.5% of Year 9 students thought that GoActive was fun. Mentors reported high satisfaction; 87.3% enjoyed participating in the programme. Recruitment and retention methods were positively received, with 76% of Year 9 students retained at 10 months post-intervention.The absence of intervention effect on time spent in MVPA from participating in the GoActive intervention  may be dThe results presented in this paper together with previously published process evaluation data  demonstrDespite the success of other peer-based physical activity interventions in increasing physical activity in adults, implementation of the mentorship aspects of GoActive was low, and did not demonstrate an impact on physical activity . This fiIn order for peer mentors to be effective, consideration should be given to the mentor selection process. For example, previous studies have used a peer nomination questionnaire to identify ‘influential’ peers to undertake mentor training, and provide support and encourage participation in the trial ,42. In aPrevious research has called for the design of multicomponent interventions to promote physical activity ,44,45,46The most commonly observed challenge to implementing GoActive was the understanding of mentor and teacher roles, followed by Year 9 student disengagement. Implementation difficulties may have also arisen from the provision of flexible intervention delivery, which was also identified in the Girls Active study . Other cThe value of in-depth process evaluations should not be underestimated in the initial design of a study. Insight gained from the current process evaluation has prompted greater reflection regarding the implementation of complex interventions, and the consideration of using the school environment as a context for physical activity interventions. Our findings have a number of implications for the development and evaluation of public health improvement interventions for use in educational settings. Given the limited success of school-based physical activity promotion to date , we callThe results presented here raise the question of the appropriateness and value of standardised intervention protocols across a multisite approach. The context of an intervention cannot be overlooked or undervalued. While the GoActive intervention itself was complex in nature, its interaction with its context was also highly complex. Our analysis highlights the importance of gaining both breadth, and depth in understanding of the context of individual schools. The disparity of resources, staffing, equipment and space between schools imposed clear challenges for the implementation of the intervention. While schools might provide significant reach to adolescents, there are multiple other factors that create challenges—for example, competing priorities, resource and time constraints, teacher/student rapport, or school culture around physical activity.Co-production is seen as an inclusive method of intervention development, which may be thought to take into consideration contextual concerns . The GoAIn addition, researchers need to prioritise the selection of actionable and practically relevant implementation strategies and intervention mapping protocol to advance the quality of school-based interventions. A strong focus on implementation science in the initial design phase of school-based adolescent physical activity interventions is necessary. Evidence of embedded implementation adoption strategies within physical activity interventions is developing ,53. FollBy combining mixed-methods data on reach, recruitment, dose, and fidelity, the process evaluation provides detailed information regarding the implementation of a school-based physical activity intervention, compared to previous research. Although time consuming and researcher intensive, the diversity in data, including the perspectives of multiple subgroups, from all schools, allowed the triangulation of sources, an important factor to consider for interpreting our findings. Furthermore, data analysis for this process evaluation was undertaken prior to and independently from the analysis of the main trial outcomes .However, this study has several limitations. The process evaluation focussed more on the quantity than quality of implementation. Implementation quality may be more important than fidelity and dose when impacting study outcomes , but it Participants identified as shy and inactive were purposefully sampled for interviews to provide a greater understanding of those most in need of health promotion engagement with whole school interventions. We were only able to interview two shy and inactive participants per school. This decision was made to enable the collection of breadth of data across all intervention schools to allow for contextual insights to be noted, as opposed to collecting in-depth data in a few schools. This allowed us to triangulate findings from subgroups to assess implementation fidelity across the school sites, as well as highlighting contextual factors. However, it prevented an in-depth exploration of this sub-population’s perspective on GoActive.Evaluation of the training for intervention delivery, provided to facilitators, teachers and mentors, was not conducted. Observation or survey data collection on these dates would have provided insight into the consistency of what was delivered, the attendance at the sessions for each school, and the preparedness perspectives of those who were facilitating the programme.Only a small number of teacher questionnaires were returned, and facilitator and mentor website logs were not completed consistently. This may lead to a biased evaluation, as those with strong views might have been more likely to provide their views. The team attempted to minimise this by creating a contact point within the school to act as a project champion, and by building rapport with teachers and facilitators via meetings and email. The views of teachers in school-based interventions is vital, particularly in terms of implementation. Barriers to this data collection need to be overcome in future research. Moreover, the lack of website logs mean that we were unable to assess how many GoActive sessions were conducted.While the development of questions that were used to evaluate GoActive’s essential components provides specificity, a limitation of this approach is the lack of evidence for the reliability or validity of the scores that such scales generate. This is an issue that has broader applicability for other studies.Multiple challenges and varying contextual considerations hindered the effective implementation of the GoActive programme to multiple school sites. The inability of the GoActive programme to elicit a positive change in MVPA compared to control may be attributed to the lack of implementation of GoActive components, explained by the ambiguity of the roles of teachers and mentors, Year 9 student disengagement, and school level constraints . This mixed-methods process evaluation provides important insight to understand the outcome results, and to guide future approaches to school-based physical activity intervention design and delivery. Recommendations for policy makers, future intervention design of school-based interventions, and researchers embarking upon upscaling of school-based interventions include a focus on implementation science, and deep consideration of contextual factors which may impact intervention scale-up. In-depth understanding of school culture, and innovative, potentially individualised, approaches to design may facilitate better implementation of school-based interventions. Our findings also suggest the need to consider alternative evaluation designs to account for contextual differences and diverse deliveries of an intervention across multiple sites.


Clinician-scientists (CSs) are vital in connecting the worlds of research and practice. Yet, there is little empirical insight into how CSs perceive and act upon their in-and-between position between these socio-culturally distinct worlds. To better understand and support CSs’ training and career development, this study aims to gain insight into CSs’ social identity and brokerage. The authors conducted semi-structured, in-depth interviews with 17, purposively sampled, CSs to elicit information on their social identity and brokerage. The CSs differ in how they perceive their social identity. Some CSs described their social identity strongly as either a research or clinical identity . Other CSs described combined research and clinical identities, which might sometimes be compartmentalised, intersected or merged (non-dominant-identity). In the types of brokerage that they employ, all CSs act as representatives. CSs with a non-dominant identity mostly act as liaison and show considerable variability in their repertoire, including representative and gatekeeper. CSs with a dominant identity have less diversity in their brokerage types. Those with a dominant research identity typically act as a gatekeeper. Combining lenses of social identity theory and brokerage types helps understand CSs who have a dual position in-and-between the worlds of clinical practice and research. Professional development programs should explicitly address CSs’ professional identities and subsequent desired brokerage. Research and policy should aim to clarify and leverage the position of CSs in-and-between research and practice. In an influential publication, Butler referred to this gap as “the valley of death” Butler  because Kluijtmans and colleagues (2017) conducted an explorative study on the identity development of early-career CSs in nursing and physiotherapy. Their results suggest that early-career CSs developed dual identities as clinicians and scientists to operate in both fields and brokerage of evidence- and practice-based knowledge. Typically, they also developed a third meta-identity as a “broker”, describing themselves as “bridgers” between worlds, allowing them to adapt their behaviour to situational demands and deal with potential tensions between both fields.in-group and, accordingly, people are perceived as members of the in-group or out-group. In the case of CSs, they may identify clinicians and scientists either as in-group or out-group. As clinical practice and science differ substantially, identifying both clinicians and scientists as in-group members is not self-evident. Roccas and Brewer . Third, in a compartmentalised identity CSs may embrace each social identity as in-group and make one’s identity situation- or context-specific. At the care facility, in interaction with patients, a CS may perceive his/her identity as a clinician dominant. In contrast, during a research convention, s/he may predominantly view her/himself as a researcher. Finally, a CS with a merged identity—the most complex social identity structure—identifies clinicians, scientists and CSs as in-group members. As such, a merged identity encompasses multiple identities—that are not easy to converge—simultaneously. These multiple identities allow the CSs to both acknowledge and accept differences across professional worlds, while simultaneously being capable of reconciling those inconsistencies and dealing with them.Roccas and Brewer  developeCSs are not only thought to act in two worlds, but they are also -often implicitly- expected to connect these worlds by brokerage. Brokerage can be thought of as a relationship or an exchange between three components in a network. Such components might be actors or sources of information. By occupying a strategic position in a network of professionals, CSs may facilitate (or hinder) exchange between traditionally distinct, separated professional worlds. As such, a theory from the network literature seemed warranted to advance our understanding of CSs’ brokerage. Gould and Fernandez  have desliaison. As a liaison, a CS may broker through connecting actors from different professional worlds. The most obvious example would be a situation in which a CS connects a clinical practitioner with a scientist. Second, as a gatekeeper, a CS may filter, translate, or block the exchange of information coming from one group to another group. For example, a CS may act as a gatekeeper when filtering publications and sending only the most relevant to clinical colleagues. Third, as a representative, a CS may broker by representing one world when interacting with the other. A CS may represent clinical practice in an academic setting by asking critical questions about the feasibility or relevance of research for practice. Fourth, as a consultant, a CS may facilitate exchange between professionals within one world to whom the CS her/himself does not belong, for example when connecting policymakers that share an interest in clinical practice. Fifth, as a coordinator, a CS exchanges knowledge primarily within the same social group of clinicians or researchers. As we focused on knowledge exchange between multiple diverse groups , the single-group perspective of a coordinator and the distinct-group perspective of the consultant both lay beyond the scope of this study.The first of the five distinct brokerage types is a Building on the theory on social identity and brokerage types, we explored how 17 experienced, practising CSs perceive their professional identity, what diverse brokerage types they belong to, and how these types are associated with their identity perceptions.Given the explorative nature of the study, a qualitative research design was used. The standards for reporting qualitative research (SRQR) were applied . When participants agreed, they signed a declaration of consent. The data were collected through semi-structured, in-depth, face-to-face interviews of 45–75 minutes. 14 participants were interviewed in their  workplace; three participants were interviewed at their homes between June and August 2017. During the interviews, additional data were collected as this research is part of a larger research project  clinical practice with a researcher. Furthermore, they described examples in which they connected clinicians, scientists, and/or CSs. The participants were asked to reflect on their role and responsibility as a CS in such situations. A pilot study was performed to test the interview guide. In the pilot study, authors DS and YB were interviewers; RD was—as an author and experienced CSs—interviewee. Such preparation within the team of authors helped to include the view of the participants in the study in a solid way codes were added and refined if needed—in line with the process of sis King . For inssis King .The results section consists of three parts. First, we elaborate on how CSs perceive their social identity. Second, we describe their brokerage types and third, we explore how these might be associated with their identity perceptions.And besides that, I like being able to deepen my knowledge of my field. If you’re just at work in the practice, stuck in the usual routine, you have very little time to grab a book or read a guideline carefully. Or read through an article”. This participant is not only getting energy out of doing research but also misses this stimulant in her/his clinical work. In contrast, CS-17 perceives her/himself more a clinician: “My role is mainly to ensure adequate input from clinical practice and that the research can be done well in clinical practice, so to say. That it’s adjusted in such a way that it fits well and—the other way around—that when we work on articles, we report what the consequences are well for clinical practitioners”. This participant considers her/himself an “investigative practitioner” and emphasises the importance of an investigative stance for the clinical practitioner.All four identity structures of Roccas and Brewer  were encintersected identity was described by CS-9 who, when asked whether (s)he felt more like a researcher or a clinician, said: “Neither. I feel like someone standing on a bridge”. Later in the interview, (s)he added that this means: “You can come up with better questions when you are a GP and a researcher but most of all when you’re a GP scientist”. (S)he also explained why (s)he maintained most professional relationships with other CSs: “Only a very few peers are doing both [research and practice]. You have a strong bond with them, which is logical. With just clinicians or just researchers, there is less of a connection”.Other CSs cope with their multiple social identities in three ways: intersectioning, compartmentalising or merging. Each of these three ways are characterised by whom they consider as in- or out-group. Some expressed they felt connected with other social identities or negatively expressed themselves about others: for instance, clinicians who were described as dull and uninspiring or researchers as ‘ivory tower’ theorists without including any relevance for clinical practice in their research projects. An compartmentalised. These CSs seemed to strategically choose when to respond from a specific identity, given the particular context or situation, switching in-group and out-group positions. As CS-6 explained: “So depending on what the situation calls for, you open a certain register or not. When I’m working in the practice with my colleagues, I close all the research registers and only open my practice register for a while when I’m actually interacting with my colleagues, because they’re not interested in the other [registers]. But in my contact with patients, I do think I open that register because then you also use your scientific knowledge and insights”. This CS explicitly explained to switch identities depending on the situation. CS-1 also spoke of ‘switching hats’, but doing so within the same context. She/he mentioned: “[They’re] always joking like, ‘There (s)he goes again, wearing all her/his different hats’. Because it’s how I work, that’s how I talk to them. I say: ‘Now I’m putting on my GP’s hat’, or my research coordinator’s hat… or the researcher’s hat. And then I talk to them from those different perspectives”. In this example, not only the CS her/himself, but also her/his colleagues recognise and acknowledge her/his multiple identity. In such an identity, the clinician, scientist and CS identities exist parallel to each other. All identities are of equal importance to CS-1 and (s)he is capable of acknowledging the differences between the distinct worlds, while, at the same time, reconciling them. Such professionals with a merged identity feel that they belong to all groups, all of the time. We had difficulties in identifying a merged identity. Some respondents did not express themselves negatively about researchers or clinicians. Respondents who speak more about ‘switching hats’ differ from those who found it impossible to split these perceptions . However, in the cross-case comparisons, these findings were not consistently visible in specific respondents .We also found evidence of CSs who Of the five potential brokerage types described by Gould and Fernandez , we usedBuilding bridges, connecting, and definitely spreading love for the field of clinical practice, love for knowledge acquisition, knowledge sharing, and learning from one another”. Or, as CS-1 formulated it: “Although I have good ideas, my job is connecting people. I like to surround myself with top scientists, who know a lot about a certain topic, and then throw clinicians in the mix, and then myself. And then we’re going to connect”. Besides, CS-11 provided a concrete example of how the brokerage type of liaison can be fulfilled “[…], he’s a good friend of mine and he […] was interested in heart failure. And he liked what I’d done [a PhD]. So I connected him to the centre, with people active in that area. And, in the end, that led to a PhD project”.Brokerage of the type of acting as liaison was by several CSs described as being at the core of being a CS. For instance, CS-9 summarised this as “And sometimes they ask me to look up something on PubMed, for example, because they don’t have access themselves. Or they do have access, but can’t read the whole article. […] Then I have more opportunities to… and the tools and skills to… to answer questions from practice. That’s what I use academia for”. This is a typical gatekeeper position, because the CS, as a researcher, can decide whom (s)he may grant or deny access. On other occasions, the gatekeeper type had a less visible character. CSs take part often in guideline development committees or act as reviewers for journals that are being read by clinicians; as such, CSs influence what research findings are communicated with a higher priority toward clinicians.CSs utilise the brokerage type of gatekeeper when they take control of the flow of resources between research and practice. For instance, CSs refer to gatekeeping from the position of a researcher, for example, by granting access to literature, as illustrated by CS-3: “…for instance, at meetings of clinicians, yes, I often put many things forward because I’ve got a very broad scope. Because of my big network and because I am sometimes ahead of things and because I think maybe we should have a look at this or I heard about this recently or maybe we should read that. […] So that’s how you just put forward things that are mainly fuelled by the university function”. Here, the CS mainly seems to represent research in clinical practice by informing clinicians of relevant research. Other CSs seem to fulfil the type of representative more firmly, for example through posing critical questions. This is illustrated by CS-15, who represents clinical practice in research: “… but what do we have? Or going back to the start, what’s the purpose, what’s the clinical relevance? How does it benefit the patient or, the potential practitioner in the hospital?”In the brokerage type of being a representative, we singled out distinct variations. Some CSs aim to represent clinical practice in research and vice versa; research in clinical practice. For instance, CS-7 explained that: “In our study, social identity theory was chosen as a theoretical lens because social identity affects how a person acts in and between distinct professional worlds and thereby may help us understand whether or not a person acts according to a specific brokerage type. Brokerage was considered relevant as connecting the different worlds of clinical practice, and research is vital in the role of CSs—but the complexity of this role is often underestimated. We explored which brokerage types seemed more prevalent in respondents that had specific identity perceptions. We compared four respondents with dominant researcher identity perceptions, four respondents with dominant clinician identity perceptions, and eight respondents with identity perceptions that were intersected, compartmentalised or merged .researcher identity are more inclined toward gatekeeping and less toward activities that belong to a liaison or a representative brokerage type. CSs with a non-dominant identity appear to be more involved in activities of a liaison brokerage type compared to the CSs with dominant identities. All of these non-dominant identity CSs alternate within their representative brokerage type. On the one hand, they keep a close eye on the clinical relevance of the studies that researchers design. On the other hand, they make clinicians aware of the importance of (being involved in) research in the domain of general practice and elderly care medicine. “Yes, I see it as a responsibility to conduct good research that is clinically relevant too. So, I try to keep the connections going as well as possible. So, it’s not just derived from the research setting [and turned into] something academic… eh … theoretical discussions that don’t have much to do with practice. […] But in practice I also want to keep away from the ‘well now, in my experience it’s this or that’ or ‘I’ve heard that this or that works’. That’s expert opinion and hearsay, so that you… well… there’s a big world of publications [on] evidence-based medicine. And you’ll surely find clinically relevant answers in there”. (CS-3)CSs with a dominant In this study, identity was investigated from a social identity perspective and how this shaped the types of brokerage. We investigated how CSs perceive and act upon their in-and-between position between research and practice. The CSs from this study seem to be driven to brokerage because of their eagerness and passion towards the development and use of evidence for clinical practice. This is similar to what was found among early-career CSs  position, primarily related to the structure of networks  the CSs perform activities that belong to a diversity of brokerage types: a liaison, a gatekeeper, or a representative. CSs with a dominant identity, clinician or researcher, perform activities that belong to just one brokerage type primarily. A CS who mainly identifies her/himself as a clinician (dominant identity), acts more prominently as a representative and takes a critical stance  towards researchers who want to research in clinical practice. CSs with a dominant research identity are mainly involved in translating research to clinical practice, supporting the implementation of research findings and designing research that fits daily work in clinical practice (gatekeeper). This diversity of brokerage types of CSs with a non-dominant identity may be explained by the fact that they are perhaps better able to consider, incorporate and reconcile the different stakes of the different groups they represent, allowing them to balance in and between those worlds. CSs with such an identity accept differences between professional worlds, allowing them to cope with conflicting issues which helps in brokerage. Because of this versatility, development of a non-dominant identity seems to be the preferred direction for identity development of CSs.Social identity structures are relevant in understanding how CSs perform brokerage. Differences in how CSs cope with their multiple identities, in particular, whether they see one of these as dominant or not, lead to differences in types of brokerage they utilise. With a translational arena in which both clinical as well as academic efforts—and especially those tasks linking these two professional worlds—are acknowledged and rewarded.Currently, in most clinical and academic settings, being a CS is not a formally recognised profession  and situations . Our results provide reasons to believe that CSs with a non-dominant identity can use the full potential of brokerage, as they undertake activities that characterise the three different brokerage types. Dominant identities are more limited in the diversity of their brokerage types. Future research is needed further to disentangle the differences between merged and intersected identities. A relevant difference between the two in the uptake of brokerage types is to be expected, based on the fact that these identities differ in who they consider in-group and out-group.This study contributed to our understanding of the highly complex and valuable position of CSs by elaborating on brokerage and their social identity.